Enrollment codes for this Plan:
2G1 Self Only
2 G2 Self and Family
This Plan had commendable accreditation for
its commercial products from
NCQA as
CapitalCare. CapitalCare will undergo a
resurvey as part of the
consolidated entity in
December, 2001. See the 2002 guide for
more
information on accreditation.
For changes
in benefits
see page 8.
A Health Maintenance Organization
CareFirst BlueChoice, Inc. Formerly
known as CapitalCare, Inc.
http:// www. carefirst. com
RI 73-718 1
1 Page
2 3
2002 CareFirst BlueChoice, Inc.
2 Table of Contents
Table of Contents
Introduction
........................................................................................................................................................................................................
4
Plain
Language......................................................................................................................................................................................................
4
Inspector General
Advisory...................................................................................................................................................................................
4
Section 1. Facts about this HMO plan
..................................................................................................................................................................
6
How we pay
providers........................................................................................................................................................................
6
Who provides my health
care?............................................................................................................................................................
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
..............................................................................................................................................................................
10
Circumstances beyond our
control....................................................................................................................................................
10
Services requiring our prior approval
...............................................................................................................................................
11
Section 4. Your costs for covered services……
............................... …………………………………………………………………………… 12
Copayments
...............................................................................................................................................................................
12
Deductible..................................................................................................................................................................................
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................................................ 25
(c)
Services provided by a hospital or other facility, and ambulance
services.............................................................................
29
(d) Emergency services/ accidents
...............................................................................................................................................
32
(e) Mental health and substance abuse
benefits...........................................................................................................................
35
(f) Prescription drug
benefits......................................................................................................................................................
37
(g) Special features
.....................................................................................................................................................................
39
Flexible benefits option
24 Hour Nurse Line 2
2 Page 3 4
2002 CareFirst BlueChoice, Inc. 3 Table of
Contents
(h) Dental benefits
......................................................................................................................................................................
40
(i) Non-FEHB benefits available to Plan
members.....................................................................................................................
41
Section 6. General exclusions --things we don't
cover......................................................................................................................................
42
Section 7. Filing a claim for covered services
....................................................................................................................................................
43
Section 8. The disputed claims process
..............................................................................................................................................................
44
Section 9. Coordinating benefits with other
coverage.........................................................................................................................................
46
When you have…
Other health coverage
...............................................................................................................................................................
46
Original Medicare
.....................................................................................................................................................................
46
Medicare managed care
plan.....................................................................................................................................................
48
TRICARE/ Workers' Compensation/ Medicaid
.................................................................................................................................
48
Other Government
agencies.............................................................................................................................................................
49
When others are responsible for
injuries..........................................................................................................................................
49
Section 10. Definitions of terms we use in this brochure
....................................................................................................................................
50
Section 11. FEHB facts
......................................................................................................................................................................................
51
Coverage information
...................................................................................................................................................................
51
No pre-existing condition
limitation.......................................................................................................................................
51
Where you get information about enrolling in the FEHB
Program.........................................................................................
51
Types of coverage available for you and your
family.............................................................................................................
51
When benefits and premiums start
.........................................................................................................................................
51
Your medical and claims records are confidential
..................................................................................................................
51
When you
retire.....................................................................................................................................................................
52
When you lose
benefits..................................................................................................................................................................
52
When FEHB coverage ends
....................................................................................................................................................
52
Spouse equity
coverage..........................................................................................................................................................
52
Temporary Continuation of Coverage
(TCC).........................................................................................................................
52
Converting to individual
coverage..........................................................................................................................................
52
Getting a Certificate of Group Health Plan
Coverage.............................................................................................................
53
Long term care insurance is coming later in 2002
...............................................................................................................................................
54
Index………..
.....................................................................................................................................................................................................
55
Summary of benefits
...........................................................................................................................................................................................
59
Rates
.....................................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 CareFirst BlueChoice, Inc.
4 Introduction/ PlainLanguage/ Advisory
Introduction
CareFirst BlueChoice, Inc.
550 12 th Street S. W.
Washington D.
C. 20065
This brochure describes the benefits of CareFirst BlueChoice, Inc. under our
contract (CS 2797) with the Office of Personnel Management
(OPM), as
authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement
can modify or otherwise
affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage,
each
eligible family member is also entitled to these benefits. You do not have a
right to benefits that were available before January 1, 2002,
unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and changes are summarized on
page 8. Rates
are shown at the end of this brochure.
CareFirst BlueChoice, Inc. is an independent licensee of the Blue Cross and
Blue Shield Association. . Registered trademark of the Blue Cross and
Blue
Shield Association. . 'Registered trademark of CareFirst of Maryland, Inc.
Plain Language
Teams of Government and health plan's 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. "You" means the
enrollee or family member; "we" means CareFirst Blue
Choice, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel
Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you compare plans.
If you have comments or
suggestions about how to improve the structure of this brochure, let OPM know.
Visit OPM's "Rate Us" feedback
area at www. opm. gov/ insure or e-mail OPM
at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel
Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650.
Inspector General Advisory
Fraud increases the cost of health care
for everyone. If you suspect that a physician,
pharmacy, or hospital has
charged you for services you did not receive, billed you twice
for the same
service, or misrepresented any information, do the following:
Stop health care fraud! 4
4 Page 5 6
2002 CareFirst
BlueChoice, Inc. 5 Introduction/ PlainLanguage/ Advisory
Call
the provider and ask for an explanation. There may be an error.
If the
provider does not resolve the matter, call us at 866/ 520-6099 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 CareFirst
BlueChoice, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that contract
with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment
for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments,
coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to
submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change
plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or other provider will be available
and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a
negotiated payment from us, and you will only be
responsible for your copayments.
Who provides my health care?
Since we are an Individual Practice
Association (IPA) model HMO, you receive care from a network of physicians who
practice in their
private offices. In addition, our plan has designated
facilities for diagnostic radiology and laboratory services. As a member, you
may
choose your own primary care doctor from our Provider Directory.
If you think you need mental health and substance abuse treatment, you should
first contact our vendor Magellan Behavioral Health (or other
vendor we
determine) at 800/ 245-7013. If you need treatment, Magellan will refer you to
one of their network providers. Magellan, not your
primary care doctor, must
coordinate all your mental health and substance abuse services.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may get information about us, our
networks,
providers, and facilities. OPM's FEHB website (www. opm. gov/
insure) lists the specific types of information that we must make available to
you. Some of the required information is listed below.
