Serving: Most of California
Enrollment in this plan is limited. You
must live or work in our geographic service area to enroll. See
page 7 for
requirements.
This plan has been granted Commendable Accreditation from the NCQA. See the
2002 Guide for more information on accreditation.
Enrollment codes for
this plan:
SJ1 Self Only SJ2 Self and Family
RI 73-574
For
changes in benefits,
see page 8. 1
1 Page
2 3
2002 Access+ 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
....................................................................................................................................................................................
9
Specialty care
...................................................................................................................................................................................
9
Hospital care
..................................................................................................................................................................................
11
Circumstances beyond our control
...............................................................................................................................................
11
Services requiring our prior approval
.........................................................................................................................................
11
Section 4. Your costs for covered
services......................................................................................................................................................
12
Copayments
....................................................................................................................................................................................
12
Coinsurance....................................................................................................................................................................................
12
Your out-of-pocket
maximum........................................................................................................................................................
12
Section 5. Benefits
.................................................................................................................................................................................................
13
Overview...............................................................................................................................................................................................
13
a) Medical services and supplies provided by physicians and other health
care professionals ................................ 14
b) Surgical and
anesthesia services provided by physicians and other health care professionals
........................... 21
c) Services provided by a hospital or other
facility, and ambulance
services................................................................ 24
d) Emergency services/
accidents.................................................................................................................................................
26
e) Mental health and substance abuse benefits
......................................................................................................................
28
f) Prescription drug benefits
.......................................................................................................................................................
30
g) Special
features...........................................................................................................................................................................
32
h) Dental benefits
............................................................................................................................................................................
33
i) Non-FEHB benefits available to Plan members
................................................................................................................
34
Section 6. General exclusions --things we don't
cover................................................................................................................................
35
Section 7. Filing a claim for covered services
................................................................................................................................................
36 2
2 Page 3 4
2002 Access+ 3 Table of Contents
Section 8. The disputed claims process
...........................................................................................................................................................
37
Section 9. Coordinating benefits with other
coverage.................................................................................................................................
39
When you have
– Other health coverage
.................................................................................................................................................................
39
– Original Medicare
........................................................................................................................................................................
39
– Medicare Managed Care
Plan..................................................................................................................................................
41
TRICARE/ Workers' Compensation/
Medicaid.......................................................................................................................
41
Other Government agencies
........................................................................................................................................................
41
When others are responsible for
injuries.................................................................................................................................
41
Section 10. Definitions of terms we use in this brochure
..............................................................................................................................
42
Section 11. FEHB
facts...........................................................................................................................................................................................
43
Coverage
information.......................................................................................................................................................................
43
No pre-existing condition limitation
........................................................................................................................................
43
Where you get information about enrolling in the FEHB
Program...............................................................................
43
Types of coverage available for you and your
family.........................................................................................................
43
When benefits and premiums
start..........................................................................................................................................
43
Your medical and claims records are confidential
..............................................................................................................
44
When you
retire.............................................................................................................................................................................
44
When you lose benefits
.....................................................................................................................................................................
44
When FEHB coverage ends
.......................................................................................................................................................
44
Spouse equity coverage
...............................................................................................................................................................
44
Temporary Continuation of Coverage
(TCC)......................................................................................................................
44
Enrolling in
TCC..........................................................................................................................................................................
44
Converting to individual
coverage...........................................................................................................................................
45
Getting a Certificate of Group Health Plan Coverage
.......................................................................................................
45
Long-term care insurance is coming later in 2002
.........................................................................................................................................
46
Department of Defense/ FEHB Demonstration
Project.................................................................................................................................
47
Index............................................................................................................................................................................................................................
59
Summary of benefits
...............................................................................................................................................................................................
50
Rates
............................................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Access+ 4 Introduction
Introduction
Blue Shield of California Access+ HMO sm
50
Beale Street San Francisco, CA 94105
This brochure describes the benefits of Blue Shield of California Access+
under our contract (CS2639) 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.
A person
enrolled in this plan is 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
Blue Shield of
California.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel
Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650. 4
4
Page 5 6
2002
Access+ 5 Inspector General Advisory
Inspector General
Advisory
Stop health care fraud! Fraud increases the cost of health care
for everyone. If you suspect that a physician, pharmacy, or hospital has charged
you for services you did not receive, billed you twice
for the same service,
or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If
the provider does not resolve the matter, call us at 800-334-5847 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 Access+ 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 except for your annual eye
exam. 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 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 your health
plan, its 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.
Corporate Form – Blue Shield of California is a not-for-profit
corporation that was founded in 1939.
Fiscal Solvency – Blue Shield
of California meets or exceeds California Department of Managed Health Care
standards for fiscal solvency, confidentiality of medical records and transfer
of medical records.
"Gag Clauses" – A "gag clause" is when a physician does not disclose
all treatment options based on cost considerations. You have the right to have a
clear understanding of the medical condition and any proposed appropriate
necessary treatment alternatives, including available success/ outcomes
information, regardless of cost or
benefit coverage, so you can make an
informed decision before receiving treatment.
Medical Records – Access+ members have the right, both under state law
and Blue Shield of California policy, to review, summarize and copy their own
medical records. Members can request and will receive amendments to their
medical records as they are made.
State Licensing – Access+ has
been licensed by the State of California since 1978.
If you want more information about us, call us at 800-334-5847, or write to
Blue Shield of California Access+, P. O. Box 7168, San Francisco, CA 94120-7168.
You may also contact us by fax at 916-350-8780 or visit our website at http://
www. mylifepath. com. 6
6 Page
7 8
2002 Access+ 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:
County Name Excluded ZIP Codes
Alameda None Butte None
Contra Costa None
El Dorado 95613, 95619, 95623, 95633, 95636, 95643,
95651, 95656, 95667, 95672, 95682, 95684, 95709, 95720, 95721, 95726, 95735, and
96150 to 96158
Fresno None
Kern 93501, 93502, 93504, 93505, 93516, 93519, 93527, 93528,
93554 to 93556, 93560 and 93596 Kings None
Los Angeles 90704
Madera None Marin None
Merced None
Nevada 95724, 95728, 96111 and 96160 to 96162 Orange None
Placer 95701, 95714, 95715, 95717, 96140 to 96143, 96145, 96146 and 96148
Riverside 92225-26 Sacramento None
San Bernardino 92242, 92280, 92304, 92319, 92338 and 92363
San Diego
91905, 91906, 91934, 91948, 91963, 91980, 91987, 91990 to 91995, 92004 and 92086
San Francisco None
San Joaquin None
San Mateo None Santa Barbara None
Santa Clara None
Santa Cruz None Solano None
Sonoma None
Stanislaus None Tulare None
Ventura None
Yolo None
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will normally pay only for
emergency or urgent care. We will not pay for any other health care service,
except those that are specifically listed on
page 34 under the heading "Medical Care for Vacations, Business Travel and
College Students."
If you or a covered family member move outside the
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 like ours that has
agreements with affiliates in other states. See page 34 for details about our
HMO Medical care available for
vacations, business travel and college students coverage. 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
Access+ 8 Section 3
Section 2. How we change for 2002
Do not rely on these change descriptions; this page is not an official
statement of benefits. For that, go to Section 5, Benefits. Also, we
edited and clarified language throughout the brochure; any language change not
shown here is a clarification that does not change
benefits.
Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will
increase by 24.3% for Self Only or 24.3% for Self and Family.
The
following counties are no longer a part of our service area: Napa, Shasta and
San Luis Obispo.
