RI 73-806
A Health Maintenance Organization
Serving the following
states:
Indiana, Kentucky, New York, Ohio and Tennessee
Enrollment in this Plan is limited. You must live or work in our
geographic service area to enroll. See page 9 for requirements.
New York
New York City Area
5/ 01
This service has
Excellent
accreditation from
the NCQA.
See the 2002 Guide for
more information on
accreditation.
Ohio Cincinnati
4/ 99
This service has
Commendable
accreditation from
the NCQA.
See the 2002 Guide for
more
information on
accreditation.
Enrollment code for Southern IN: Enrollment code for Southeastern IN:
7L1 Self Only RD1 Self Only
7L2 Self and Family RD2 Self and Family
Enrollment code for Louisville, KY: Enrollment code for Northern, KY:
7L1 Self Only RD1 Self Only
7L2 Self and Family RD2 Self and Family
Enrollment code for Cincinnati, OH: Enrollment code for New York, NY:
RD1 Self Only JC1 Self Only
RD2 Self and Family JC2 Self and Family
Enrollment code Cleveland & Toledo, OH: Enrollment code for Syracuse
and Binghamton, NY:
7D1 Self Only TG1 Self Only
7D2 Self and Family TG2
Self and Family
Enrollment code for Nashville & Middle TN: Enrollment code for
Memphis, TN:
6J1 Self Only UB1 Self Only
6J2 Self and Family UB2 Self
and Family
For changes
in benefits
see page 12.
Special Notice: This brochure includes benefits for Aetna U. S.
Healthcare members transferred from
Indiana, Kentucky, New York, Ohio and
Tennessee and Prudential Healthcare-Tennessee members from
Tennessee. Your
benefits have changed.
Aetna U. S. Healthcare 2002 http:// www. aetnaushc. com/ feds 1
1 Page 2 3
2002 Aetna U. S. Healthcare HMO 2 Table of Contents
Table of Contents
Introduction
...........................................................................................................................................................................
4
Plain
Language......................................................................................................................................................................
4
Inspector General Advisory
.................................................................................................................................................
5
Section 1. Facts about this HMO
plan..................................................................................................................................
6
How we pay
providers........................................................................................................................................
6
Your
Rights.........................................................................................................................................................
7
Service
Area........................................................................................................................................................
9
Section 2. How we change for
2002...................................................................................................................................
12
Program-wide
changes.....................................................................................................................................
12
Changes to this Plan
.........................................................................................................................................
12
Section 3. How you get care
...............................................................................................................................................
14
Identification
cards...........................................................................................................................................
14
Where you get covered
care.............................................................................................................................
14
Plan providers
............................................................................................................................................
14
Plan
facilities..............................................................................................................................................
14
What you must do to get covered
care.............................................................................................................
14
Primary
care...............................................................................................................................................
14
Specialty
care.............................................................................................................................................
14
Hospital
care...............................................................................................................................................
15
Circumstances beyond our control
..................................................................................................................
16
Services requiring our prior
approval..............................................................................................................
16
Section 4. Your costs for covered
services.........................................................................................................................
17
Copayments................................................................................................................................................
17
Coinsurance................................................................................................................................................
17
Deductible
..................................................................................................................................................
17
Your out-of-pocket maximum
........................................................................................................................
. 17
Section 5.
Benefits...............................................................................................................................................................
18
Overview...........................................................................................................................................................
18
(a) Medical services and supplies provided by
physicians and
other health care
professionals..............................................................................................................
19
(c) Services provided by a hospital or other facility, and
ambulance services......................................... 30
(d) Emergency services/ accidents
..............................................................................................................
33
(e) Mental health and substance abuse
benefits.........................................................................................
36
(f) Prescription drug benefits
.....................................................................................................................
38 2
2 Page 3 4
2002 Aetna U. S. Healthcare HMO 3 Table of Contents
(g) Special
features......................................................................................................................................
41
(h) Dental
benefits.......................................................................................................................................
42
(i) Non-FEHB benefits available to Plan members
..................................................................................
45
Section 6. General exclusions things we don't
cover...................................................................................................
46
Section 7. Filing a claim for covered services
...................................................................................................................
47
Section 8. The disputed claims
process..............................................................................................................................
48
Section 9. Coordinating benefits with other
coverage.......................................................................................................
50
When you have
Other
health
coverage..............................................................................................................................
50
Original
Medicare....................................................................................................................................
50
Medicare managed care
plan...................................................................................................................
52
TRICARE/ Workers' Compensation/ Medicaid
...............................................................................................
53
Other Government
agencies.............................................................................................................................
53
When others are responsible for
injuries.........................................................................................................
53
Section 10. Definitions of terms we use in this
brochure..................................................................................................
55
Section 11. FEHB
facts.......................................................................................................................................................
58
Coverage
information.......................................................................................................................................
58
No pre-existing condition limitation
.......................................................................................................
58
Where you get information about enrolling in the
FEHB Program....................................................... 58
Types of coverage available for you and your
family............................................................................
58
When benefits and premiums
start..........................................................................................................
59
Your medical and claims records are confidential
.................................................................................
59
When you
retire........................................................................................................................................
59
When you lose benefits
....................................................................................................................................
59
When FEHB coverage
ends.....................................................................................................................
59
Spouse equity coverage
...........................................................................................................................
59
Temporary Continuation of Coverage
(TCC).........................................................................................
60
Converting to individual coverage
..........................................................................................................
60
Getting a Certificate of Group Health Plan
Coverage............................................................................
60
Long Term Care Insurance is coming later in
2002...........................................................................................................
61
Department of Defense/ FEHB Demonstration
Project......................................................................................................
63
Index
....................................................................................................................................................................................
65
Summary of benefits
...........................................................................................................................................................
66
Rates.....................................................................................................................................................................................
67 3
3 Page 4 5
2002 Aetna U. S. Healthcare HMO 4
Introduction/ Plain Language
Introduction
Aetna U. S.
Healthcare, Inc.
1425 Union Meeting Road
P. O. Box 1126, Mail Stop U32A
Blue Bell, PA 19422
This brochure describes the benefits you can receive from Aetna U. S.
Healthcare* under our contract (CS 2867) 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 these
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 9. Rates
are shown at the end of this brochure.
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 Aetna U. S. Healthcare.
We limit acronyms to ones you know. FEHB is 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 email 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.
*HMO benefits are provided or administered by:
Carrier Code Legal
Entity
7L Aetna U. S. Healthcare of Illinois Inc.
RD/ 7L/ 7D Aetna
U. S. Healthcare Inc. (OH)
JC/ TG U. S. Healthcare, Inc. D/ B/ A Aetna U. S.
Healthcare Inc. (NY)
6J/ UB Aetna U. S. Healthcare Inc. (TN) 4
4 Page 5 6
2002 Aetna U. S. Healthcare HMO 5 Inspector
General Advisory
Inspector General Advisory Stop health care fraud!
Fraud increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has
charged you for services you did not
receive, billed you twice for the same
service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error.
If
the provider does not resolve the matter, call us at 1-800-537-9384 and explain
the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE
202-418-3300 or write to: 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 Aetna U. S. Healthcare HMO
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 Provider Compensation We contract with
individual physicians, medical groups, and hospitals
to provide the benefits
in this brochure. These Plan providers accept a
negotiated payment from us,
and you will only be responsible for your
copayments or coinsurance.