We are in compliance with Federal and State licensing and certification
requirements
We have been in existence since 1984
We are a for
profit corporation
If you want more information about us, call 866/ 520-6099, 410/ 356-4602, or
write to CareFirst Blue Choice, Inc., P. O. Box 644, Owings
Mills, MD
21117-9998. You may also contact us by fax at 202/ 479-1300 or 410/ 998-5809 or
visit our website at www. carefirst. com. 6
6
Page 7 8
2002
CareFirst BlueChoice, Inc. 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: The District of Columbia, Maryland (entire State), and
the Virginia counties of Arlington, Fairfax, Fauquier, Lounden,
Prince
William, Spotsylvania, and Stafford, plus the cities of Alexandria, Falls Church
and Fredericksburg.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will pay only for
emergency
care benefits. We will not pay for any other health care services out of our
service area unless the services have prior plan
approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the area
(for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has
agreements with
affiliates in other areas. If you or a family member move, you do not have to
wait until Open Season to change plans.
Contact your employing or retirement
office. 7
7 Page 8
9
2002 CareFirst BlueChoice, Inc. 8 Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5 Benefits. Also,
we edited and clarified language throughout the
brochure; any language change not shown here is a clarification that does not
change
benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will
decrease by 1.6% for Self Only or 7.9% for Self and Family.
We added a new
Section after Section 11 to discuss the Long Term Care Insurance Program that is
coming in 2002
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 increased speech therapy benefits by
removing the requirement that services must be required to restore functional
speech. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
You now
pay a $10 generic drug copay, $20 copay for prescriptions on the Plan's
formulary brand name list, and a $35 copay for all other prescriptions. (Section
5( f))
For mail order prescriptions, you now pay a $20 copay for generic drugs,
$40 copay for drugs on the Plan's formulary brand name list, and $70 copay for
all other prescription drugs for a 90 day supply. (Section 5( f))
We now
provide durable medical benefits (DME) benefits. (Section 5( a))
We now
offer a benefit for chiropractic care. (Section 5( a)) 8
8 Page 9 10
2002 CareFirst BlueChoice Inc. 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 866/ 520-6099
or 410/ 356-4602.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
Plan providers Plan providers are physicians and other health
care professionals in our service area that we
contract with to provide
covered services to our members. We credential Plan providers
according to
national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also
on our website.
Plan facilities Plan facilities are hospitals and other
facilities in our service area that we contract with to
provide covered
services to our members. We list these in the provider directory, which we
update periodically. The list is also on our website.
What you must do It depends on the type of care you need. First, you
and each family member must choose a
to get covered care primary care
physician. This decision is important since your primary care physician provides
or arranges for most of your health care. Each member may choose his or her own
primary
care doctor from our Provider Directory.
Primary care Your primary care physician can be a family
practitioner, general practitioner, internist, or pediatrician. Your primary
care physician will provide most of your health care, or give you a
referral
to see a specialist.
If you want to change primary care physicians or if
your primary care physician leaves the
Plan, call us. We will help you
select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive
a referral from your primary
care physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain
number
of visits without additional referrals. The primary care physician must provide
or
authorize all follow-up care. Do not go to the specialist for return
visits unless your
primary care physician gives you a referral. However, you
may see your Plan
gynecologist for a routine visit without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will work with the Plan to develop a
treatment plan
that allows you to see your specialist for a certain number
of visits without additional
referrals. Your primary care physician will use
our criteria when creating your treatment
plan (the physician may have to
get an authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care
physician. Your primary care physician will decide what
treatment you need. If he or she
decides to refer you to a specialist, ask
if you can see your current specialist. If your
current specialist does not
participate with us, you must receive treatment from a specialist
who does.
Generally, we will not pay for you to see a specialist who does not participate
with our Plan. 9
9 Page
10 11
2002 CareFirst BlueChoice Inc.
10 Section 3
If you are seeing a specialist and your specialist
leaves the Plan, call your primary care
physician, who will arrange for you
to see another specialist. You may receive services
from your current
specialist until we can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program and you
enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to your specialist
based on the above circumstances, you can continue to see
your specialist until the end of
your postpartum care, even if it is beyond
the 90 days.
Hospital care Your Plan primary care physician or specialist
will make necessary hospital arrangements and
supervise your care. This
includes admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service
department immediately at 866/ 520-6099 or 410/ 356-4602.
If you are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay
until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd
day after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all reasonable
efforts to provide you with the necessary care. 10
10 Page 11 12
2002 CareFirst BlueChoice Inc. 11 Section 3
Services requiring our
prior approval Your primary care
physician has authority to refer you for most services. For certain services,
however, your physician must obtain approval from us. Before giving approval, we
consider
if the service is covered, medically necessary, and follows generally
accepted medical
practice.
We call this review and approval process pre-authorization. Your physician
must obtain pre-authorization
for the following services such as:
Inpatient services
Outpatient services
Hospice care
Skilled nursing facility
Home health care
Intravenous (IV)/ Infusion
Therapy -Home IV and antibiotic therapy
Growth Hormone Therapy
Dialysis in a hospital setting
Your primary care physician will contact us for pre-authorization or an
extension of a pre-authorized
service. Your services may be denied if
pre-authorization is not obtained. 11
11 Page 12 13
2002 CareFirst
BlueChoice, Inc. 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.
Deductible We do not have a deductible
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 25% of our
allowance for durable medical equipment.
Your catastrophic protection
out-of-pocket maximum for
copayments
After your copayments total $1,900 per person or $5,500 per family
enrollment in any calendar year, you do not have to pay any more for covered
services. However, copayments
for the following services do not count toward your out-of-pocket maximum,
and you must
continue to pay copayments for these services:
Prescription drugs
Durable Medical Equipment (DME)
Be
sure to keep accurate records of your copayments since you are responsible for
informing
us when you reach the maximum. 12
12
Page 13 14
2002
CareFirst BlueChoice, Inc. 13 Section 5
Section 5. Benefits –
OVERVIEW
(See page 8 for how our benefits changed this year and
page 59 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain claims forms,
claims filing
advice, or more information about our benefits, contact us at 866/ 520-6099
or 410/ 356-4602 or at our website at
www. carefirst. com.