We no longer limit total blood cholesterol tests to
certain age groups. (Section 5( a))
We now cover routine screening for
chlamydial infection. (Section 5( a))
We now cover certain intestinal
transplants. (Section 5( b))
The copayments for prescription drugs have
changed. Members can now obtain non-formulary drugs for $25 per retail plan
pharmacy prescription/ $50 per plan mail service prescription. The charge for a
generic formulary retail plan pharmacy
prescription has been reduced from $6 per prescription to $5 per
prescription. Other copayment changes are: $10 per brand name formulary plan
pharmacy prescriptions; $10 per generic formulary plan mail service
prescription; and $20 per brand
name formulary plan mail service
prescription. As before, a generic equivalent will be dispensed if it is
available, unless
your physician specifically requires a brand name. If you
receive a brand name drug when a federally-approved generic drug is available
and your physician has not specified "Dispense as Written" for the brand name
drug, you will pay the
difference in the cost between the brand name drug and the generic plus the
appropriate copayment.
Smoking cessation medications requiring a
prescription are covered at the appropriate prescription copayment but are
limited to one 12-week course of treatment per calendar year.
We have clarified that the coordination of benefits provision does not
apply to the Prescription Drug Benefit.
We have clarified that treatment
of damage to natural teeth caused solely by an accidental injury is covered.
We have clarified that a member can self-refer for mental health and
substance abuse care using the Access+ feature as long as the specialist is an
USBHPC provider.
We have also clarified that OB/ GYN services obtained within the same
Medical Group/ IPA as the primary care physician;
services for which the
Medical Group or IPA routinely allows the Member to self-refer without
authorization from the primary care physician; and internet consultants are not
covered Access+ visits. (Section 5( g))
We have clarified that home testing devices are not covered except as
specifically listed in the covered section. 8
8
Page 9 10
2002
Access+ 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 800-334-5847.
Where you get covered care You get care from "plan providers" and
"plan facilities." You will only pay copayments and/ or coinsurance, and you
will not have to file claims, except for your annual eye
examination.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our members. All plan providers are
credentialed, according to national standards.
We list plan providers in
the provider directory, which we update periodically. The list is
also on
our website, http:// www. mylifepath. com.
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to our
members. We list these in the provider directory, which
we update periodically. The list is also on our website, http:// www.
mylifepath. com.
What you must do to get covered care It depends on
the type of care you need. First, you and each family member must choose a
primary care physician. This decision is important since your primary care
physician
provides or arranges for most of your health care. You must
complete a Primary Care Physician Selection Form.
Primary care Your primary care physician can be a general
practitioner, family practitioner, internist, pediatrician, or an OB/ GYN. Your
primary care physician will provide most of your
health care, or give you a
referral to see a specialist.
If you want to change primary care physicians
or if your primary care physician leaves the plan, call us at 800-334-5847. We
will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain number of
visits without additional referrals.
The primary care physician must provide or authorize all follow-up care. Do
not go to the specialist for return visits unless your primary care physician
gives you a referral.
The exceptions to this are:
1. for true medical
emergencies; 2. when another physician is on call for your physician;
3. when you self-refer to an Access+ participating specialist (not applicable
to
infertility, emergency and urgent care and allergy services; mental
health and substance abuse Access+ specialist care must be provided by an USBHPC
provider);
and
4. OB/ GYN services provided by an obstetrician/ gynecologist or
family practitioner within the same IPA/ Medical Group as your primary care
physician.
In all other instances, referral to a specialist is done at the primary care
physician's direction; if non-plan specialists or consultants are required, the
primary care physician
will arrange appropriate referrals. 9
9 Page 10 11
2002 Access+ 10 Section 3
Here are
other things you should know about specialty care:
If you need to see a
specialist frequently because of a chronic, complex or serious medical
condition, your primary care physician will develop a treatment plan with you
that allows an adequate number of direct access visits with that specialist.
Your primary care physician will use our criteria when creating your treatment
plan.
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. We will not pay
for you to see a specialist who does not participate
with our plan, unless your primary care physician refers you to a non-plan
specialist for a
second opinion.
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; – 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 or when
clinically
appropriate 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. Contact us to
coordinate care for these types of cases.
Second Opinions If there is a question about your diagnosis or if
additional information concerning your condition would be helpful in determining
the most appropriate plan of treatment, your
primary care physician will,
upon request, refer you to another physician for a second medical opinion. If
you are requesting a second opinion about care you received from
your
primary care physician, a physician within the same Medical Group\ IPA as your
primary care physician will provide the second opinion. If you are requesting a
second
opinion about care received from a specialist, any plan specialist of
the same equivalent
specialty may provide the second opinion. All second
consultations must be authorized by us. 10
10
Page 11 12
2002
Access+ 11 Section 3
Hospital care Your plan primary
care physician or specialist will make necessary hospital arrangements and
supervise your care. This includes admission to a skilled nursing or other type
of
facility.
If you are in the hospital when your enrollment in our plan
begins, call our member service department immediately at 800-334-5847. 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; The day
your benefits from your former plan run out; or
The 92 nd day after you
become a member of this plan, whichever happens first.
These provisions
apply only to the benefits of the hospitalized person.
Circumstances
beyond our control Under certain extraordinary circumstances, such as
natural disasters, we may have to delay your services or we may be unable to
provide them. In that case, we will make all
reasonable efforts to provide
you with the necessary care.
Services requiring our prior approval
Your primary care physician has authority to refer you for most services.
For certain services, however, your physician must obtain approval from us.
Before giving approval,
we consider if the service is covered, medically necessary, and follows
generally accepted medical practice.
Your primary care physician must obtain a preauthorization from us for; (1)
selected drugs and drug dosages which require prior authorization for medical
necessity, (2)
growth hormone therapy (GHT) (3) organ transplants and (4)
bone marrow transplants.
See page 23 in Section 5( b) for the
preauthorization process for organ and bone marrow transplants. 11
11 Page 12 13
2002 Access+ 12 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.
Coinsurance Coinsurance is the percentage of our allowable fee that
you must pay for your care.
Example: In our plan, you pay 50% of our
allowance for infertility services or durable medical equipment.
Your out-of-pocket maximum for coinsurance and copayments After your
copayments and your percentage of allowable charges for medical and surgical
services total $1,000 per person or $2,000 per family enrollment in any calendar
year, you do not have to pay any more for covered services. However, the
following services do not count toward your out-of-pocket maximum, and you must
continue to pay
copayments for these services:
1. your prescription drugs 2. infertility
services
3. the Access+ self-referral specialty visit copayments.
For
mental health and substance abuse benefits you pay $1,000 in copayments or
coinsurance for a Self Only enrollment or $2,000 for a Self and Family
enrollment. After that you do not have to make any further payments the rest of
the year for authorized
treatment or services. However, you must continue to pay copayments for
prescription
drugs.
Be sure to keep accurate records of your copayments and coinsurances since
you are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 Access+ 13 Section 5
Section
5. Benefits --OVERVIEW
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
for annual eye exams, or more information about our benefits, contact us at
800-334-5847 or at our website at
http:// www. mylifepath. com.
Medical services and supplies provided by
physicians and other health care professionals
................................................................... 14-20
Diagnostic and treatment services
Lab, x-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity
care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapies
Speech therapy
Hearing services (screening)
Vision services
(screening)
Orthopedic and prosthetic devices
Durable medical
equipment (DME)
Home health services
Chiropractic
Alternative
treatments
Educational classes and programs
Surgical and anesthesia services provided by physicians and other health care
professionals ...............................................................
21-23
Surgical procedures
Reconstructive surgery
Oral and
maxillofacial surgery
Organ/ tissue transplants
Anesthesia
Services provided by a hospital or other facility, and ambulance
services.................................................................................................