This is a direct contract prepayment Plan, which means that participating
providers are neither agents nor employees of the Plan. Rather, they are
independent doctors and providers who practice in their own offices or
facilities. The Plan arranges with licensed providers and hospitals to
provide medical services for both the prevention of disease and the
treatment of illness and injury for benefits covered under the Plan.
Plan providers in our network have agreed to be compensated in
various
ways. Many participating primary care physicians (PCPs) are
paid by
capitation. Under capitation, a physician receives payment for a
patient
whether the physician sees the patient that month or not.
Specialists, hospitals, primary care physicians and other providers in
the Aetna U. S. Healthcare network may also be paid in the following
ways:
Per individual service (fee-for-service at contracted rates),
Per
hospital day (per diem contracted rates),
Under other capitation methods (a
certain amount per member, per month), and
By Integrated Delivery Systems (" IDS"), Independent Practice Associations ("
IPAs"), Physician Medical Groups (" PMGs"),
Physician Hospital Organizations
(" PHOs"), behavioral health
organizations and similar provider
organizations or groups that are
paid by Aetna U. S. Healthcare; the
organization or group pays the
physician or facility directly. In such
arrangements, that group or
organization has a financial incentive to
control the costs of providing
care.
You are encouraged to ask your physicians and other providers how
they
are compensated for their services, including whether their specific
arrangements include any financial incentives to control costs. 6
6 Page 7 8
2002 Aetna U. S. Healthcare HMO 7 Section 1
Your Rights OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about
us, or 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.
Medical Necessity
Covered services include most types of treatment
by PCPs, specialists and hospitals. However, the health plan also
excludes
or limits coverage for some services, including but not limited to cosmetic
surgery and experimental
procedures. In addition, in order to be covered,
all services, including the location (type of facility), duration and costs
of services, must be medically necessary as defined in this Plan and as
determined by us. (See definition on Page 56.)
Direct Access Ob/ Gyn Program
This program allows female members
to visit any participating gynecologist for a routine well-woman exam, including
a Pap smear (if appropriate) and an unlimited number of visits for
gynecologic problems and follow-up care as
described in your benefits plan.
Gynecologists may also refer a woman directly for covered gynecologic services
without the patient's having to go back to her participating primary care
physician. If your Ob/ Gyn is part of an
Independent Practice Association
(IPA), a Physician Medical Group (PMG) or a similar organization, covered care
must be coordinated through the IPA, the PMG or the similar organization.
Mental Health/ Substance Abuse
In most areas, certain behavioral
health care services (e. g., treatment or care for mental disease or illness,
alcohol abuse
and/ or substance abuse) are managed by an independently
contracted organization. This organization makes initial
coverage
determinations and coordinates referrals; any behavioral health care referrals
will generally be made to
providers affiliated with the organization, unless
your needs for covered services extend beyond the capability of the
affiliated providers. You can receive information regarding the appropriate
way to access the behavioral health care
services that are covered under
your specific plan by calling Member Services at 1-800-537-9384. As with other
coverage determinations, you may appeal behavioral health care coverage
decisions in accordance with the provisions
of your Plan.
Ongoing Reviews
We conduct ongoing reviews of those services and
supplies which are recommended or provided by health
professionals to
determine whether such services and supplies are covered benefits under this
Plan. If we determine
that the recommended services and supplies are not
covered benefits, you will be notified. If you wish to appeal such
determination, you may then contact us to seek a review of the
determination.
Authorization
Certain services and supplies under this Plan may
require authorization by us to determine if they are covered benefits
under
this Plan.
Patient Management
We have developed a patient management program
to assist in determining what health care services are covered under
the
health plan and the extent of such coverage. The program assists members in
receiving the appropriate health care
and maximizing coverage for those
health care services.
Only medical directors make decisions denying coverage for services for
reasons of medical necessity. Coverage denial
letters delineate any unmet
criteria, standards and guidelines, and inform the provider and member of the
appeal
process.
Our patient management staff uses national guidelines and resources to guide
the precertification, concurrent review and
retrospective review processes.
Using the information obtained from providers, patient management staff utilize
Milliman & Robertson Health Care Management Guidelines when conducting
concurrent review. If there is no
applicable Milliman & Robertson
Guideline, patient management staff utilizes InterQual ISD criteria. When
applicable,
Medicare National Coverage Decisions are followed for Medicare
managed care members. To the extent certain patient
management functions are
delegated to integrated delivery systems, independent practice associations or
other provider
groups (" Delegates"), such Delegates utilize criteria that
they deem appropriate.
Precertification Certain health care services, such as hospitalization
or outpatient surgery, require precertification by us to ensure coverage. When a
member is to
obtain services requiring precertification through a Plan provider, this
provider should precertify those services prior to treatment. 7
7 Page 8 9
2002 Aetna U. S. Healthcare HMO 8 Section 1
Concurrent Review The concurrent review process assesses the
necessity for continued stay, level of care, and quality of care for members
receiving inpatient services.
All inpatient services extending beyond the
initial certification period will
require Concurrent Review.
Discharge Planning Discharge planning may be initiated at any stage of
the patient management process and begins immediately upon identification of
post-discharge
needs during precertification or concurrent review. The
discharge plan
may include initiation of a variety of services/ benefits to be
utilized by
the member upon discharge from an inpatient stay.
Retrospective Record Review The purpose of retrospective review is to
retrospectively analyze potential quality and utilization issues, initiate
appropriate follow-up action based on
quality or utilization issues, and review all appeals of inpatient concurrent
review decisions for coverage and payment of health care services. Our
effort to manage the services provided to members includes the
retrospective review of claims submitted for payment, and of medical
records submitted for potential quality and utilization concerns.
Member Services
Representatives from Member Services are trained
to answer your questions and to assist you in using the Aetna
U. S.
Healthcare plan properly and efficiently. After you receive your ID card, you
can call the Member Services toll-free
number on the card when you need to:
Ask questions about benefits and coverage.
Notify us of changes in your
name, address or telephone number.
Change your primary care physician or
office.
Obtain information about how to file a grievance or an appeal.
Confidentiality
We protect the privacy of confidential Plan member
medical information. We contractually require that participating
providers
keep member information confidential in accordance with applicable laws.
Furthermore, you have the right
to access you medical records from
participating providers, at any time. Aetna U. S. Healthcare (including its
affiliates
and authorized agents, collectively (" Aetna U. S. Healthcare")
and participating providers require access to member
medical information for
a number of important and appropriate purposes, including claims payment, fraud
prevention,
coordination of care, data collection, performance measurement,
fulfilling state and federal requirements, quality
management, utilization
review, research and accreditation activities, preventive health, early
detection and disease
management programs. Accordingly, for these purposes,
members authorize the sharing of member medical information
about themselves
and their dependents between Aetna U. S. Healthcare and Plan providers and
health delivery systems.