(a) Medical services and supplies provided by physicians and other health
care professionals.................................................. 14-24
Diagnostic and treatment services
Lab, X-ray, and other diagnostic
tests
Preventive care, adult
Preventive care, children
Maternity
care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and Occupational therapies
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals .............................................. 25-28
Surgical procedures
Reconstructive surgery
Oral and maxillofacial
surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services............................................................................
29-31
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility
benefits
Hospice care
Ambulance
(d) Emergency services/
accidents..............................................................................................................................................
32-34
Medical Emergency Ambulance
(e) Mental health and substance abuse benefits
.........................................................................................................................
35-36
(f) Prescription drug benefits
.....................................................................................................................................................
37-38
(g) Special
features.........................................................................................................................................................................
39
Flexible benefits option
24 hour nurse line
(h) Dental
benefits............................................................................................................................................................................
40
(i) Non-FEHB benefits available to Plan
members...........................................................................................................................
41
Summary of benefits
........................................................................................................................................................................
59 13
13 Page 14
15
2002 CareFirst BlueChoice, Inc. 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
In physician's office
$10 per office visit
Professional services of physicians
In a Plan urgent care center
Office medical consultation
Second surgical opinion
At home
$10 per office visit
During a hospital stay
In a skilled nursing facility Nothing
Diagnostic and treatment services --Continued on next page 14
14 Page 15 16
2002 CareFirst BlueChoice, Inc. 15 Section
5( a)
Diagnostic and treatment services (Continued) You
pay
Not covered:
Tests and/ or services not medically
necessary; or experimental
Test required for marriage; employment;
foreign travel; or government
licensing
All charges
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing, if these services are
rendered at an approved radiological
provider or approved laboratory.
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – annually
Colorectal Cancer Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening – every five years
starting at age 50
Nothing, if these services are
rendered at an approved laboratory.
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Nothing, if these services are rendered at an approved laboratory.
Routine
pap test
Note: The office visit is covered at a $10 copay if pap test is
received on
the same day
Nothing, if these services are
rendered at an approved laboratory.
Preventive Care, Adult— Continued on next page 15
15 Page 16 17
2002 CareFirst BlueChoice, Inc. 16 Section
5( a)
Preventive care, adult (Continued) You pay
Routine mammogram –covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
Nothing, if these services are
rendered at an approved radiology
provider.
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing if you receive these
services through a well child visit or
a
complete physical. Otherwise, $10
per office visit.
Not covered: Immunizations for the purpose of school, work, or travel All
charges
Preventive care, children
Childhood immunizations recommended by the American Academy of
Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care
(through age 22)
Examinations, such as:
-Eye exams through age 17 to
determine the need for vision correction.
-Ear exams through age 17 to determine the need for hearing correction
-Examinations done on the day of immunizations (through age 22)
$10 per visit at participating vision
centers or $25 per visit at
participating opthalmologists with a
referral
$10 per office visit 16
16 Page 17 18
2002 CareFirst
BlueChoice, Inc. 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in
mind:
You do not need to precertify your normal delivery; see page 10 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and
96 hours after a cesarean delivery. We will extend your inpatient
stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
$10 per visit ($ 100 copay maximum
per pregnancy)
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, including:
Voluntary sterilization
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 office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling
All charges 17
17 Page 18 19
2002 CareFirst
BlueChoice, Inc. 18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
-intravaginal insemination (IVI)
-intracervical insemination
(ICI)
-intrauterine insemination (IUI)
Fertility drugs
Note: We cover oral fertility drugs under the prescription drug benefit.
$10 per visit
Not covered:
Assisted reproductive technology (ART)
procedures, such as:
-In vitro fertilization
-embryo transfer, gamete GIFT, and
zygote ZIFT
-Zygote transfer
Services and supplies
related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
All charges
Allergy care
Testing and treatment
Allergy injection
$25
per testing series
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges 18
18 Page 19 20
2002 CareFirst BlueChoice, Inc. 19 Section
5( a)
Treatment therapies You pay
Chemotherapy and
radiation therapy
Note: High dose chemotherapy in association with
autologous bone marrow
transplants are limited to those transplants listed
under Organ/ Tissue
Transplants on page 28.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone
is covered under the prescription drug benefit.
Note: – We will only cover GHT when we preauthorize the treatment.
Call
Advance Secure at 800/ 294-5979 for preauthorization. We will ask
you to
submit information that establishes that the GHT is medically
necessary. Ask
us to authorize GHT before you begin treatment;
otherwise, we will only
cover GHT services from the date you submit the
information. If you do not
ask or if we determine GHT is not medically
necessary, we will not cover the
GHT or related services and supplies. See
Services requiring our prior
approval in Section 3.
$10 per office visit
Not covered:
Experimental or investigative services
Services that are not medically necessary
All charges 19
19 Page 20 21
2002 CareFirst
BlueChoice, Inc. 20 Section 5( a)
Physical and occupational
therapies You pay
Up to two consecutive months per condition for the
services of each of the following if significant improvement can be expected
within 90
days:
-qualified physical therapists and
-occupational therapists
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.
Note: Occupational therapy is limited to services which assist the
member
to achieve and maintain self-care and improved functioning in
other
activities of daily living.
$10 per office visit
$10 per outpatient visit
Nothing during covered
inpatient
admission
Not covered:
Long-term rehabilitative therapy
Exercise program
Cardiac rehabilitation
Chiropractic services
All charges
Speech therapy
Benefits limited to:
Up to two consecutive
months per condition
$10 per office visit
Nothing during covered inpatient
admission
Hearing services (testing, treatment, and supplies)
Hearing
testing for children through age 17 (see Preventive care, children)
Note: Adult hearing tests are covered only if referred by a PCP.