24-25
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care
Hospice care
Ambulance
Emergency services/ accidents
............................................................................................................................................................................
26-27
Medical emergency Ambulance
Mental health and substance abuse benefits
....................................................................................................................................................
28-29
Prescription drug
benefits....................................................................................................................................................................................
30-31
Special features
...........................................................................................................................................................................................................
32
High risk pregnancies Self– referral to specialty services
Dental
benefits.............................................................................................................................................................................................................
33
Non-FEHB benefits available to Plan members
....................................................................................................................................................
34
Summary of benefits
..................................................................................................................................................................................................
50 13
13 Page 14
15
2002 Access+ 14 Section 5 (a)
Section 5( a). Medical services and supplies provided by physicians
and other health care professionals
I
M P
O
R T
A
N T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no
calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
I
M P
O
R T
A
N T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
During a hospital stay
In a skilled nursing facility
Vaccines for pediatric and adult
immunizations
Inpatient non-dental treatment of temporomandibular joint
(TMJ) syndrome
Nothing
Office visits
Office medical consultations
Second opinions
$10 per office visit
Home visit by physician $25 per visit
Self-referral to a plan specialist
under Access+ option $30 per office visit
In an urgent care center $50 per
visit
Home visit by nurse or health aide $5 per visit
Lab, x-ray and
other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Pathology
X-rays
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing
Non-routine Pap tests
Non-routine mammograms
$10 per test 14
14 Page 15 16
2002 Access+ 15 Section 5 (a)
Preventive care, adult You Pay
Routine screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer
Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening
– every five years starting at age 50
Nothing
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Nothing
Routine Pap test Nothing
Routine mammogram – covered for women
age 35 and older, as follows:
From age 35 through 39, one during this five
year period
From age 40 through 49, one every one or two years
From
age 50 through 64, one every year
At age 65 and older, one every two years
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges
Routine immunizations as recommended by the United States Public Health
Service
Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and
over (except as
provided for under Childhood immunizations)
Influenza vaccines, annually, age 50 and older
Pneumococcal vaccine
for adults 65 and older
Recommended travel immunizations
Hepatitis
A, hepatitis B and lyme disease immunization for individuals at high risk
Nothing
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing
Well-child care charges for routine examinations, immunizations and care
(through age 17)
Examinations, such as:
Eye screenings through age 17 to determine the
need for vision correction
Ear screenings through age 17 to determine the
need for hearing correction
Examinations done on the day of immunizations
(through age 17)
Nothing 15
15 Page
16 17
2002 Access+ 16 Section 5
(a)
Maternity care You Pay
Complete maternity (obstetrical)
care, such as:
Prenatal care
Delivery
Postnatal care
Nothing
Note: Here are some things to keep in mind:
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 5( b)).
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family planning
services, such as:
Physician office visit for fitting a diaphragm.
Nothing
Surgically implanted contraceptives (such as Norplant)
Injectable
contraceptive drugs (such as Depo Provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
$10 per item
Voluntary Sterilization
Vasectomy
Tubal ligation
$75 $100
Not covered: reversal of voluntary surgical sterilization All charges
Infertility services
Diagnosis and treatment of infertility,
such as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Covered injectable fertility drugs
50% of allowable charges
Oral fertility drugs (See Prescription Drug Benefits) Regular cost
sharing 16
16 Page
17 18
2002 Access+ 17 Section 5
(a)
Infertility services (continued) You pay
Not covered:
Infertility services after voluntary
sterilization
Assisted reproductive technology (ART) procedures,
such as:
-in vitro fertilization
-embryo transfer, gamete
GIFT and zygote ZIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm, eggs and frozen embryos and their collection and storage
All charges
Allergy care
Allergy serum Nothing
Testing and treatment
Allergy injection
$10 per office visit
Customized antigens 50% of allowable charges
Not covered:
provocative food testing and sublingual allergy desensitization All charges
Treatment therapies
Growth hormone therapy (GHT)
Note:
We will only cover GHT for medically necessary conditions when we have
preauthorized the treatment. Such authorization must be obtained through your
primary
care physician.
Chemotherapy and radiation therapy
Note: High dose
chemotherapy in association with autologous bone marrow transplants are limited
to those transplants listed under Organ/ Tissue Transplants on page 23.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy and antibiotic
therapy
$10 per office visit
Physical and occupational therapies
These are covered benefits
when determined by us to be medically necessary and it is demonstrated that the
member's condition will significantly improve as a result of the
services.
-qualified physical therapists; and
-occupational
therapists.
Note: Occupational therapy is limited to services that assist the member to
achieve and
maintain self-care and improved functioning in other activities
of daily living.
$10 per visit
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided at a plan facility, if medically necessary
with the appropriate
treatment plan.
$10 per visit
Not covered:
long-term rehabilitative therapy
exercise programs
All charges 17
17 Page 18 19
2002 Access+
18 Section 5 (a)
Speech therapy You Pay
Speech therapy
by a qualified speech therapist is covered when it is determined by us to be
medically necessary and it is demonstrated that the member's condition will
significantly improve as a result of the services.
$10 per visit
Hearing services (testing, treatment, and supplies)
Hearing
screening for children through age 17 (see Preventive care, children)
Nothing
Not covered:
all other hearing testing
hearing
aids, testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
Contact lenses,
if medically necessary to treat eye conditions such as keratoconus and keratitis
sicca or when required as a result of cataract surgery when no intraocular lens
has been implanted, are covered.
$10 per office visit
Annual eye refraction; in addition to the medical and surgical benefits
provided for diagnosis and treatment of disease of the eye, an annual eye
refraction (to provide a
written lens prescription) may be obtained from
Medical Eye Services (MES) providers. MES directories can be ordered by calling
800-334-5847.
Note: See Preventive care, children for eye screenings for children.
$10 per office visit
Not covered:
Eyeglasses or contact lenses (See page 34 for
details about eyewear discounts)
Eye exercises and orthoptics
Radial keratotomy, refractive keratoplasty and other refractive
surgery
All charges
Foot care
Not covered: Routine foot care All charges
Orthopedic and prosthetic devices
Surgically implanted breast
implant following mastectomy Nothing
Surgically implanted prosthetic devices, such as artificial joints,
pacemakers:
Inpatient Hospital
Outpatient Hospital
Nothing
$50 per surgery
Orthopedic devices (and their repair) such as braces and functional foot
orthoses
Prosthetic devices (and their repair) such as artificial limbs,
Blom-Singer prostheses and
contact lenses necessary to treat certain medical
eye conditions. Contact us for details.
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
50% of allowable charges 18
18 Page 19 20
2002 Access+
19 Section 5 (a)
Orthopedic and prosthetic devices
(continued) You Pay
Not covered:
Orthopedic and corrective shoes
Arch supports
Heel
pads and heel cups
Lumbosacral supports
Corsets,
trusses, elastic stockings, support hose, and other supportive devices
Penile prostheses
All charges
Durable medical equipment (DME)
Purchase or rental up to the
purchase price, including repair and adjustment, of durable
medical
equipment prescribed by your plan physician. Under this benefit, we cover:
Colostomy/ ostomy supplies
Hospital beds
Wheelchairs
Crutches
Walkers
Canes
Traction equipment
Peak flow
monitor for self-management of asthma
Glucose monitor for self-management
of diabetes
Apnea monitor for management of newborns
Note: Call us at 800-334-5847 as soon as your plan physician prescribes this
equipment. We have contracted with health care providers to rent or sell you
durable medical
equipment at discounted rates and we will tell you more about this service
when you call.