If you want more information about us, call 1-800-537-9384, or write to 1425
Union Meeting Road, P. O. Box 1126,
Mail Stop U32A, Blue Bell, PA 19422. You
may also contact us by fax at 215-775-6550 or visit our website at
www.
aetnaushc. com/ feds. 8
8 Page 9 10
2002 Aetna U. S.
Healthcare HMO 9 Section 1
Service Area To enroll in this
Plan, you must live or work in our service area. This is where our providers
practice. Our service area is:
Indiana Serving: Southern Indiana area
Enrollment Code:
7L1 Self Only
7L2 Self and Family
Clark, Floyd, Harrison, Scott and Washington counties
Serving: Southeastern Indiana area
Enrollment Code:
RD1 Self Only
RD2 Self and Family
Dearborn, Franklin, Ohio and Switzerland counties
Kentucky Serving: Louisville area
Enrollment Code:
7L1 Self Only
7L2 Self and Family
Bullitt, Hardin, Henry, Jefferson, Larue, Meade, Nelson, Oldham, Shelby,
Spencer
and Trimble counties
Serving: Northern Kentucky area
Enrollment Code:
RD1 Self Only
RD2 Self and Family
Boone, Campbell, Gallatin, Grant, Kenton and Pendleton counties
New York
5/ 01
This service has Excellent
accreditation from the NCQA.
See
the 2002 Guide for more
information on accreditation.
Serving: New York City area
Enrollment Code:
JC1 Self Only
JC2
Self and Family
Bronx, Dutchess, Kings (Brooklyn), Nassau, New York (Manhattan), Orange,
Putnam, Queens, Richmond (Staten Island), Rockland, Suffolk, Sullivan,
Ulster
and Westchester counties
Serving: Syracuse and Binghamton areas
Enrollment Code:
TG1 Self
Only
TG2 Self and Family
Broome, Cayuga, Onandoga, Oswego and Tioga counties 9
9 Page 10 11
2002 Aetna U. S. Healthcare HMO 10 Section 1
Ohio
4/ 99
This service has Commendable
accreditation
from the NCQA.
See the 2002 Guide for more
information on
accreditation.
Serving: Greater Cincinnati area
Enrollment Code:
RD1 Self Only
RD2 Self and Family
Adams, Brown, Butler, Champaign, Clark, Clermont, Clinton, Greene, Hamilton,
Highland, Miami, Montgomery, Preble, Shelby and Warren.
Serving: Cleveland and Toledo areas
Enrollment Code:
7D1 Self Only
7D2 Self and Family
Allen, Ashland, Ashtabula, Carroll, Crawford, Cuyahoga, Erie, Geauga,
Hancock,
Hardin, Henry, Holmes, Lake, Lorain, Lucas, Mahoning, Medina,
Ottawa, Portage,
Putnam, Richland, Sandusky, Seneca, Stark, Summit,
Trumbull, Tuscarawas and
Wayne counties and portions of the following
counties defined by listed towns:
Auglaize: Minster, New Bremen, New Hampshire, New Knoxville, Saint John's,
Saint Mary's, Uniopolis, Wapakoneta and Waynesfield
Columbiana: Beloit, Columbiana, East Rochester, East Palinstine, Elkton,
Hanoverton, Homeworth, Kensington, Leetonia, Libson, Minerva, Negley,
New Waterford, North Georgetown, Rogers, Salem, Salineville,
Washingtonville,
West Point and Winona
Fulton: Metamora and Swanton
Huron: Collins, Greenwich, Huron, New London
and Wakeman
Wood: Grand Rapids, Haskins, Millbury, Northwood, Perrysburg,
Rossford,
Stony Ridge and Walbridge
Tennessee Serving: The Memphis area
Enrollment Code:
UB1 Self Only
UB2 Self and Family
Crockett, Dyer, Fayette, Haywood, Lauderdale, Shelby and Tipton counties
Serving: Nashville and Middle Tennessee areas
Enrollment Code:
6J1
Self Only
6J2 Self and Family
Bedford, Cannon, Cheatham, Coffee, Davidson, Dekalb, Dickson, Franklin,
Giles,
Hickman, Humphreys, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury,
Moore, Perry, Robertson, Rutherford, Smith, Sumner, Trousdale, Wayne,
Williamson and Wilson counties 10
10 Page 11 12
2002 Aetna U.
S. Healthcare HMO 11 Section 1
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 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 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. 11
11 Page 12 13
2002 Aetna U. S. Healthcare HMO 12 Section 2
Section 2. How we change for 2002
Program-wide changes 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.
Changes to this Plan Code 7L. Your share of the non-postal premium
will increase by 16.0% for Self Only or increase by 16.0% for Self
and
Family.
Code RD. Your share of the non-postal premium will increase by 54.8%
for Self Only or increase by 51.1% for Self
and Family.
Code JC. Your share of the non-postal premium will increase by 5.4% for Self
Only or increase by 0.3% for Self and
Family.
Code TG. Your share of the non-postal premium will decrease by 3.0% for Self
Only or decrease by 2.4% for Self
and Family.
Code 7D. Your share of the non-postal premium will increase by 23.0% for Self
Only or increase by 18.8% for Self
and Family.
Code UB. Your share of the non-postal premium will increase by 34.6% for Self
Only or increase by 57.2% for Self
and Family.
Code 6J. Your share of the non-postal premium will increase by 20.0% for Self
Only or increase by 32.1% for Self
and Family.
We changed the address for sending disputed claims to OPM. Section 8.
We
no longer limit total blood cholesterol tests to certain age groups. Section 5(
a).
We now cover routing screening for chlamydial infection. Section 5( a).
We changed 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).
We clarified
the Preventive care, adult benefits by removing the entry for blood lead level
testing for adults because it
is a test more typically done for children.
Section 5( a).
We changed the primary care doctor office visit copay to $20. Section 5( a).
We changed the primary care doctor home visit copay to $25. Section 5( a).
We changed the specialty care office visit copay to $25. Section 5( a).
We changed the specialty care home visit copay to $30. Section 5( a).
We removed the copay for professional services of a physician during an
in-patient hospital stay. Section 5( b).
We added a $75 copay per date of
service for outpatient surgery. Section 5( c).
We reduced the covered
skilled nursing facility visit maximum from unlimited to 90 day maximum. Section
5( c).
We increased the copay from $35 to $75 per emergency room visit
Section 5( d).
We added coverage for air ambulance. Section 5( d). 12
12 Page 13 14
2002 Aetna U. S. Healthcare HMO STD 13
Section 2
We increased the copays for generic formulary, brand name
formulary and non-formulary drugs obtained at retail and
through mail order
pharmacies. Section 5( f).
We increased the copay for a diaphragm to $20. Section 5( f).
We
increased the copay for a Depo Provera to $20. Section 5( f).
We increased
the copay for certain dental services. Section 5( h).
We added durable
medical equipment to the list of services requiring precertification. See
Section 3.
We clarified the benefit for blood or blood plasma. See Section
5( c).
We removed the age limit for hearing tests. Section 5( a).
We
added a copay of $200 per day up to a maximum of $600 per admission. This
applies to medical confinements,
residential treatment facilities and
inpatient hospital admissions to treat mental health and substance abuse.
Section 5( e).
We stated your out-of-pocket maximum of $1,500 for Self Only and $3,000 for
Self and Family enrollments.
Section 4.
We stated growth hormone therapy requires prior authorization. See page 5(
a).
If you are enrolled in code 7L in Kentucky, and live or work in the
following counties: Anderson, Bourbon, Clark,
Fayette, Franklin, Harrison,
Henry, Jessamine, Madison, Owen, Scott, and Woodford, you must select another
Plan
during Open Season. We eliminated these counties from our service and
enrollment area. If you do not change plans,
you will have to travel to our
remaining service area for code 7L in Kentucky or Indiana to receive full HMO
benefits.