$10 per
office visit
Not covered:
All other hearing testing
Hearing
aids, testing and examinations for them
All charges 20
20 Page 21 22
2002 CareFirst
BlueChoice, Inc. 21 Section 5( a)
Vision services (testing,
treatment, and supplies) You pay
One pair of eyeglasses or contact
lenses to correct an impairment directly related to intraocular surgery (such as
for cataracts) $10 per office visit
Eye exam (exam by ophthalmologist requires a referral) to determine the
need for vision correction for children and adults (see preventive care) $10 per
visit at participating vision centers or $25 per visit at participating
opthalmologists
Daily wear contact lens exam and fittings $48 per visit and three follow-up
fittings
Disposable contact lens exam, fitting and one year follow-up $78 per visit
(includes fitting and follow-up)
Not covered:
Eyeglasses or
contact lenses
Eye exercises and orthoptics
Radial
keratotomy and other refractive surgery
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic or
peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot, except
as stated above
Treatment of weak, strained or flat feet or
bunions or spurs; and of any instability, imbalance or subluxation of the foot
(unless the treatment is
by open cutting surgery)
All charges 21
21 Page 22 23
2002 CareFirst
BlueChoice, Inc. 22 Section 5( a)
Orthopedic and prosthetic
devices You pay
Externally worn breast prostheses and surgical bras,
including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: See 5( b) for coverage of the surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
$10 per visit
Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel
cups
Lumbosacral supports
Corsets, trusses, elastic
stockings, support hose, and other supportive devices
Prosthetic devices, such as artificial limbs and lenses following
cataract removal
Prosthetic replacements provided less than 3 years
after the last one we covered
All charges
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of
durable medical equipment prescribed by
your Plan physician, such as
oxygen equipment up to $7,500 per calendar
year. Under this benefit, we
also cover:
Hospital beds;
Wheelchairs;
Crutches;
Walkers;
Canes;
Commodes;
Suction machines;
Medical supplies (i. e.
ostomy and catheter supplies, dialysis supplies, medical foods for inherited
metabolic diseases and inborn deficiencies
of amino acid metabolism)
25% coinsurance up to Plan $7500
benefit maximum is met and all
charges over that amount.
Durable medical equipment continued on next page 22
22 Page 23 24
2002 CareFirst BlueChoice, Inc. 23 Section
5( a)
Durable medical equipment (DME) (Continued) You pay
Not covered:
Hearing aids, eye glasses, contact lenses
Environment control products
Medical equipment of an
expendable nature (i. e. ace bandages, incontinent pads)
Replacement of DME equipment not due to normal wear and tear
Comfort and convenience items
Exercise equipment
Equipment that can be used for non-medical purposes
All charges
Home health services
Home health care ordered by a Plan
physician and provided by a registered nurse (R. N.), licensed practical nurse
(L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
Nursing care requested by, or for the
convenience of, the patient or the patient's family;
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.
All charges
Chiropractic
Chiropractic services, limited to spinal
manipulation evaluation and treatment, up to a maximum of 20 visits per calendar
year when
provided by a chiropractor who is a Plan Provider.
$10 per
office visit
Not covered
Services other than for musculoskeletal
conditions of the spine. All charges 23
23
Page 24 25
2002
CareFirst BlueChoice, Inc. 24 Section 5( a)
Alternative
treatments You Pay
No benefit All charges
Diabetic services
Coverage is limited to:
Diabetes equipment
and supplies
Diabetes self-management training and educational services
and nutrition therapy.
Note: Self-management training and educational services must be
supervised by an appropriately licensed, registered, or certified health
care
provider whose scope of practice includes diabetes education and
management.
Note: Certain diabetes supplies are covered under the prescription benefit
and subject to prescription copays.
Note: Certain diabetes supplies such as insulin pumps and glucometers are
covered under the medical coverage and you will need to file a claim with us
for reimbursement.
$10 copay
Not covered: Services related to the treatment of diabetes other than
types I and
II. All charges
Educational classes and programs
Coverage is limited to:
Diabetes self-management (Sponsored by the Plan's Health Education
Department)
Smoking cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as drugs.
Nothing 24
24 Page 25 26
2002 CareFirst BlueChoice, Inc. 25 Section
5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other
health care professionals
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no
calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which
services require precertification
and identify which surgeries require
precertification.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative
care by the surgeon
Correction of amblyopia and strabismus
Endoscopy
procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity – a condition in which an individual
weighs 100 pounds or 100% over his or her normal weight
according to current underwriting standards; eligible members must
be age
18 or over
Insertion of internal prostethic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
$10 per office or outpatient visits;
nothing for inpatient visits
Surgical procedures continued on next page. 25
25 Page 26 27
2002 CareFirst BlueChoice, Inc. 26 Section
5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization
Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per office or outpatient visits;
nothing for inpatient visits
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and
-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes.
$10 per office or outpatient visits;
nothing for inpatient visits
All stages of breast reconstruction surgery following a mastectomy, such
as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
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 26
26 Page 27 28
2002 CareFirst
BlueChoice, Inc. 27 Section 5( b)
Oral and maxillofacial
surgery You pay
Oral surgical procedures, limited to:
Reduction of
fractures of the jaws or facial bones;
Surgical correction of cleft lip,
cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures.
$10 per office or outpatient visits;
nothing for inpatient visits
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 27
27 Page 28 29
2002 CareFirst
BlueChoice, Inc. 28 Section 5( b)
Organ/ tissue transplants
You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell
tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as liver, stomach, and
pancreas
Limited Benefits – Treatment for breast cancer, multiple
myeloma, and
epithelial ovarian cancer may be provided in an NCI-or
NIH-approved
clinical trial at a Plan-designated center of excellence and if
approved by
the Plan's medical director in accordance with the Plan's
protocols.
Note: We cover pre & post recipient related medical and hospital expenses
of the donor when we cover the recipient.
Nothing if provided in an inpatient
setting. Otherwise, $10 per visit.
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as
covered
All charges
Anesthesia
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing 28
28 Page
29 30
2002 CareFirst BlueChoice, Inc.
29 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.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care. Any
costs associated
with the professional charge (i. e., physicians, etc.) are covered in
Sections 5( a) or
(b).
YOUR PYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
Ward, semiprivate, or intensive care accommodations;
General
nursing care; and
Meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 29
29 Page 30 31
2002 CareFirst BlueChoice, Inc. 30 Section
5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating,
recovery, maternity, and other treatment rooms
Prescribed drugs and
medicines
Diagnostic laboratory tests and X-rays
Administration of
blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical
supplies and equipment, including oxygen
Anesthetics, including nurse
anesthetist services
Take-home items
Medical supplies, appliances,
medical equipment, and any covered items billed by a hospital for use at home
(Note: calendar year
deductible applies.)