50% of allowable charges
Not covered:
Exercise equipment
Disposable
medical supplies for home use
Speech/ language assistance devices
except as listed under prosthetic devices
Self-monitoring equipment
and home testing devices, except as listed in the covered
section
Wigs
All charges
Home health services
Home health care ordered by a plan
physician and provided by a registered nurse (R. N.), Physical Therapist (PT),
Occupational Therapist (OT), Speech Therapist (ST),
Respiratory Therapist
(RT), licensed vocational nurse (L. V. N.), or home health aide
Services
include oxygen therapy, intravenous therapy and medications
$5 per visit
Home visit by physician $25 per visit 19
19
Page 20 21
2002
Access+ 20 Section 5 (a)
Home health services
(continued) You pay
Not covered:
Nursing
care requested by, or for the convenience of, the patient or the patient's
family
Services primarily for hygiene, feeding, exercising, moving
the patient, homemaking,
companionship or giving oral medication
All charges
Chiropractic/ Alternative treatments
Chiropractic services (with
an annual limit of 20 visits per year) $10 per office visit
Each member is allowed a pre-authorized appliance benefit of up to $50 per
year.
Appliance benefits that are pre-authorized such as:
Elbow
supports
Back supports (Thoracic)
Cervical collars
All charges above $50 per year
Not covered:
All charges after the 20 visit annual maximum
Naturopathic services
Hypnotherapy
Services for or related to acupuncture (see page 34 for Non-FEHB discount
information.)
Note: See page 34 Non-FEHB benefits available to plan members. Significant
discounts through the mylifepath sm Alternative Health Services Discount Program
-acupuncture,
massage & more
All charges
Educational classes and programs
Coverage is limited to:
Health education newsletter
Health Resource Directory; provides
information about health education classes and support groups offered by Blue
Shield providers and community organizations
Healthwise Handbooks for new members
First Steps sm prenatal
education program
Preventative health reminders
Nothing 20
20 Page
21 22
2002 Access+ 21 Section 5
(b)
Section 5( b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P
O R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no
calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
The amounts listed below are for the charges
billed by a physician or other health care professional for your surgical care.
Look in Section 5 (c) for charges associated with the facility
charge (i. e. hospital, surgical center, etc.).
I M
P
O R
T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative
care by the surgeon
Correction of amblyopia and strabismus, when medically
necessary
Endoscopy procedures
Biopsy procedures
Removal of
tumors and cysts
Correction of congenital anomalies (see reconstructive
surgery)
Surgical treatment of morbid obesity – for members who meet Blue
Shield Medical Policy and clinical criteria for defined procedures and services
that have been approved
by their Primary care physicians
Treatment of burns
Nothing in hospital
Insertion of internal prosthetic devices. See Section 5( a) – Orthopedic and
prosthetic
devices for device coverage information.
$10 per procedure
Outpatient hospital surgery and supplies $50 per surgery
Voluntary
Sterilization
Vasectomy
Tubal ligation
$75 $100
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot
All charges 21
21 Page 22 23
2002 Access+
22 Section 5 (b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition
caused by injury or illness if:
-the condition produced a major effect on
the member's appearance and
-the condition can reasonably be expected to be
corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenial
anomalies are: protruding ear
deformities, cleft lip, cleft palate, birth marks, webbed fingers, and webbed
toes
Nothing as an inpatient
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
Note: If you need a mastectomy, you may choose to have this procedure
performed on an inpatient basis and remain in the hospital up to 48 hours after
the procedure.
See above
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair
of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones
Surgical
correction of cleft lip, cleft palate or severe functional malocclusion
Removal of stones from salivary ducts
Excision of leukoplakia or
malignancies
Excision of cysts and incision of abscesses when done as
independent procedures
Surgical and anthroscopic treatment of TMJ is
covered if prior history shows conservative medical treatment has failed. Splint
therapy and physical therapy is covered,
see Section 5( a)
Other surgical procedures that do not involve the
teeth or their supporting structures
Nothing as an inpatient
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva, and alveolar bone)
All charges 22
22 Page 23 24
2002 Access+
23 Section 5 (b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Skin
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Intestinal transplants (small intestine) and the small intestine with the liver
or small
intestine with multiple organs such as the liver, stomach, and
pancreas
Limited Benefits – Allogenic (donor) bone marrow transplant; autologous bone
marrow transplants ( autologous stem cell and peripheral stem cell support) for
the following
conditions when authorized in writing by the Blue Shield
Medical Director and performed at approved facilities: acute lymphocytic or
non-lymphocytic leukemia,
advanced Hodgkin's lymphoma, advance non-Hodgkin's
lymphoma, advanced
neuroblastoma, and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors. Breast cancer, multiple myeloma
and epithelial ovarian cancer are covered only when
approved by our Medical Director. Related medical and hospital expenses of
the donor
are covered when the recipient is covered by this plan.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the
actual donor
Implants of artificial organs
Transplants not listed as
covered
Pancreas only transplants
Travel expenses
unless authorized by us
All charges
Anesthesia
Professional services provided in:
Hospital
(inpatient)
Skilled Nursing Facility
Nothing
Professional services provided in:
Hospital outpatient department
Ambulatory surgical center
Office
$50 outpatient copayment per treatment or surgery including
necessary
supplies 23
23 Page
24 25
2002 Access+ 24 Section 5
( c)
Section 5( c). Services provided by a hospital or other
facility, and ambulance services
I
M P
O
R T
A
N T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage,
including with Medicare.
The amounts listed below are for the charges
billed by the facility (i. e., hospital or surgical center) or ambulance service
for your surgery or care. Any costs associated with the professional
charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).
I
M P
O
R T
A
N T
Benefit Description You pay
Inpatient hospital
Room and board,
such as:
semiprivate or intensive care accommodations
general
nursing care
meals and special diets when medically necessary
special duty nursing when medically necessary
private rooms when medically
necessary
NOTE: If you want a private room when it is not medically necessary, you pay
the
additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as:
Operating, recovery,
delivery room, newborn nursery, and other treatment rooms
Prescribed drugs
and medicines
Diagnostic laboratory tests and x-rays
Administration
of blood and blood products
Blood or blood plasma, if not donated or
replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including
nurse anesthetist services
Take-home items
Medical supplies,
appliances, medical equipment, and any covered items billed by a hospital for
use at home
Radiation therapy, chemotherapy, and renal dialysis
Nothing
Not covered:
Custodial care
Non-covered
facilities, such as nursing homes, convalescent care facilities, schools
Personal comfort items, such as telephone, television, barber
services, guest meals and beds
Private nursing care
All charges 24
24 Page 25 26
2002 Access+
25 Section 5 ( c)
Outpatient hospital or ambulatory surgical
center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, x-rays, and
pathology services
Administration of blood, blood plasma, and other
biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental procedures
when
necessitated by a non-dental physical impairment. We do not cover
dental procedures for non-accidental injury to natural teeth. See page 33.
$50 per treatment or surgery including necessary supplies
Not covered: blood and blood derivatives if replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
We provide benefits up to 100 days each calendar year when full
time skilled nursing
care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by your plan physician and
approved by us. Admissions to a sub-acute care
setting require prior approval and are limited to 100 days each calendar
year. All
necessary services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a plan physician
Nothing
Not covered: custodial care, rest cures, domiciliary or convalescent care
and comfort items such as a telephone and television. All charges after the 100
day annual maximum. All charges
Hospice care
Supportive and
palliative care for a terminally ill member is covered in the home or a hospice
facility. Care received in the home is limited to 100 visits per year. Care
received in a hospice facility provides for 100 days of service, applied
against the
Extended Care Day Limits, without copayment. Services include
inpatient and outpatient care, and family counseling; these services provided
under the direction of a
plan physician who certifies that the patient is in the terminal stages of
illness, with a life
expectancy of approximately six months or less.