If you are enrolled in code UB, in Mississippi, and live and work in the
following counties: Desoto, Marshall, Tate
and Tunica, you must select
another plan during Open Season. We eliminated these counties from our service
and
enrollment area. If you do not change plans, you will have to travel to
our remaining service area for code UB, in
Tennessee, to receive full HMO
benefits. 13
13 Page
14 15
2002 Aetna U. S. Healthcare HMO
14 Section 3
Section 3. How you get care
Identification
cards We will send you an identification (ID) card when you enroll. You
should carry your ID card with you at all times. You must show it whenever
you receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at
1-800-537-9384.
Where you get covered care You get covered care from "Plan providers"
and "Plan facilities." You will only pay copayments or coinsurance, and you will
not have to file claims.
Plan providers Plan providers are physicians
and other health care professionals in our service area that we contract with to
provide covered services to our
members. We credential Plan providers
according to national standards.
We list Plan providers in the provider
directory, which we update
periodically. The most current information on our
Plan providers is also
on our website at www. aetnaushc. com/ feds.
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
facilities in the provider directory, which we update periodically. The most
current information on our Plan facilities is also on our website at
www. aetnaushc. com/ feds.
What you must do
to get covered care It depends on the type of
care you need. First, you and each family member must choose a primary care
physician. This decision is important since your primary care
physician provides or arranges for most of your health care. You must select
a Plan
provider who is located in your service area as defined by your
enrollment code.
Primary care Your primary care physician can be a general
practitioner, family practitioner, internist or pediatrician. Your primary care
physician will provide or coordinate
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 or visit our website. We will change your primary
care
physician to a newly-selected primary care physician.
Specialty care Your primary care physician will refer you to a
specialist for needed care. If you need laboratory, radiological and physical
therapy services, your primary care
physician must refer you to certain plan providers. Your primary care
physician
may refer you to any participating specialist for other specialty
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
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 a Plan
gynecologist, (within an IPA, you must see an IPA-approved
gynecologist),
for a routine well-woman exam, including a pap smear
(if appropriate) and an
unlimited number of visits for gynecological problems 14
14 Page 15 16
2002 Aetna U. S. Healthcare HMO 15 Section 3
and follow-up care as described in your benefit plan without a referral.
You
may also see a Plan mental health provider, Plan vision specialist or a
Plan
dentist without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number
of visits without additional referrals. Your primary care physician will use
our criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does
not participate with us, you must receive treatment from a specialist
who does. Generally, we will not pay for you to see a specialist who
does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
Terminate our contract with your specialist for other than cause; or
Drop out of the Federal Employees Health Benefits (FEHB)
Program and you
enroll in another FEHB Plan; or
Reduce our service area and you enroll in another FEHB Plan,
You may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.
If you are in the second or third
trimester of pregnancy and you lose access
to your specialist based on the
above circumstances, you can continue to
see your specialist until the end
of your postpartum care, even if it is
beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise covered 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 1-800-537-9384. 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 92nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 15
15 Page 16 17
2002 Aetna U. S. Healthcare HMO 16 Section 3
Circumstances beyond
our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.
Services requiring our
prior approval Your primary care physician
has authority to refer you for most services. For certain services, however,
your physician must obtain approval from
us. Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.
We call this review and approval process precertification.
You
must obtain approval for certain services such as:
For artificial
insemination you must contact the Infertility Case Manager at 1-800-575-5999;
You must obtain precertification from your primary care doctor and Aetna U.
S. Healthcare for covered follow-up care with non-participating
provider;
You must contact Customer Service at 1-800-537-9384 for information on
precertification before you have mental health and
substance abuse services;
Your Plan physician must obtain approval
for certain services such as
hospitalization and the following services:
For surgical treatment of morbid obesity;
For outpatient surgery;
For
covered transplant surgery from the Plan's medical director;
When full-time
skilled nursing care is necessary in an extended care facility;
For ambulance transportation service; and
For certain drugs before they
can be prescribed;
For growth hormone therapy treatment.
You or your
physician must obtain an approval for certain durable
medical equipment.
Members must call 1-800-537-9384 for authorization. 16
16 Page 17 18
2002 Aetna U. S. Healthcare HMO 17 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
$20 per office visit or $25 when you see a participating specialist.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 50% of negotiated charges for
nonformulary
drugs.
Deductible We do not have a deductible.
Your catastrophic protection
out-of-pocket maximum for
copayments
and coinsurance After your copayments and coinsurance total $1,500 per
person or $3,000 per family enrollment in any calendar year, you do not have to
pay any
more for covered services. However, copayments and coinsurance for the
following services do not count toward your out-of-pocket maximum, and
you must continue to pay copayments and coinsurance for these services:
Prescription drugs
Dental services
Be sure to keep accurate records
of your copayments and coinsurance since
you are responsible for informing
us when you reach the maximum. 17
17 Page 18 19
2002 Aetna U.
S. Healthcare HMO 18 Section 5
Section 5. Benefits OVERVIEW
(See page 12 for how our benefits changed this year and page 66 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. For more
information about our benefits, contact us at 1-800-537-9384 or at our website
at
www. aetnaushc. com/ feds.
(a) Medical services and supplies provided by physicians and other health
care professionals .................................... 19
Diagnostic and
treatment services Speech therapies
Lab, X-ray, and other diagnostic tests
Hearing services (testing, treatment, and supplies)
Preventive care, adult
Vision services (testing, treatment, and supplies)
Preventive care, children
Foot care
Maternity care Orthopedic and prosthetic devices
Family
planning Durable medical equipment (DME)
Infertility services Home health
services
Allergy care Chiropractic
Treatment therapies Alternative
treatments
Physical and occupational therapies Educational classes and
programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................ 26
Surgical procedures
Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and
maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services
............................................................... 30
Inpatient
hospital Hospice care
Outpatient hospital or ambulatory surgical center
Ambulance
Extended care benefits/ skilled nursing care facility benefits
(d) Emergency services/
accidents.....................................................................................................................................
33
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
...............................................................................................................
36
(f) Prescription drug
benefits............................................................................................................................................
38
(g) Special features
............................................................................................................................................................
41
Services for deaf and hearing-impaired
...................................................................................................................
41
Informed Health Line
...............................................................................................................................................
41
Reciprocity
................................................................................................................................................................
41
High risk pregnancies
...............................................................................................................................................
41
Centers of Excellence for transplants/ surgery etc.
..................................................................................................
41
Travel benefit/ services
overseas...............................................................................................................................
41
(h) Dental benefits
.............................................................................................................................................................
42
(i) Non-FEHB benefits available to Plan
members.........................................................................................................
45
Summary of benefits
...........................................................................................................................................................
66 18
18 Page 19
20
2002 Aetna U. S. Healthcare HMO 19
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 covered care.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
M
P
O
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T
A
N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second surgical or medical opinion
Initial examination of a newborn child covered under a family
enrollment
$20 per primary care
physician (PCP) visit
$25 per specialist visit
Professional services of physicians
In an urgent care center for a
routine service
In a skilled nursing facility
$20 per PCP visit
$25 per specialist visit
At home $25 per PCP visit
$30 per specialist visit
At home visits by nurses and health aides Nothing
Lab, X-ray and other diagnostic tests
Test, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive
these services during
your office visit;
otherwise, $20 per PCP
visit or $25 per specialist
visit 19
19 Page 20 21
2002 Aetna U. S. Healthcare HMO 20 Section
5( a)
Preventive care, adult You pay
Routine screenings, such
as:
Total Blood Cholesterol Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years
starting at age 50
Prostate Specific Antigen (PSA test) one annually for men age 40
and
older
Routine Pap test
NOTE: No copay for the pap test if performed on
the same day as the
office visit
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
$20 per PCP visit
$25 per specialist visit
Nothing if provided
during the office visit
Routine immunizations limited to:
Tetanus-diphtheria (Td) booster once
every 10 years, ages 19 and over (except as provided for under childhood
immunizations
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing if provided
during the office visit
Not covered:
Physical exams required for obtaining or
continuing employment or insurance, attending schools or camp, or travel.