Nothing
Not covered:
Custodial care, rest cures, domiciliary or
convalescent care
Non-covered facilities, such as nursing homes,
schools
Personal comfort items, such as telephone, television,
barber services, guest meals and beds
Private nursing care
All charges
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and
medications
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including
oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We do
not cover the dental procedures.
$10 copay
Not covered: blood and blood derivatives not replaced by the member All
charges 30
30 Page
31 32
2002 CareFirst BlueChoice, Inc.
31 Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You Pay
If a Plan doctor determines that you need
full-time skilled nursing care or need
to stay in a skilled nursing
facility, and we approve that decision, we will give
you the comprehensive
range of benefits with no dollar or day limit.
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or Arranged by the skilled nursing facility when
prescribed by a Plan doctor.
Nothing
Not covered: custodial care All charges
Hospice care
If terminally ill, you are covered for supportive and palliative care in your
home or at a hospice. This includes inpatient and outpatient care and
family counseling. A Plan doctor, who certifies that you are in the terminal
stages of illness, with a life expectancy of approximately six months or
less,
will direct these services.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when
medically appropriate Nothing 31
31 Page 32 33
2002 CareFirst
BlueChoice, Inc. 32 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:
For emergencies, please call your primary care physician. If your PCP is
unavailable, call FirstHelp at 800/ 535-9700 and a
registered nurse will
give you health care advice. In extreme emergencies, where your life or limbs
are in jeopardy, and you
cannot reach your doctor, contact the local
emergency system (911, for example) or go to the nearest hospital emergency
room.
Be sure to tell the workers in the emergency room that you are a Plan
member so they can notify the Plan
If you need to stay in a facility our plan does not designate (a non-Plan
facility), you must notify the Plan at 800/ 367-1799 or
202/ 646-0090 within
48 hours or on the first working day after the day they admitted you, unless you
cannot reasonably do so.
If you stay in a non-Plan facility and a Plan
doctor believes that a Plan hospital can give you better care, then the facility
will
transfer you when medically feasible and we will fully cover any
ambulance charges.
You can receive benefits for care from non-Plan providers if you did not
reach a Plan provider in time and the delay would
result in death,
disability or significantly jeopardize your condition.
For this Plan to cover you, only Plan-providers can give you follow-up care
that the non-Plan providers recommend.
Emergency Services— continued on next page 32
32 Page 33 34
2002 CareFirst BlueChoice, Inc. 33 Section
5( d)
Emergency Services (Continued)
Emergencies
outside our service area: You can receive benefits for any medically
necessary health service that you require immediately because of injury or
unforeseen illness.
For emergencies, please contact FirstHelp at 800/ 535-9700 and a registered
nurse will give you health care advice. In extreme
emergencies, where your
life or limbs are in jeopardy, contact the local emergency system (911, for
example) or go to the
nearest hospital emergency room.
If you need to stay in a medical facility, you must notify the Plan at 800/
367-1799 or 202/ 646-0090 within 48 hours or on the
first working day after
the date they admit you, unless not reasonably possible to do so. If a Plan
doctor believes a Plan hospital
can give you better care, then the facility
will transfer you when medically feasible, and we will fully cover any ambulance
charges.
For this Plan to cover you, Plan providers must provide any of the follow-up
care that non-Plan providers may recommend to
you. 33
33 Page 34 35
2002 CareFirst BlueChoice, Inc. 34 Section
5( d)
Benefit Description You pay
Emergency within our service
area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
$10 per visit
$25 per non-participating
urgent care center
visit;
$10 per
participating urgent
care center visit;
$25 per hospital
emergency room
visit.
Note: Emergency room
copay waived if
admitted into the
hospital
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
$10 per visit
$25 per hospital
emergency room or
urgent care
center visit.
Note: Emergency room copay
waived if admitted into the
hospital
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of
a baby outside the service area
All charges
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing
Not covered: air ambulance All charges 34
34
Page 35 36
2002
CareFirst BlueChoice, Inc. 35 Section 5( e)
Section 5 (e).
Mental health and substance abuse benefits
I
M
P
O
R
T
A
N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and
limitations for Plan mental health and substance
abuse benefits will be no greater than for similar
benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how
cost sharing works. Also read Section 9 about
coordinating benefits with other coverage,
including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions
after the benefits description below.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Mental health and substance abuse benefits
Diagnostic and treatment services recommended by a
Plan provider and
contained in a treatment plan that we
approve. The treatment plan may
include services,
drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we
determine the care is
clinically appropriate to treat your
condition and only when you receive the
care as part of
a treatment plan that we approve.
Your cost sharing responsibilities are no greater
than for other illness
or conditions.
Professional services, including individual or group
therapy by
providers such as psychiatrists,
psychologists, or clinical social workers
Medication management
$10 per visit
Mental health and substance abuse benefits – Continued on next page 35
35 Page 36 37
2002 CareFirst BlueChoice, Inc. 36 Section
5( e)
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in
approved alternative care settings such as partial hospitalization,
halfway
house, residential treatment, full-day hospitalization, facility based
intensive outpatient treatment.
Nothing
$10 per visit
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the
treatment plan's clinical
appropriateness. OPM will generally not order us
to pay or provide one
clinically appropriate treatment plan in favor of
another.
All charges
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
We administer mental health and substance abuse benefits under a contract
with
Magellan Behavioral Health (or another vendor we determine). If you
think
you need mental health or substance abuse services you must first call
Magellan
at 800/ 245-7013. If you need treatment, Magellan will refer you to
one of their
network providers. Magellan must coordinate all mental health
and substance
services, not your primary care doctor.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 36
36 Page
37 38
2002 CareFirst BlueChoice, Inc.
37 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 deductible
Certain drugs require clinical
prior authorization. Contact the Plan for a listing of which drugs are subject
to the prior authorization policy. Prior authorization may
be initiated by the Prescriber or the pharmacy by calling Advance Secure at
800/ 294-5979 (or other vendor as determined by the Plan)
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits
with other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write
the prescription.