Nothing in a hospice facility
$10 copayment per home physician visit
$5 copayment per visit of other health care providers
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when ordered
or authorized by a plan physician. Nothing 25
25
Page 26 27
2002
Access+ 26 Section 5 (d)
Section 5( d). Emergency services/
accidents
I M
P
O R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage,
including with Medicare.
I M
P
O R
T
A N
T
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or
could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are emergencies because, if not treated
promptly, they might become more serious; examples include deep cuts and broken
bones. Others are
emergencies because they are potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or
sudden inability to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area
If you are in an emergency situation, please call your primary care
physician. In extreme emergencies, if you are unable to
contact your
physician, contact the local emergency system (e. g., the 911 telephone system)
or go to the nearest hospital emergency room. Be sure to tell the emergency room
personnel that you are a plan member so they can notify us. You or a
family member should notify us. It is your responsibility to ensure that we
have been notified.
If you need to be hospitalized, we must be notified immediately following
your admission, unless it was not reasonably possible to notify us within that
time. If you are hospitalized in non-plan facilities and a plan physician
believes care can be
better provided in a plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-plan providers in a medical
emergency only if delay in reaching a plan provider would result in death,
disability or significant jeopardy to your condition. Any follow-up care
recommended by non-plan providers
must be approved by us or provided by plan
providers.
We pay reasonable charges for emergency services to the extent the services
would have been covered if received from plan providers. If the emergency
results in admission to a hospital, any applicable copayment is waived.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center
Emergency care as an
outpatient or inpatient at a hospital, including doctors' services
Note: If
the emergency results in admission to a hospital, the copayment is waived.
$50 per visit
Not covered: Elective care or non-emergency care All charges 26
26 Page 27 28
2002 Access+ 27 Section 5 (d)
Emergency outside our service area You pay
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, we must be notified immediately following
your admissions, unless it was not reasonably possible to notify us within that
time. If you are
hospitalized in non-plan facilities and a plan physician
believes care can be better
provided in a plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in full.
Reasonable charges for emergency care services to the extent the services
would have
been covered if received from plan providers.
Note: If the emergency results in admission to a hospital, the copayment is
waived.
Emergency care at a doctor's office $10 per visit
Emergency care at
an urgent care center
Emergency care as an outpatient or inpatient at a
hospital, including doctors' services
$50 per visit
Not covered: Elective care or non-emergency care All charges
Ambulance
Professional ambulance service when medically
appropriate. See 5( c) for non-emergency service. Nothing
Not covered: taxi, wheelchair van, other non-ambulance assisted
transportation All charges 27
27 Page 28 29
2002 Access+
28 Section 5 (e)
Section 5( e). Mental health and substance
abuse benefits
Network Benefit
I M
P O
R
T A
N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and
limitations for plan mental health and substance
abuse benefits will be no greater than for similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about these benefits:
Please remember that benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions
after the benefits description below.
I M
P O
R
T A
N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by plan providers and
contained in a treatment plan that we approve. The treatment plan may include
services, drugs, and
supplies described elsewhere in this brochure.
Note: Plan benefits are
payable only when we determine the care is clinically appropriate to treat your
condition and only when you receive the care as part of a treatment plan
that we approve.
Your cost sharing responsibilities are no greater
than for other illness
or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit
Diagnostic tests Nothing
Services provided by a hospital or other
facility
Services approved in alternative care settings such as partial
hospitalization, half-way
house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order us to pay or provide one
clinically appropriate treatment plan in favor of another.
All charges 28
28 Page 29 30
2002 Access+
29 Section 5 (e)
Mental health and substance abuse benefits
(continued)
Preauthorization To be eligible to receive
these benefits you must follow your treatment plan and all the following
authorization processes:
To obtain an authorization, call 877-263-8827. You should continue to
identify yourself as a Blue Shield member and use your Blue Shield
identification card and identification
numbers when contacting USBHPC or its
participating providers.
Your health care provider should contact USBHPC at 877-263-9870 to obtain
information about joining the USBHPC network, obtaining an authorization for
your
treatment, or to speak with a member of USBHPC's clinical staff about
issues related to
this benefit or your care.
If you would like a copy of a provider directory, you can contact the Blue
Shield Member Services Department at 800-334-5847.
Out-of-Network Benefit
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.
See page 28 for In-Network benefits.
Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also
read Section 9 about coordinating benefits with other
coverage, including with Medicare.
Benefit Description You pay
Out-of-Network mental health and substance
abuse benefits
Not covered out-of-network All charges 29
29 Page 30 31
2002 Access+ 30 Section 5 (f)
Section 5( f). Prescription drug benefits
I M
P O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
We have no calendar year deductible.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works..
I M
P O
R
T A
N
T
There are important features you should know about your prescription drug
benefit. These include:
Who can write your prescription? A
licensed physician, or other covered provider acting within the scope of their
license.
Where can you obtain your prescriptions? You must fill the
prescription at a retail plan pharmacy, or plan mail service pharmacy for a
maintenance medication.
Mail Service Drug Program. Prescriptions are available by mail for up
to a 90-day supply. Generic drugs will be dispensed in lieu of brand name drugs
when substitution is permissible by the physician. Call Member Services at
800-334-5847 to receive a
packet for ordering prescriptions through the
mail.
We use a formulary. Prescription drug coverage is based on the use of
the prescription drug formulary, a copy of which is available to you.
Non-formulary drugs are always covered at the non-formulary copayment, unless
excluded from prescription
drug benefit. Selected drugs and drug dosages,
require prior authorization for medical necessity. You should not become
directly involved with us for this pre-authorization process. Your physician
is responsible for obtaining prior authorization and documenting medical
necessity. If all necessary documentation is available from your physician,
prior authorization approval
or denial will be provided to your physician within two working days of the
request.
Medications are selected for inclusion in Blue Shield's Outpatient
Prescription Drug Formulary based on safety, efficacy, and FDA bio-equivalency
data. The Blue Shield Pharmacy and Therapeutics Committee reviews new drugs and
clinical data four
times a year.
Members may call Blue Shield Member Services at 800-334-5847 to find out if a
specific drug is included in the Formulary. New members receive a printed copy
of the formulary with their welcome kits. Formulary information is also
available on Blue
Shield's website at http:// www. mylifepath. com.
In lieu of brand name drugs, generic drugs will be dispensed when
substitution is permissible by the physician. If you request a brand name drug
when a generic drug is available, you pay the difference between the cost of the
brand name drug and its
equivalent generic drug, plus the appropriate
copayment.
Prescription Days Supply Covered: Present your Access+ ID card at the
participating pharmacy. A retail plan pharmacy may dispense up to a 30-day
supply for the appropriate copayment. You will pay the appropriate copayment per
prescription for
out-of-state emergencies. Maintenance drugs are available
for up to a 90-day supply at the appropriate copayment per
prescription
through the plan mail service pharmacy.
Why use generic drugs? Generic drugs offer a safe and economic way to
meet your prescription drug needs. The generic name of a drug is its chemical
name; the brand name is the name under which the manufacturer advertises and
sells a drug.