Immunizations and boosters for travel or work-related exposure.
All charges
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing
Well-child visits for routine examinations, immunizations and care (up to age
22) $20 per PCP visit $25 per specialist visit
Examinations, such as:
Eye exams through age 17 to determine the need
for vision
correction.
Ear exams to determine the need for hearing correction
Examinations
done on the day of immunizations (up to age 22)
$20 per PCP visit
$25 per specialist visit 20
20 Page 21 22
2002 Aetna U. S. Healthcare HMO 21 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 below 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 cover an extended
inpatient stay if
your Physician determines it is 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).
$20 for the first PCP visit
only or $25 for the first
specialist
visit only
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives, such as Norplant
Injectable contraceptive drugs,
such as Depo Provera
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives and Depo Provera under the
prescription drug benefit.
$20 per PCP visit
$25 per specialist visit
Not covered: Reversal of voluntary surgical sterilization, genetic
counseling, All charges
Infertility services
Diagnosis and
treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
NOTE: Coverage is for 6 cycles.
Artificial insemination must be authorized.
You must contact the Infertility
Case Manager at 1-800-575-5999. You must
use our select network of Plan
infertility providers.
Fertility drugs except injectables
NOTE: We cover oral fertility drugs under the prescription drug
benefit.
$25 per specialist visit
Infertility Services Continued on the next page 21
21 Page 22 23
2002 Aetna U. S. Healthcare HMO 22 Section
5( a)
Infertility services (Continued) You pay
Not covered:
Reversal of voluntary, surgically-induced
sterility.
Treatment for infertility when the cause of the infertility was a previous
sterilization.
Injectable fertility drugs are not covered.
Infertility
treatment when the FSH level is greater than 19 mIU/ ml.
The
purchase, freezing and storage of donor sperm and donor embryos.
Assisted reproductive technology (ART) procedures , such as in vitro
fertilization and embryo transfer including, but not limited to, GIFT
and
ZIFT.
All charges
Allergy care
Testing and treatment
Allergy injection
NOTE: You pay the applicable copay for each doctor visit. Each visit
to a
nurse for injection only, you pay nothing
$20 per PCP visit
$25 per specialist visit
Nothing for a visit to a
nurse
Allergy serum Nothing
Treatment therapies
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 Medical Benefits, office copay
applies.
NOTE: We will only cover GHT when we preauthorize the treatment.
Call 1-800-245-1206 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.
$25 per specialist visit 22
22 Page 23 24
2002 Aetna U.
S. Healthcare HMO 23 Section 5( a)
Physical, pulmonary and
occupational therapies You pay
Two consecutive months per condition,
beginning with the first day of treatment for each of the following:
Qualified physical therapies
Occupational therapy
Pulmonary
rehabilitation
NOTE: Occupational therapy is limited to services that
assist the
member to achieve and maintain self-care and improved functioning
in
other activities of daily living. Inpatient rehabilitation is covered
under
Hospital/ Extended Care Benefits.
Cardiac rehabilitation following angioplasty, cardiovascular surgery,
congestive heart failure or a myocardial infarction is provided for up
to 3 visits a week for a total of 18 visits.
Physical therapy to treat
temporomandibular joint (TMJ) dysfunction syndrome
$25 per visit,
Nothing during a covered
inpatient admission
Not covered:
Long-term rehabilitative therapy
All charges
Speech therapy
Two consecutive months per condition, beginning
with the first day of treatment $25 per visit, Nothing during a covered
inpatient admission
Hearing services (testing, treatment, and supplies)
Covered for
audiological testing and medically necessary treatment for hearing problems $20
per PCP visit $25 per specialist visit
Not covered:
Hearing aids, testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
Treatment of
eye diseases and injury $20 per PCP visit $25 per specialist visit
Corrective eyeglasses and frames or contact lenses (hard or soft) per 24
month period. All charges over $100
Routine eye refraction based on the
following schedule:
If member wears eyeglasses or contact lenses:
Age
1 through 18 once every 12-month period
Age 19 and over once every
24-month period
If member does not wear eyeglasses or contact lenses:
To age 45 once
every 36-month period
Age 45 and over once every 24-month period refractions
NOTE: See Preventive Care, Children, for eye exams for children
$25 per specialist visit
Vision services (testing, treatment, and supplies) Continued on the next
page 23
23 Page
24 25
2002 Aetna U. S. Healthcare HMO
24 Section 5( a)
Vision services (testing, treatment, and
supplies)
(Continued)
You pay
Not covered:
Fitting of contact lenses
Eye exercises
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 more information.
$20 per PCP visit
$25 per specialist 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)
Foot orthotics
Podiatric
shoe inserts
All charges
Orthopedic and prosthetic devices
External prosthetic devices
which replace all or part of an internal or external body organ or an external
body part
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy, orthopedic devices
such as braces and
prosthetic devices such as artificial limbs
Internal prosthetic devices,
such as artificial joints, pacemakers, cochlear implants, defibrillator,
surgically implanted breast implant
following mastectomy, and lenses following cataract removal. 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.
NOTE: Coverage includes repair and replacement when due to growth
or normal wear and tear.
Nothing
Not covered:
Orthopedic and corrective shoes not attached to a
covered brace
Arch supports
Foot orthotics
Heel
pads and heel cups
Lumbosacral supports
All charges 24
24 Page 25 26
2002 Aetna U.
S. Healthcare HMO 25 Section 5( a)
Durable medical equipment
(DME) You pay
Rental or purchase, including replacement, repair and
adjustment, of
durable medical equipment prescribed by your Plan Physician,
such as
oxygen equipment. Under this benefit, we also cover:
Hospital beds
Wheelchairs
Crutches
Walkers
Insulin pumps
NOTE: Some DME may require precertification by you or your physician.
Nothing
Not covered:
Elastic stockings and support hose
Bathroom equipment such as bathtub seats, benches, rails and lifts
Home modifications such as stairglides, elevators and wheelchair
ramps
All charges
Home health services
Home health care ordered by a Plan Physician
and provided by nurses and home health aides. Your Plan Physician will
periodically review
the program for continuing appropriateness and need.
Services include intravenous therapy and medications.
Nothing
Not covered:
Home care primarily for personal assistance that
does not include a medical component and is not diagnostic, therapeutic or
rehabilitative
All charges
Chiropractic care
Chiropractic services up to 20 visits per
calendar year
Manipulation of the spine and extremities
Adjunctive
procedures such as ultrasound, electric muscle stimulation, vibratory therapy
and cold pack application
$25 per specialist visit
Not covered: Any services not listed above All charges
Alternative treatments
No benefits All charges
Educational classes and programs
Asthma
Diabetes
Congestive heart failure
Low back pain
Coronary artery disease
Also see the Non-FEHB page for our Member Health Education,
Informed
Health Line and Intelihealth.