Where you can obtain them. You must fill the
prescription at a Plan pharmacy, or by mail for a maintenance medication.
We use a formulary. A formulary is a preferred list of drugs that we
selected to meet patient needs at a lower cost The formulary includes both
generic and brand name drugs. You will be responsible for
higher charges if
your doctors prescribes a drug not on our formulary list. However, non-formulary
drugs
will be covered when prescribed by a Plan doctor.
We have an open formulary. If your physician believes a name brand product is
necessary or there is no
generic available, your physician may prescribe a
name brand drug from a formulary list. This list of
name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower cost.
To
order a prescription drug brochure, call AdvancePCS at 1-800-241-3371.
These are the dispensing limitations. You can receive up to 34 days
worth of medication for each fill of non-maintenance prescriptions at a local
Plan pharmacy. In addition, you can receive up to 90 days of
medications
through our mail order pharmacy program. Your copay will be $10, $20, or $35 for
a 34-day
supply or less at the retail pharmacy and twice that amount for
35-day supply or greater up to 90 days by
mail. The same prescriptions can
be purchased through the mail order service as your community pharmacy.
In
most cases, you can get a refill once you have taken 75% of the medication. Your
prescription will not be
refilled prior to the 75% usage guidelines. A
generic equivalent will be dispensed if it is available, unless
your
physician specifically requires a name brand.
Why use generic drugs? A generic drug is the chemical equivalent of
a corresponding brand name drug
dispensed at a lower cost. You can reduce
your out-of-pocket expenses by choosing a generic drug over a
brand name
drug.
When you have to file a claim. Call our preferred drug vendor,
AdvancePCS, at 800/ 241-3371 to order prescription drug claim forms. You will
send the prescription drug claim form to: AdvancePCS,
PO Box 853901,
Richardson TX 75085-3901.
Prescription drug benefits begin on the next page. 37
37 Page 38 39
2002 CareFirst BlueChoice, Inc. 38 Section
5( f)
Benefit Description You pay
Covered medications and
supplies
We cover the following medications and supplies prescribed by a
Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those listed as Not
covered.
Insulin
Disposable needles and syringes for the
administration of covered medications
Drugs for sexual dysfunction (Subject to dosage limitations. Contact the
Plan for these limitations)
Contraceptive drugs and devices
Smoking
deterrents
Diabetic supplies, including insulin syringes, needles, glucose
test strips, lancets and alcohol swabs
Allergy serum
Note: Intravenous fluids and medications for home use,
implantable drugs (such as
Norplant), some injectable drugs (such as Depo
Provera), and IUDs are covered
under the Medical and Surgical Benefits.
Note: Injectable coverage will be limited to those medications that are
usually
self-injected.
$ 10 per unit or refill for generic
prescriptions
$ 20 per unit or refill for
prescriptions on the Plan's
formulary
brand name list
$ 35 per unit or refill for all other
prescripitons
Note: You may use the Plan's mail
Service and receive a 90-day supply
For two copayments.
Nothing
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Nonprescription medicines
Drugs obtained at a non-Plan
pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to
enhance athletic performance
Drugs for weight loss
All Charges 38
38 Page 39 40
2002 CareFirst
BlueChoice, Inc. 39 Section 5( g)
Section 5 (g). Special
features
Feature Description
Flexible benefits
options
Under the flexible benefits option, we determine the most effective way to
provide services.
We may identify medically appropriate alternatives to traditional care and
coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving
an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse line If you have any health concerns, call FirstHelp at
1-800-535-9700, 24 hours a day, 7 days a week and talk with a registered nurse
who will discuss treatment
options and answer your health questions. 39
39 Page 40 41
2002 CareFirst BlueChoice, Inc. 40 Section
5( h)
Section 5 (h). Dental benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year deductible
We cover hospitalization for
dental procedures only when a nondental physical impairment exists which makes
hospitalization necessary to safeguard the health of the
patient; we do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair
sound natural teeth. The need for
these services must result from an
accidental injury.
$10 per visit
Dental benefits
We have no other dental benefits. 40
40 Page 41 42
2002 CareFirst BlueChoice, Inc. 41 Section
5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed claim about them.
Fees you pay
for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Dental care
What is covered
The following preventive and diagnostic
services are covered when provided by Plan dentists; you pay a $14 adult copay
or a $10 child
copay per visit:
Oral examinations
Prophylaxis, or cleaning (every 6 months)
Fluoride treatment
Pulp Vitality tests
Diagnostic casts
Oral
Hygiene instruction
You pay 50% of your participating dentist's usual and customary fees for:
X-rays
Fillings
Sealants
For all other non-accidental services under this program, you pay 75% of the
participating dentist's usual and customary fees, including:
Restorations
Crown and bridge services
Endodontic services
Periodontics
Prosthodontics, removables
Oral surgery services
Broken
appointment fee
Orthodontic services
TMJ treatment
Cosmetic
and anesthetic services
Please note: Availability of dental providers is limited to the Metro
Washington DC area.
CareFirst Options
As a member of a CareFirst BlueCross BlueShield HMO,
you can receive 25% discounts on alternative therapies including acupuncture,
massage therapy and chiropractic care. You can also receive discounts for
fitness centers including personal trainers, spas and yoga
classes. There
are no claim forms, referrals or other paperwork for you to fill out. Just show
your BlueChoice ID card at the time you
receive service and you will get the
discount. Please call CareFirst Options Member Services at 888/ 999/ 4140 for
additional information
and a list of practitioners in your area. 41
41 Page 42 43
2002 CareFirst BlueChoice, Inc. 42 Section 6
Section 6. General exclusions – things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless
your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your illness
disease, injury or condition
and we agree, as discussed under What
Services Require Our Prior Approval on page 11.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric practice;
Experimental or investigational
procedures, treatments, drugs or devices;
Services, drugs, or supplies
related to abortions, except when the life of the mother would be endangered if
the fetus were carried to term or when the pregnancy is the result of an act of
rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program. 42
42 Page
43 44
2002 CareFirst BlueChoice, Inc.
43 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will
not have to file claims. Just present your identification card and pay your
copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly.
Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form. Facilities will file on the UB-92 form. For
claims
questions and assistance, call us at 866/ 520-6099 or 410/ 356-4602.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a
claim form that includes the information shown below. Bills
and receipts should be itemized
and show:
Covered member's name and ID number;
Name and address of the
physician or facility that provided the service or supply;
Dates you
received the services or supplies;
Diagnosis;
Type of each service
or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial any primary payer --such as the
Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to:
CareFirst BlueChoice, Inc, 550 12 th Street SW, Washington DC 20065
Prescription drugs Submit your claims to:
AdvancePCS, PO Box
853901, Richardson TX 75085-3901
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. 43
43 Page
44 45
2002 CareFirst BlueChoice, Inc.
44 Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your
claim or request for services, drugs, or
supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: CareFirst BlueChoice Inc, P. O. Box 644, Owings Mills, MD
21117-9998 and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit
provisions in this brochure;
and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or if applicable arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our
request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information
was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us –
if we did not answer that request in some way within 30 days; or
120 days
after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E
Street, NW, Washington, DC
20415-3630.
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. 44
44
Page 45 46
2002
CareFirst BlueChoice, Inc. 45 Section 8
The Disputed Claims process
(Continued)
Note: You are the only person who has a right
to file a disputed claim with OPM. Parties acting as your
representative,
such as medical providers, must include a copy of your specific written consent
with the review
request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
5 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 866/ 520-6099 or
410/
356-4602 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment
too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 45
45
Page 46 47
2002
CareFirst BlueChoice, Inc. 46 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health care expenses
without regard to fault. This
is called "double coverage."
When you have
double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary payer. We,
like other
insurers, determine which coverage is primary according to the
National Association of
Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan
pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay
more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities,
under 65 years of age.
People with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a
transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people
do not have to pay for Part A. If you or your spouse worked for at least 10
years in Medicare-covered employment, you should be
able to qualify for premium-free Part A insurance (Someone who was a Federal
employee on January 1, 1983 or since automatically qualifies.) Otherwise, if
you are
age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE
for more
information.
Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security check
or your retirement
check
If you are eligible for Medicare, you may have choices in how you
get your health care.
Medicare + Choice is the term used to describe the
various health plan choices available to
Medicare beneficiaries. The
information in the next few pages shows how we coordinate
benefits with
Medicare, depending on the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere in the United States.
(Part A or Part
B) It is the way everyone used to get Medicare benefits and is the way most
people get their Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital
that accepts Medicare. The Original Medicare Plan pays its share and you pay
your share.
Some things are not covered under Original Medicare, like
prescription drugs
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the
rules in this brochure for us to cover your care. Your
care must continue to be authorized by
your Plan PCP, or precertified as
required.
We will not waive any of our copayments.
(Primary payer chart begins
on next page.) 46
46 Page
47 48
2002 CareFirst BlueChoice, Inc.
47 Section 9
The following chart illustrates whether the Original
Medicare Plan or this Plan should be the primary payer for you according to
your
employment status and other factors determined by Medicare. It is
critical that you tell us if you or a covered family member has Medicare
coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a
family member are eligible for
Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for
Part B 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
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare.
You will be responsible for amounts
not covered by Medicare, Plan copays and amounts over the Plan allowance. 47
47 Page 48 49
2002 CareFirst BlueChoice, Inc. 48 Section 9
Claims process when you have the Original Medicare Plan --You
probably will never have to
file a claim form when you have both our Plan
and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim
first. In most cases, your claims will be coordinated automatically. You will
not need to do
anything. To find out if you need to do something about
filing your claims, call us at
866/ 520-6099.
We do not waive any costs when you have the Original Medicare.
Medicare managed care plan If you are eligible for Medicare, you
may choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a Medicare managed care plan. These are
health care
choices (like HMOs) in some areas of the country. In most Medicare managed
care plans, you can only go to doctors, specialists, or hospitals that are
part of the plan.
Medicare managed care plans provide all the benefits that
Original Medicare covers. Some
cover extras, like prescription drugs. To
learn more about enrolling in a Medicare managed
care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care
plan: You may enroll in another
plan's Medicare managed care plan and
also remain enrolled in our FEHB plan. We will still
provide benefits when
your Medicare managed care plan is primary, even out of the managed
care
plan's network and/ or service area (if you use our Plan providers), but we will
not waive
any of our copayments, coinsurance, or deductibles. If you enroll
in a Medicare managed care
plan, tell us. We will need to know whether you
are in the Original Medicare plan or in a
Medicare managed care plan so we
can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an
annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your
Medicare managed care plan premium.) For
information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB
Program, generally you
may do so only at the next open season unless you involuntarily lose
coverage or move out of the Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered under the FEHB
Medicare Part A or Part
B program. We will not require you to enroll in Medicare Part B and, if you
can't get premium-free
Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for members, 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 48
48 Page 49 50
2002 CareFirst
BlueChoice, Inc. 49 Section 9
OWCP or a similar agency pays for
through a third party injury settlement or other similar
proceeding that is
based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover
your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries or
for injuries illness
caused by another person, you must reimburse us for any expenses we paid.
However we will cover the cost of treatment that exceeds the amount you received
in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If
you need more information, contact us for our subrogation
procedures. 49
49 Page
50 51
2002 CareFirst BlueChoice Inc 50
Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new
enrollees, the calendar year begins on the effective date of their enrollment
and ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed
amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Treatment or services that could be rendered
safely or reasonably by a person not medically skilled to provide such services
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for those services. See page 12.
Experimental or
Investigational
services
Services legally used in testing or other studies on human patients
Services recognized as safe and effective for the treatment of a specific
condition.
Services approved by any governmental authority whose approval is required.
Services approved for human use by the Federal Food and Drug
Administration in the case a drug, therapeutic regimen, or device is used.
Group health coverage Health coverage made available through
employment or membership with a particular organization or group.
Medical
necessity Services or supplies that: are proper and needed for the
diagnosis or treatment of your medical condition;
are provided for the
diagnosis, direct care, and treatment of your medical condition;
meet the
standards of good practice in the medical community of your local area; and,
are not mainly for the convenience for you or your doctor.
Us/ We Us and we refer to CareFirst BlueChoice, Inc.