Under federal law, generic and brand name drugs must meet the
same standards for safety, purity, strength, and effectiveness. A generic
prescription costs you --and us --less than a brand name prescription. 30
30 Page 31 32
2002 Access+ 31 Section 5 (f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a plan
physician and
obtained from a retail plan pharmacy or through our mail
service pharmacy:
Diabetic supplies limited to disposable insulin syringes, needles, pen
delivery systems for the administration of insulin as determined by Blue Shield
to be medically necessary and
glucose testing tablets and strips
Smoking cessation medication
requiring a prescription (limited to one 12-week course of treatment per
calendar year)
Formulary and non-formulary drugs for sexual dysfunction or sexual
inadequacies will
be covered when the dysfunction is caused by medically
documented organic disease. Prior plan approval is required and the maximum
dosage dispensed will be limited by the
protocols established by us. Certain drugs for these conditions are not
available through
the Mail Service option.
Formulary and non-formulary drugs and medicines that by federal law of the
United States require a physician's prescription for their purchase, except as
excluded below.
Insulin
Disposable needles and syringes for the administration of
covered medications
Formulary and non-formulary oral contraceptive drugs
and diaphragms.
$5 per generic formulary retail
plan pharmacy prescription
$10 per brand name formulary retail plan pharmacy
prescription
$25
per non-formulary retail plan pharmacy prescription
$10 per generic formulary mail service prescription
$20 per brand name
formulary
mail service prescription
$50 per non-formulary mail service prescription
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 brand name. If your receive a brand name drug
when a federally-approved
generic drug is available and your physician has not specified "Dispense as
Written" for the brand name drug, you will pay the difference in the cost
between the
brand name drug and the generic plus the copayment.
Appropriate copayment plus the difference in price of brand
name and
generic drugs
Not covered:
Drugs available without a prescription or for
which there is a nonprescription equivalent available
Drugs obtained at a non-plan pharmacy except for out-of-area emergencies
Compounded medication with formulary alternatives or those with no
FDA approved indications
Medical supplies such as dressings and antiseptics
Drugs
for cosmetic purposes
Drugs to enhance athletic performance
Drugs for weight loss
Smoking cessation drugs without
a prescription or for which there is a nonprescription equivalent available
Vitamins and nutritional substances that can be purchased without a
prescription
Intravenous fluids and medications for home use and
some injectable drugs, such as
Depo Provera, are covered under Sections 5(
a) or 5( b) Medical or Surgical services, not the Prescription Drug Benefit.
Note: IUDs and Norplant dispensed by your physician are covered under
Section 5( b)
Surgical Services, not the Prescription Drug Benefit.
All Charges 31
31 Page 32 33
2002 Access+
32 Section 5 (g)
Section 5 (g). Special Features
Feature
Description
High risk pregnancies We cover the prenatal diagnosis of
genetic disorders of the fetus in high-risk pregnancy cases.
Self-referral to Specialty services Access+ allows you to arrange
office visits with plan specialists in the same Medical Group or IPA as your
primary care physician without a referral. A few physicians are
not Access+
providers. You are advised to refer to the Access+ 2002 Provider Directory
for Federal Employees to determine if your physician participates in the
Access+ self-referral option. Members who use this convenient feature are
subject to a $30 copayment per specialty office visit. If the medical condition
requires follow-up
care to the same specialist, you are encouraged to
request that the specialist receive
prior authorization from your primary
care physicians for additional visits at the regular office copayment of $10 per
visit.
The Access+ specialist includes:
Examinations and consultations;
Conventional x-rays of the chest and abdomen;
X-rays of bones to
diagnose suspected fractures;
Laboratory services;
Diagnostic or
treatment procedures that would normally be provided with a referral; and
Vaccines and antibiotics.
The Access+ specialist visit does not include:
Diagnostic
imaging such as CAT Scans, MRI or bone density measurements;
Services that
are not covered benefits or that are not medically necessary;
Services of
a provider not in the Access+ or USBHPC network (see section 5( e));
Allergy testing;
Endoscopic procedures;
Injectables, chemotherapy or
other infusion drugs (not listed above);
Infertility services;
Emergency services;
Urgent care services;
Inpatient services or
facility charges;
Services for which the Medical Group or IPA routinely
allows the Member to self-refer without authorization from the Personal
Physician;
OB/ GYN services by an obstetrician/ gynecologist or family practice
Physician within
the same Medical Group/ IPA as the Personal Physician; and
Internet based consultations. 32
32 Page 33 34
2002 Access+
33 Section 5 (h)
Section 5( h). Dental benefits
I
M P
O
R T
A
N T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan providers must provide or arrange your care.
We have no calendar
year deductible.
We cover hospitalization for dental procedures only when
a non-dental physical impairment
exists which makes hospitalization
necessary to safeguard the health of the patient; we do not cover the dental
procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how
cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
M P
O
R T
A
N T
Accidental injury benefit
Hospital and professional services
provided for conditions of the teeth, gums, or jaw joints and jawbones,
including adjacent tissues are a benefit only to the extent that they are
provided for the treatment of damage to natural teeth caused solely by an
accidental injury is covered by this plan. Prosthodontics, orthodontia, and
cosmetic services are not covered. This benefit
does not include damage to
the natural teeth that is not accidental; e. g., resulting from chewing or
biting
Dental benefits
We have no other FEHB dental benefits. Please
refer to page 34 for details about a comprehensive, non-FEHB optional Blue
Shield Dental Plan. 33
33 Page 34 35
2002 Access+
34 Section 5 (i)
Section 5( i). Non-FEHB benefits available to
Plan members
The benefits described on this page are neither offered nor
guaranteed under the contract with FEHB, but are made available to all enrollees
and family members who are members of this plan. The cost of the benefits
described on this page is not included in the
FEHB premium and any charges
for these services do not count toward any FEHB deductibles or out-of-pocket
maximums. These
benefits are not subject to the FEHB disputed claims
procedure.
Blue Shield Dental Option --Comprehensive and Affordable CAUTION: When
shopping for a dental plan, please carefully compare: (1) copayments, (2)
waiting periods and (3) dues.
Enroll in Access+ and pay dues directly to Blue Shield to join this DHMO
dental plan. Dues can be paid monthly or quarterly
(Dues are also shown on a
biweekly basis for your convenience in comparing costs.). Call 888-271-4929 for
a list of dentists, a summary of benefits and an enrollment form.
Biweekly Dues Monthly Dues Quarterly Dues Self only $8.14 $17.63
$52.89
Two party $15.69 $33.99 $101.97
Family $23.10 $50.05 $150.15
Care must be received from or arranged by a Blue Shield Dental Option
provider. Below are sample copayments:
Office visits $5 Fillings (per
surface) $15 Root canal (one canal) $125 Bitewing x-rays $0 Metal crowns (each)
$250 Full upper or lower denture $250
Prophylaxis $0 Single, routine extraction $20 Orthodontics (children only)
$1,800
Receive Discounts from Vision One Eyecare Program on Frames and
Lenses
Federal employees with Access+ coverage can enjoy savings of up
to 66.7% on frames and lenses through our Vision One
Eyecare Program at all
250 Cole Vision California locations. Cole Vision services are available in the
optical departments of many Sears, Montgomery Ward and JCPenney stores, at
Pearle Vision locations and at offices of participating private practice
doctors. There is no added premium for this money-saving feature. Simply
present your Access+ identification card when you pay for your eyewear and the
discounts are automatic.
For coverage of eye refractions see page 18.