Nothing 25
25 Page
26 27
2002 Aetna U. S. Healthcare HMO
26 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
covered care.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by a physician or other health
care professional for your surgical care. Look in Section (c) for
charges associated with the facility (i. e. hospital, surgical center, etc.)
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES.
I
M
P
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T
A
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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.
This procedure must be approved in advance by the HMO.
Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization
Treatment of burns
NOTE: Generally, we pay for internal prosthesis (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.
$20 per PCP office visit,
$25 per specialist visit
Not covered:
Reversal of voluntary surgically-induced
sterilization
Surgery primarily for cosmetic purposes
Refractive eye surgery,
such as radial keratotomy
Blood and blood derivatives, except blood
derived clotting factors, and the storage of the patient's own blood for later
administration
All charges 26
26 Page 27 28
2002 Aetna U.
S. Healthcare HMO 27 Section 5( b)
Reconstructive surgery You
pay
Surgery to correct a functional defect
Surgery to correct a
condition caused by injury or illness if:
The condition produced a major
effect on the member's appearance
and
The condition can reasonably be expected to be corrected by such
surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
Surgery to produce a symmetrical appearance on the other breast;
Treatment of any physical complications, such as lymphedema;
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.
$25 per specialist visit
Not covered:
Cosmetic surgery any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, such as:
Treatment of fractures of the jaws or facial bones;
Surgical correction
of congenital defects, such as cleft lip and cleft palate;
Medically necessary surgical treatment of TMJ;
Removal of stones from
salivary ducts;
Excision of leukoplakia or malignancies;
Removal of bony
impacted wisdom teeth;
Excision of tumors and cysts
Other surgical
procedures that do not involve the teeth or their supporting structures.
$25 per specialist visit
Not covered:
Dental implants
Dental care involved
with the treatment of temporomandibular joint dysfunction
All charges 27
27 Page 28 29
2002 Aetna U.
S. Healthcare HMO 28 Section 5( b)
Organ/ tissue transplants
You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single Double
Pancreas
Intestinal transplants
(small intestine) and the small intestine with the liver or small intestine with
multiple organs such as the liver, stomach
and pancreas
Skin
Tissue
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
National Transplant Program (NTP) Transplants which are non-experimental or
non-investigational are a covered benefit. Covered
transplants must be ordered by your primary care doctor and plan
specialist physician and approved by our medical director in advance
of
the surgery. The transplant must be performed at hospitals
specifically
approved and designated by us to perform these
procedures. A transplant is
non-experimental and non-investigational
when we have determined, in our
sole discretion, that the medical
community has generally accepted the
procedure as appropriate
treatment for your specific condition. Coverage for
a transplant where
you are the recipient includes coverage for the medical
and surgical
expenses of a live donor, to the extent these services are not
covered
by another plan or program.
Limited Benefits Treatment for breast cancer, multiple myeloma and
epithelial ovarian cancer may be provided in an NCI-or NHI-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 related medical and hospital expenses of the donor
when we cover the recipient.
$25 per specialist office
visit and nothing for the
surgery
Not covered:
Transplants not listed as covered
All charges
28
28 Page 29
30
2002 Aetna U. S. Healthcare HMO 29
Section 5( b)
Anesthesia You pay
Professional services
provided in
Hospital (inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing 29
29 Page
30 31
2002 Aetna U. S. Healthcare HMO
30 Section 5( c)
Section 5 (c). Services provided by a
hospital or other facility, and ambulance services
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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 covered 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
covered care. Any costs associated with the professional charge (i. e.,
physicians, etc.) are covered in Section 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services
require precertification.
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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.
$200 per day up to a
maximum of $600 per
admission
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
The withdrawal, processing and storage of the patient's own blood
for later administration, and the administration of this blood to the patient
Serum, clotting factors and immunoglobulins
Blood or blood plasma, if
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
Nothing
Inpatient hospital Continued on the next page 30
30 Page 31 32
2002 Aetna U. S. Healthcare HMO 31 Section
5( c)
Inpatient hospital (Continued) You pay
Not covered: Blood and blood derivatives, except blood clotting
factors,
and the storage of the patient's own blood for later
administration.
All charges
Not covered:
Custodial care, rest cures, domiciliary or
convalescent cares
Personal comfort items, such as telephone and
television
All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Radiologic procedures, diagnostic laboratory tests, and X-rays when
associated with a medical procedure being done the same day
Pathology Services
Administration of blood, blood plasma, and other
biologicals
Blood or blood plasma, if 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.
$75 per day
Services not associated with a medical procedure being done the same
day,
such as:
Mammogram
Radiologic procedures
Heart catheterization
$25 per specialist visit
Not covered: Blood and blood derivatives, except blood clotting factors,
and the storage of the patient's own blood for later administration.
All
charges
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit: All necessary services during confinement in a
skilled nursing facility with a 90-day limit per calendar year when
full-time
nursing care is necessary and the confinement is medically
appropriate as determined by a Plan doctor and approved by the Plan.
Nothing
Not covered: custodial care All charges 31
31 Page 32 33
2002 Aetna U. S. Healthcare HMO 32 Section
5( c)
Hospice care You pay
Supportive and palliative care for
a terminally ill member in the home or
hospice facility, including inpatient
and outpatient care and family
counseling, when provided under the direction
of a Plan doctor, who
certifies the patient is in the terminal stages of
illness, with a life
expectancy of approximately 6 months or less.
Nothing
Ambulance
Ambulance service ordered or authorized by a Plan doctor
Nothing
Not covered: Ambulance services for routine transportation to
receive
outpatient or inpatient services.
All Charges 32
32 Page 33 34
2002 Aetna U. S. Healthcare HMO 33 Section
5( d)
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
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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:
If you need emergency care, you
are covered 24 hours a day, 7 days a week, anywhere in the world. An
emergency medical condition is one manifesting itself by acute symptoms of
sufficient severity such that a
prudent layperson, who possesses average
knowledge of health and medicine, could reasonably expect the
absence of
immediate medical attention to result in serious jeopardy to the person's
health, or with respect to a
pregnant woman, the health of the woman and her
unborn child.
Whether you are in or out of an Aetna U. S. Healthcare HMO service area, we
simply ask that you follow the
guidelines below when you believe you need
emergency care.
Call the local emergency hotline (ex. 911) or go to the nearest emergency
facility. If a delay would not be detrimental to your health, call your primary
care provider. Notify your primary care provider as soon as
possible after receiving treatment.
After assessing and stabilizing your
condition, the emergency facility should contact your primary care physician so
they can assist the treating physician by supplying information about your
medical history.
If you are admitted to an inpatient facility, you or a family member or
friend on your behalf should notify your primary care physician or us as soon as
possible.
What to Do Outside Your Aetna U. S. Healthcare HMO Service Area
Members who are traveling outside their HMO service area or students who
are away at school are covered
for emergency and urgently needed care.
Urgent care may be obtained from a private practice physician, a
walk-in
clinic, an urgent care center or an emergency facility. Certain conditions, such
as severe vomiting,
earaches, sore throats or fever, are considered "urgent
care" outside your Aetna U. S. Healthcare HMO service
area and are covered
in any of the above settings.