You
You refers to the enrollee and each covered family member. 50
50 Page 51 52
2002 CareFirst BlueChoice Inc 51 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had
limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www. opm. gov/ insure . Also, your
employing or retirement office
about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter
military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot change your
enrollment status without information from
your employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, your spouse;
for you and your family
and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain
circumstances, you may also continue coverage for a disabled child 22 years
of age or older
who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you
marry, give birth, or add a child to your family. You may
change your enrollment 31 days
before to 60 days after that event. The Self
and Family enrollment begins on the first day of
the pay period in which the
child is born or becomes an eligible family member. When you
change to Self
and Family because you marry, the change is effective on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits
will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer
eligible to receive health benefits, nor will we. Please
tell us immediately when you add or
remove family members from your coverage
for any reason, including divorce, or when your
child under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be
enrolled in or covered as a family member by another FEHB
plan.
When benefits and The benefits in this brochure are effective on
January 1. If you joined this Plan during Open
premiums start Season,
your coverage begins on the first day of your first pay period that starts on or
after January 1. Annuitants' coverage and premiums begin on January 1. If you
joined at
any other time during the year, your employing office will tell you the
effective date of
coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the following
records are confidential
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of
Workers' Compensation Programs (OWCP), when coordinating
benefit payments and
subrogating claims; 51
51
Page 52 53
2002
CareFirst BlueChoice Inc 52 Section 11
Law enforcement officials when
investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you do not meet this requirement,
you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB
coverage ends You will receive an additional 31 days of coverage, for no
additional premium, when:
Your enrollment ends, unless you cancel your
enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
Spouse equity If you are divorced from a Federal
employee or annuitant, you may not continue to get
coverage 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 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.
Converting to You may convert to a non-FEHB individual policy
if:
individual coverage
Your coverage under TCC or the spouse
equity law ends (If you canceled your coverage
or did not pay your premium,
you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert.
You must apply in writing to us within 31 days after you
receive this notice. However, if you
are a family member who is losing
coverage, the employing or retirement office will not
notify you. You
must apply in writing to us within 31 days after you are no longer eligible for
coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will
not have to answer questions about your health, and we
will not impose a waiting period or
limit your coverage due to pre-existing
conditions. 52
52 Page
53 54
2002 CareFirst BlueChoice Inc 53
Section 11
Getting a Certificate of The Health Insurance
Portability and Accountability Act of 1996 (HIPAA) is a Federal law
Group
Health Plan Coverage 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 website
(www.
opm. gov/ insure/ health) refer to the "TCC and HIPAA" frequently asked
questions.
These highlight HIPAA rules, such as the requirement that Federal
employees must
exhaust any TCC eligibility as one condition for guaranteed
access to individual health
coverage under HIPAA, and have information about
Federal and State agencies you can
contact for more information. 53
53 Page 54 55
2002 CareFirst BlueChoice Inc 54 Long Term Care
Insurance
Long Term Care Insurance Is Coming Later in 2002!
The
Office of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in
October 2002. As part of its educational
effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease
such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice care, and more.
LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
Welcome to the club!
76% of Americans believe they will never need
long term care, but the facts are that about half them will. And it's not just
the old folks. About 40% of people needing
long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
We hope you
will never need long term care, but everyone should have a plan just in case.
Many people now consider long term care insurance to be vital to their
financial and retirement planing.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's
before inflation!
Long term care can easily exhaust your
savings. Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a stay in
an assisted
living facility or a continuing need for a home health aide to
help you get in and out
of bed and with other activities of daily living.
Limited stays in skilled nursing
facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest
level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin
in mid-2002. In the meantime, you can learn more about the program on our web
site at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need? You should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 54
54 Page 55 56
2002 CareFirst BlueChoice Inc 55 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the term appears.
Accidental injury
40 Allergy tests 18
Alternative treatment 24 Allogenetic (donor) bone
marrow transplants 28 Ambulance 31
Anesthesia 28 Autologous bone marrow
transplant 28
Blood and blood plasma 30 Breast cancer screening 16
Casts 30 Catastrophic protection 12
Changes for 2002 8
Chemotherapy 19
Childbirth 17 Chiropractic 23
Cholesterol tests 15
Claims 43
Coinsurance 50 Colorectal cancer screening 15
Congenital
anomalies 25 Contraceptive devices and drugs 38
Coordination of benefits 47
Covered providers 6
Deductible 50 Definitions 50
Dental care 40
Diagnostic services 15
Disputed claims review 44 Donor expenses
(transplants) 28
Dressings 30 Durable medical equipment (DME) 22
Educational classes and programs 24 Effective date of enrollment 51
Emergency 32 Experimental or investigational 50
Eyeglasses 21
Family planning 17 Fecal occult blood test 15
General Exclusions 42 Hearing services 20
Home health
services 23 Hospice care 31
Home nursing care 23 Hospital 29
Immunizations 16 Infertility 18
Inhospital physician care 30
Inpatient Hospital Benefits 29
Insulin 38
Laboratory and
pathological services 15
Machine diagnostic tests 15 Magnetic Resonance Imagings
(MRIs) 15
Mail Order Prescription Drugs 38
Mammograms 16 Maternity Benefits 17
Medicaid 49 Medically necessary 50
Medicare 46 Members 9
Mental
Conditions/ Substance Abuse Benefits 35
Newborn care 17 Non-FEHB
Benefits 41
Nurse 23 Licensed Practical Nurse 23
Registered Nurse 23
Nursery charges 17
Obstetrical care 17 Occupational therapy 20
Ocular injury 21 Office visits 14
Oral and maxillofacial surgery 27
Orthopedic devices 22
Out-of-pocket expenses 12 Outpatient facility care 30
Oxygen 22
Pap test 15 Physical examination 16
Physical therapy 20 Physician 6
Precertification 11 Preventive care,
adult 15
Preventive care, children 16 Prescription drugs 37
Preventive
services 15 Prior approval 11
Prostate cancer screening 15 Prosthetic
devices 22
Psychologist 35 Radiation therapy 19
Renal dialysis 46
Room and board 29
Second surgical opinion 14 Skilled nursing facility
care 31
Speech therapy 20 Splints 30
Sterilization procedures 17
Subrogation 49
Substance abuse 35 Surgery 25
Anesthesia 28 Oral 27
Outpatient 25 Reconstructive 26
Syringes 38
Temporary
continuation of cover