Receive Discounts through
the mylifepath sm Alternative Health Services Discount Program -Acupuncture,
Massage & More
Access+ offers you participation in the mylifepath discount program, which
entitles you to discounts of 10%-25% off certain
health and wellness
services. When you see a participating practitioner or visit a facility in the
mylifepath alternative health services discount network, you'll experience
savings on acupuncture, chiropractic, massage therapy and somatic education,
fitness centers and athletic clubs, health spas, and wellness programs. You
will be responsible for all charges remaining after
the discounts are
applied. For more details on all features, please call 888-999-9452 or visit our
website at http:// www. mylifepath. com for health information and news about
value-added features.
Medical Care for Vacations, Business Travel and College Students
You, and your eligible family members are covered for urgent and
emergency care in all 50 states while you are on vacation or business travel.
There are no additional premiums for this coverage. "Guest membership" is also
available on a temporary
basis for members and dependents who will be living away from home and who
need a local primary care provider. You pay office copayments, which vary from
state to state ($ 5 to $25) for guest visits and $50 for urgent care visits. For
additional
information on these coverages, call 800-334-5487.
Blue
Shield 65 Plus, A Medicare+ Choice Prepaid Plan
This Plan offers
Medicare recipients the opportunity to enroll in the plan through Medicare. As
indicated on page 41,
annuitants and former spouses with FEHB coverage and
Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare
prepaid plan if one is available in their area. They may then later reenroll in
the FEHB Program. Most federal
annuitants have Medicare Part A. Those without Medicare Part A may join this
Medicare prepaid plan but will have to pay
for hospital coverage in certain
instances in addition to the Part B premium. Before you join the plan, ask
whether the plan covers hospital benefits and, if so, what you will have to pay.
Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at
888-713-0000 for information on the Medicare
prepaid plan and the cost of
that enrollment. Blue Shield 65 Plus is now available in Kern, Los Angeles,
Orange, Riverside, San Bernardino, San Diego, and Ventura counties.
Benefits on this page are not part of the FEHB Contract 34
34 Page 35 36
2002 Access+ 35 Section 6
Section
6. General exclusions --things we don't cover
The exclusions in this
section apply to all benefits. Although we may list a specific service as a
benefit, we will not cover it unless your plan physician determines it is
medically necessary to prevent, diagnose, or treat your illness, disease,
injury or condition.
We do not cover the following:
Care by
non-plan providers except for authorized referrals or emergencies (see Emergency
Benefits);
Services, drugs, or supplies you receive while you are not
enrolled in this plan;
Services, drugs, or supplies that are not medically
necessary;
Services, drugs, or supplies not required according to accepted
standards of medical, dental, or mental health practice;
Experimental or
investigational procedures, treatments, drugs or devices;
Services, drugs,
or supplies related to abortions, except when the life of the mother would be
endangered if the fetus were carried to term or when the pregnancy is the result
of an act of rape or incest;
Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program;
Services, drugs or supplies related to sexual
dysfunction or sexual inadequacies (including penile prostheses) except as
provided for medically documented treatment of organically based conditions; or
Services performed by a close relative (the spouse, child, brother, sister,
or parent of a member) or a person who ordinarily resides in the member's home.
35
35 Page 36 37
2002 Access+ 36 Section 7
Section
7. Filing a claim for covered services
When you see plan physicians,
receive services at plan hospitals and facilities, or obtain your prescription
drugs at plan pharmacies, you will not have to file claims except for your
annual eye examination. Just present your identification card and
pay your
copayment or coinsurance.
You will also 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 CMS-1500,
Health Insurance Claim Form. Facilities will file on the UB-92
form. For
claims questions and assistance, call us at 800-334-5847.
When you must file a claim --such as for out-of-area care --submit it on the
CMS-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:
Blue Shield of California
Access+ Member Services P. O. Box 272550
Chico, CA 95927
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you received the service,
unless timely filing was prevented
by administrative operations of government or
legal incapacity, provided the
claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 36
36 Page
37 38
2002 Access+ 37 Section 8
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on your claim or request for services, drugs, or supplies –
including a request for preauthorization:
Step Description
1 You
may appeal by either calling or writing the Member Services Department
requesting Blue Shield of California to reconsider our initial decision. You
must:
a) Write or call us within 6 months from the date of our decision; b) Send
your written request to us at: Blue Shield of California, Appeals &
Grievance Department, P. O. Box 92945,
Los Angeles, CA 90009-2945. You may
call our member service department at 800-334-5847 and request a
Grievance
Form. We will mail or fax the form to you. c) Include a statement about why you
believe our initial decision was wrong, based on specific benefit provisions in
this
brochure; and
d) Include copies of documents that support your claim,
such as physicians' letters, operative reports, bills, medical records, and
explanation of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
b) Write to you and maintain our denial --go to step 4; or c) Ask
you or your provider for more information. If we ask your provider, we will send
you a copy of our request— go
to step 3.
3 You or your provider
must send the information so that we receive it within 60 days of our request.
We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with
our decision, you may ask OPM to review it. You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request
in some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division II, 1900 E
Street, NW, Washington, DC
20415-3620
Send OPM the following information:
A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note:
If you want OPM to review different claims, you must clearly
identify which documents apply to which claim.
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.
The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond
your control.
(continued on next page) 37
37 Page 38 39
2002 Access+
38 Section 8
5 OPM will review your disputed claim request
and will use the information it collects from you and us to decide whether our
decision is correct. OPM will send you a final decision within 60 days. There
are no other administrative
appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in federal court
by December 31 of the third year after the year in which you received the
disputed
services, drugs or supplies or from the year in which you were
denied precertification or prior approval. This is the only deadline that may
not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims
process. Further, federal law governs your lawsuit,
benefits, and payment of
benefits. The federal court will base its review on the record that was before
OPM when OPM decided to uphold or overturn our decision. You may recover only
the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that may cause
permanent loss of bodily functions or death if
not treated as soon as
possible), and
a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at 800-334-5847 and we will
expedite our review; or
b) We denied your initial request for care or preauthorization/ prior
approval, then:
-If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment too, or
-You can call OPM's Health Benefits Contracts Division II at 202-606-3818
between 8 a. m. and 5 p. m. Eastern Standard Time. 38
38 Page 39 40
2002 Access+ 39 Section 9
Section
9. Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full
as the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary according
to the National Association of Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up to our regular
benefit. We will not pay more than our allowance.
The coordination of
benefits provision does not apply to the Prescription Drug Benefit
What is Medicare? Medicare is a Health Insurance Program for:
–
People 65 years of age and older.
– Some people with disabilities, under 65
years of age.
– People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
– Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free Part A
insurance. (Someone who was a federal employee on January 1, 1983 or since
automatically qualifies.) Otherwise, if you are age 65 or older, you may
be able to buy it. Contact 1-800-MEDICARE for more information.
– Part B
(Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or
your retirement check.
If you are eligible for Medicare, you may have
choices in how you get your health care. Medicare+ Choice is the term used to
describe the various health
plan choices available to Medicare beneficiaries. The information in the next
few
pages shows how we coordinate benefits with Medicare, depending on the
type of Medicare managed care plan you have.
The Original Medicare
Plan The original Medicare plan (Original
Medicare) is available everywhere in the United States. It is the way everyone
used to get Medicare benefits and is the
way most people get their Medicare Part A and Part B benefits now. You may go
to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare plan pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this plan, you still
need
to follow the rules in this brochure for us to cover your care. Your
care must continue to be authorized by your plan primary care physician.
We will not waive any of our copayments or coinsurances.
(Primary
payer chart begins on next page.) 39
39 Page 40 41
2002 Access+
40 Section 9
The following chart illustrates whether the Original
Medicare or this plan should be the primary payer for you according to
your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered family member has Medicare coverage so we can
administer these requirements correctly.