If, after reviewing information submitted to us by the provider that supplied
care, the nature of the urgent or
emergency problem does not qualify for
coverage, it may be necessary to provide us with additional
information. We
will send you an Emergency Room Notification Report to complete, or a Member
Services
representative can take this information by telephone. 33
33 Page 34 35
2002 Aetna U. S. Healthcare HMO 34 Section
5( d)
Follow-up Care after Emergencies All follow-up care should
be coordinated by your PCP. Follow-up care with nonparticipating providers is
only covered
with a referral from your primary care physician and
pre-approval from Aetna U. S. Healthcare. Whether you were
treated inside or
outside your Aetna U. S. Healthcare service area, you must obtain a referral
before any follow-up care
can be covered. Suture removal, cast removal,
X-rays and clinic and emergency room revisits are some examples of
follow-up
care.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, call you primary care doctor. In
extreme emergencies or if you are unable to contact your doctor, contact the
local emergency system (e. g. the 911
telephone system) or go to the nearest hospital emergency room. Be sure to
tell the emergency room personnel that you
are a Plan member so they can
notify your primary care doctor. You or a family member must notify your primary
care
doctor as soon as possible after receiving emergency care. It is your
responsibility to ensure that your primary care
doctor has been timely
notified.
If you need to be hospitalized, the Plan must be notified as soon as
possible. If you are hospitalized in non-Plan facilities
and a Plan doctor
believes care can be better provided in a Plan hospital, you will be transferred
when medically
feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by
non-participating providers must be approved by us or
provided by plan
providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified as soon as
possible. If a Plan doctor believes care can be better
provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance
charges covered in full.
To be covered by this Plan, any follow-up care recommended by
non-participating providers must be approved by us or
provided by plan
providers.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $20 per PCP visit $25 per specialist
visit
Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay
is
waived.
$75 per visit
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a
doctor's office $25 per specialist visit
Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay
is
waived.
$75 per visit
Emergency outside our service area Continued on the next page 34
34 Page 35 36
2002 Aetna U. S. Healthcare HMO 35 Section
5( d)
Emergency outside our service area (Continued)
You pay
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. Air
ambulance may be covered. Prior approval is required.
See 5( c) for non-emergency service.
Nothing for covered care
Not covered: air ambulance without prior approval All charges 35
35 Page 36 37
2002 Aetna U. S. Healthcare HMO 36 Section
5( e)
Section 5 (e). Mental health and substance abuse benefits
Network Benefit
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Parity
When you get our approval for services and follow a
treatment plan we approve,
cost-sharing and limitations for Plan mental
health and substance abuse benefits
will be no greater than for similar
benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions
after the benefits description below.
I
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Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.
NOTE: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing
responsibilities are no
greater than for other
illness or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers
Medication
management
$25 per visit
Diagnostic tests $25 per visit
Services provided by a hospital or other
facility
Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, facility based intensive
outpatient treatment
$25 per outpatient visit
Inpatient service:
Approved residential treatment facility
Hospital
service
$200 per day up to
a maximum of $600
per admission
Mental health and substance abuse benefits Continued on the next
page 36
36 Page
37 38
2002 Aetna U. S. Healthcare HMO
37 Section 5( e)
Mental health and substance abuse benefits
(Continued) You pay
Not covered:
Services we have not approved
Out of network mental health
and substance abuse services
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 the following authorization processes:
Contact Customer Services at 1-800-537-9384 to identify providers and
obtain information on the referral process.
Network limitation We may limit your benefits if you do not obtain a
treatment plan. 37
37 Page
38 39
2002 Aetna U. S. Healthcare HMO
38 Section 5( f)
Section 5 (f). Prescription drug benefits
I
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about
coordinating benefits with other coverage, including with Medicare.
Certain drugs require your doctor to get precertification from the Plan
before they can be prescribed under the Plan. Upon approval by the Plan, the
prescription is good for the current calendar year or a specified time
period,
whichever is less.
I
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There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist must
write the prescription.
Where you can obtain them. You must fill
non-emergency prescriptions at a Plan pharmacy for up to a 30-day supply, or by
mail for a 31-90 day supply of medication (if authorized by your physician).
Please
call Member Services at 1-800-537-9384 for more details on how to use the
mail order program. In an
emergency or urgent care situation, you may fill
your covered prescription at any retail pharmacy. If you
obtain your
prescription at a participating pharmacy and request direct reimbursement from
us, we will
review your claim to determine whether the claim is covered
under the terms and conditions of your
benefit plan. If you obtain your
prescription at a pharmacy that does not participate with the plan, you will
need to pay the pharmacy the full price of the prescription and submit a
claim for reimbursement subject to
the terms and conditions of the plan.
We use a formulary. Drugs are prescribed by Plan doctors and dispensed
in accordance with the Plan's drug formulary. The Plan's formulary does not
exclude medications from coverage, but requires a higher
copayment for nonformulary drugs. We cover nonformulary drugs when prescribed
by a Plan doctor at a
50% copayment. For covered nonformulary drugs you pay
50% of the negotiated rate for the drug between
the Plan and the
participating retail or mail order pharmacy. Certain drugs require your doctor
to get
precertification from the Plan before they can be prescribed under
the Plan. Visit our website at
www. aetnaushc. com/ feds to review
our Formulary Guide or call 1-800-537-9384.
Precertification. Your pharmacy benefits plan includes our
precertification program. Precertification helps encourage the appropriate and
cost-effective use of certain drugs. These drugs must be pre-authorized by
our Pharmacy Management Precertification Unit before they will be covered.
Only your physician or
pharmacist in the case of an antibiotic or analgesic
can request prior authorization for a drug.
The precertification program is based upon current medical findings,
manufacturer labeling, FDA
guidelines and cost information.
The drugs requiring precertification are subject to change. Visit our website
for the current Precertification
List.
These are the dispensing limitations. Covered prescription drugs
prescribed by a licensed physician or dentist and obtained at a Participating
Plan Pharmacy may be dispensed for up to a 30-day supply.
Members must obtain a 31-to 90 day supply of covered prescription medication
through mail order. A
generic equivalent will be dispensed if available,
unless your physician specifically requires a name brand.
Why use generic drugs? Generics contain the same active ingredients in
the same amounts as their brand name counterparts and must have been approved by
the FDA. By using generic drugs, when available,
most members see cost savings, without jeopardizing clinical outcome or
compromising quality.
When you have to file a claim. Send your
itemized bill( s) to: Aetna U. S. Healthcare, Pharmacy Management, Claim
Processing, P. O. Box 398106, Minneapolis, MN 55439-8106.
Prescription drug benefits Begin on the next page 38
38 Page 39 40
2002 Aetna U. S. Healthcare HMO 39 Section
5( f)
Benefit Description You pay
Covered medications and
supplies
We cover the following medications and supplies prescribed by a
Plan
physician or dentist and obtained from a Plan pharmacy or through our
mail order program:
Drugs for which a prescription is required by Federal law
Oral
contraceptive drugs
Insulin
Disposable needles and syringes need to
inject covered prescribed medication, including insulin
Diabetic supplies limited to lancets, alcohol swabs, urine test strips/
tablets, and blood glucose test strips
Contraceptive drugs and devices
Oral fertility drugs
Intravenous fluids and medications for home use, implantable drugs, such as
Norplant, IUDs and some injectable drugs are covered under
Medical and Surgical benefits. See Section 5( a) for details.