Primary Payer Chart
A. When either you --or your covered spouse --are
age 65 or over and … Then the primary payer is…
Original Medicare This Plan
1) Are an active employee with the federal government (including when
you or a
family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a re-employed annuitant with the federal
government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you).
4) Are a federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your covered
spouse is this type
of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services)
(for other services)
6) Are a former federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are unable to
return to
duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely
because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to
ESRD after Medicare became primary for you
under another provision,
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant,
or
d) Are a former spouse of an active employee 40
40 Page 41 42
2002 Access+ 41 Section 9
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your
Medicare benefits from another type of
Medicare+ Choice plan --a Medicare managed care plan. These are health care
choices (like HMOs) in some areas of
the country. In most Medicare managed 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+ Choice 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.
Suspended FEHB coverage and a Medicare+ Choice 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.) Medicare 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
Medicare Part A or Part B If you do not have one or both Parts of Medicare,
you can still be covered under
the FEHB Program. We will nor require you to
enroll in Medicare Part B and, if you can't get premium free Part A, we will not
ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both
TRICARE and this plan cover you, we pay first. See your
TRICARE Health
Benefits Advisor if you have questions about TRICARE
coverage.
Workers' Compensation We do not cover services that:
You need
because of a workplace-related illness or injury that the Office of
Workers'
Compensation Programs (OWCP) or a similar federal or state agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or
other similar proceeding that is based on a claim you filed under OWCP or
similar laws.
Once OWCP or a similar agency pays its maximum benefits for your treatment,
we will cover your care. You must use our providers.
Medicaid When you have this plan and Medicaid, we pay first.
When other Government agencies are responsible for your
care
We do not cover services and supplies when a local, state, or federal
government
agency directly or indirectly pays for them
When others are responsible for injuries When you receive money to
compensate you for medical or hospital care for injuries or illness caused by
another person, you must reimburse us for any
expenses we paid. However, we
will cover the cost of treatment that exceeds the
amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us at 530-666-2238 for our
subrogation procedures. 41
41 Page 42 43
2002 Access+
42 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.
Copayment A
copayment is a fixed amount of money you pay when you receive covered services.
See page 12.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care.
Covered services Care we provide benefits
for, as described in this brochure.
Experimental or investigational
services Access+ covers drugs, devices that are medically indicated and
biological products no longer considers to be investigational by the Food and
Drug
Administration. Coverage for other procedures are reviewed by and
decided by the Blue Shield of California Medical Policy Committee. The primary
criteria
are that the proposed new procedures are safe and effective.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. These are negotiated lower
provider rates and
savings are passed on to you.
Us/ We Us and we refer to Blue
Shield of California Access+ or USBHPC for mental health and substance abuse
coverage.
You You refers to the enrollee and each covered family member. 42
42 Page 43 44
2002 Access+ 43 Section 11
Section 11. FEHB facts
No pre-existing condition limitation
We will not refuse to cover the treatment of a condition that you had before
you enrolled in this plan solely because you had the condition before you
enrolled.
Where you can get information about enrolling in the FEHB
Program
See www. opm. gov/ insure. Also, your employing or
retirement office can answer your questions, and give you a Guide to Federal
Employees Health
Benefits Plans, brochures for other plans, and other
materials you need to make
an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.
Types of coverage available for you and your family
Self-Only coverage is for you alone. Self and Family coverage is for you,
your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren for which your employing or retirement office
authorizes coverage. Under certain circumstances, you may also continue
coverage for a disabled child 22 years of age or older who is incapable of
self-support.
If you have a Self-Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is
born or becomes an eligible family member. When you change to Self
and
Family because you marry, the change is effective on the first day of
the pay period that begins after your employing office receives your enrollment
form;
benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member
is no longer eligible to receive health benefits, nor will we. Please tell us
immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person
may not be enrolled in or covered as a family member by another FEHB
plan.
When benefits and premiums start The benefits in this brochure are
effective on January 1. If you joined 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' coverage and premiums
begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage. 43
43 Page 44 45
2002 Access+ 44 Section 11
Your
medical and claims records are confidential We will keep your medical and
claims information confidential. Only 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).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium,
when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
Spouse equity coverage If you are divorced from a federal employee
or annuitant, you may not continue
to get benefits under your former
spouse's enrollment. But, you may be
eligible for your own FEHB coverage
under the spouse equity law. If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's
employing or retirement office to get RI 70-5, the Guide to Federal
Employees
Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees, or other information about your coverage choices.
Temporary Continuation
of Coverage (TCC) If you leave federal
service, or if you lose coverage because you no longer qualify as a family
member, you may be eligible for Temporary Continuation
of Coverage (TCC). For example, you can receive TCC if you are not able to
continue your FEHB enrollment after you retire, if you lose your job, if you are
a covered dependent child and you turn 22 or marry, etc.
You may not
elect TCC if you are fired from your federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, from your
employing
or retirement office or from www. opm. gov/ insure. It explains
what you have to do to enroll. 44
44 Page 45 46
2002 Access+
45 Section 11
Converting to individual coverage You may
convert to a non-FEHB individual policy if:
-Your coverage under TCC or the
spouse equity law ends (If you canceled your coverage or did not pay your
premium, you cannot convert);
-You decided not to receive coverage under TCC or the spouse equity law;
or
-You are not eligible for coverage under TCC or the spouse equity law.
If you leave federal service, your employing office will notify you of your
right
to convert. You must apply in writing to us within 31 days after you
receive this notice. However, if you are a family member who is losing coverage,
the
employing or retirement office will not notify you. You must apply in writing
to us within 31 days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we will
not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal law
that offers limited federal protections for health coverage
availability and
continuity to people who lose employer group coverage. If you leave the FEHB
Program, we will give you a Certificate of Group Health Plan
Coverage that
indicates how long you have been enrolled with us. You can use this certificate
when getting health insurance or other health care coverage.
Your new plan
must reduce or eliminate waiting periods, limitations, or
exclusions for
health related conditions based on the information in the certificate, as long
as you enroll within 63 days of losing coverage under this
plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation
of Coverage (TCC) under the FEHB Program. See also the FEHB web site (www.
opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked
question. These highlight HIPAA rules, such as the requirement that federal
employees must exhaust any TCC eligibility as one condition for guaranteed
access to individual health coverage under HIPAA, and have information about
federal and state agencies you can contact for more information. 45
45 Page 46 47
2002 Access+ 46 Long Term Care Insurance is
Coming Later in 2002
Long Term Care Insurance Is Coming Later in
2002!
Many FEHB enrollees think that their health plan and/ or
Medicare will cover their long-term care needs.
Unfortunately, they are
WRONG!
How are YOU planning to pay for the future custodial or
chronic care you may need?
You should consider buying long-term care
insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is
long term care
(LTC) insurance? It's insurance to help pay for long
term care services you may need if you can't take care of yourself because of an
extended illness or injury, or an age-related
disease such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care,
care
in an assisted living facility, care in your home, adult day care,
hospice care, and more. LTC can supplement care provided by family members,
reducing the
burden you place on them.
I'm healthy. I won't need long term
care. Or, will I? Welcome to the club!
76% of Americans believe they will never need long term care, but the facts
are that about half of them will. And it's not just the old folks. About 40% of
people needing long term care are under age 65. They may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital
to
their financial and retirement planning.
Is long term care
expensive? Yes, it can be very expensive. A year in a nursing home can
exceed $50,000.
Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And
that's before inflation!
Long term care can easily exhaust your savings. Long term care insurance
can protect your savings.
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?
Not