$10 per covered generic
formulary prescription/ refill
(up to a 30
day supply) or
$20 for a 31-to 90-day supply
through mail order
$20 per covered brand name
formulary prescription/ refill
(up to a 30
day supply) or $40
for a 31-to 90-day supply
through mail order.
50% of the negotiated rate
between the Plan and the
participating
retail or mail
order pharmacy per covered
non-formulary (generic or
brand) prescription/ refill.
Limited benefits
Drugs to treat sexual dysfunction are limited.
Contact the Plan for dose limits
Depo Provera is limited to 5 vials per calendar year
One diaphragm per
calendar year
50%
$20 copay per vial
$20 per diaphragm
Here are some things to keep in mind about our prescription drug program:
A generic equivalent may be dispensed if it is available, and where allowed
by law.
To request a copy of the Aetna U. S. Healthcare Medication Formulary Guide,
call 1-800-537-9384. The information in the Medication
Formulary Guide is
subject to change. Please visit our website at
www. aetnaushc. com/ feds
for current Medication Formulary Guide
information.
Covered medications and supplies Continued on the next page 39
39 Page 40 41
2002 Aetna U. S. Healthcare HMO 40 Section
5( f)
Covered medications and supplies (Continued)
You pay
Not covered:
Drugs available without a
prescription or for which there is a nonprescription equivalent available, (i.
e., an over-the-counter (OTC)
drug)
Drugs obtained at a non-Plan pharmacy except when related
to out-of-area emergency care
Vitamins and nutritional substances that can be purchased without
prescription.
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic
performance.
Smoking-cessation drugs and medication, including, but
not limited to, nicotine patches and sprays.
Injectable fertility drugs
Drugs used for the purpose of weight
reduction (i. e., appetite suppressants)
All charges 40
40 Page 41 42
2002 Aetna U.
S. Healthcare HMO 41 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Services for the deaf and
hearing-impaired
1-800-628-3323
Informed Health Line Provides eligible members with telephone access
to registered nurses experienced in providing information on a variety of health
topics.
Informed Health Line is available 24 hours a day, 7 days a week. You
may call Informed Health Line at 1-800-556-1555, Informed health Line
nurses cannot diagnose, prescribe medication or give medical advice.
Reciprocity benefit If you need to visit a participating primary care
physician for a covered service, and you are 50 mile or more away from home you
may visit a
primary care physician from our Plan's approved network.
Call 1-800-537-9384 for provider information and location
Select a
doctor from 3 primary care doctors in that area
The Plan will authorize you
for one visit and any tests or X-rays ordered by that primary care physician.
You must coordinate all subsequent visits through your own participating care
physician.
High-risk pregnancies The Aetna U. S. Healthcare Moms-to-Babies
Maternity Management Program TM helps members give their babies a healthy start
with
educational materials and services that complement covered benefits.
This
program includes nurse case management, educational materials, one
prenatal and one newborn home nurse visit, breast feeding information
and support, and other benefits.
Centers of Excellence for
transplants/ heart
surgery/ etc
Our National Medical Excellence Program coordinates services for
complicated or rare illnesses and transplants. The National Medical
Excellence Program is unique to Aetna U. S. Healthcare and has been created
for members with particularly difficult conditions such as rare cancers and
other complicated diseases and disorders.
Usually, the recommended treatment can be found in your area. But if your
needs extend beyond your region, the National Medical Excellence Program
may be available to send you to out-of-area experts.
The first priority is to determine an appropriate treatment program. If your
treatment program cannot be provided in the local area, we will arrange and
pay for covered care as well as related travel expenses to wherever the
necessary care is available. Prior approval is required.
Travel benefit/ services
overseas
Our National Medical Excellence Program is a case management program
that
provides consistency in the coordination of care for life threatening
and
complex illnesses. This includes bone marrow and solid organ
transplants,
investigational and new technology (when covered), and
unique services that
are offered at a limited number of medical facilities.
We also coordinate
care for members if they need covered care that is not
available in their
local area and if they become ill when traveling
temporarily outside the
Continental United States. 41
41 Page 42 43
2002 Aetna U.
S. Healthcare HMO 42 Section 5( h)
Section 5 (h). Dental
benefits
I
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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.
Your selected Plan primary care dentist must provide or arrange covered care.
We cover hospitalization for dental procedures only when a nondental
physical
impairment exists which makes hospitalization necessary to
safeguard the health of
the patient; we do not cover the dental procedure
unless it is described below.
Be sure to read Section 4, Your costs for covered services for
valuable information
about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
I
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A
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Accidental injury benefit
No benefits other than those listed
on the following schedule.
Dental Benefits You pay
Service
Diagnostic
Office visit
for oral evaluation limited to 2 visits per year
Bitewing x-rays limited
to 2 sets of bitewing x-rays per year
Entire x-ray series limited to 1
entire x-ray series in any 3 year period
Periapical x-rays and other dental
x-rays as necessary
Diagnostic models
Preventive
Prophylaxis (cleaning of teeth) limited to 2
treatments per year
Topical fluoride limited to 2 courses of treatment per
year and to
children under age 18
Oral hygiene instruction
Restorative (Fillings)
Amalgam (primary) 1 surface
Amalgam
(primary) 2 surfaces
Amalgam (primary) 3 surfaces
Amalgam (primary) 4
surfaces
Amalgam (permanent) 1 surface
Amalgam (permanent) 2 surfaces
Amalgam (permanent) 3 surfaces
Amalgam (permanent) 4 surfaces
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
Dental Benefits Continued on next page 42
42 Page 43 44
2002 Aetna U. S. Healthcare HMO 43 Section
5( h)
Dental Benefits (Continued) You pay
Service
Prosthodontics Removable
Denture adjustments (complete
or partial/ upper or lower)
Endodontics
Pulp cap direct
Pulp cap indirect
$5
$5
$5
NOTE: The above services are only covered when provided by your
selected participating primary care
dentist in accordance with the terms of
your Plan. If rendered by a participating specialist, they are provided
at reduced fees. Pediatric dentists are considered specialists. Certain
other services will be provided by your
selected participating primary care
dentist at reduced fees. A partial list appears below. Ask your selected
participating primary care dentist for a complete schedule of current
reduced member fees. All member fees
must be paid directly to the
participating dentist.
Each employee and dependent must select a primary care dentist from the
directory and include the dentist's
name on the enrollment or provider
selection form.
The following procedures are also available from your selected participating
primary care dentist up to the
maximum fee shown. These same services
received from a participating specialist may require you to pay a
fee that
is higher than the stated maximum. Call your selected participating primary
care dentist or
participating dental specialist for the specific fee in your
area.
Service
You pay up to
a maximum fee of
Diagnostic
Sealant per permanent tooth
Space maintainer
Restorative (Fillings)
Resin (anterior) 1 surface
Resin
(anterior) 2 surfaces
Resin (anterior) 3 surfaces
Resin (anterior) 4 or
more surfaces or incisal angle
Metallic inlay
$35
$560
$110
$145
$175
$190
$725
Prosthodontics, removable
Complete denture, (upper or lower)
Immediate denture (upper or lower)
Partial denture resin base (upper or
lower)
Partial denture cast metal framework with resin base (upper or lower)
Denture repairs
Add tooth to existing partial
Add clasp to existing
partial
$1,025
$1,110
$790
$1,200
$150
$135
$150
Dental Benefits Continued on the next page 43
43 Page 44 45
2002 Aetna U. S. Healthcare HMO 44 Section
5( h)
Dental Benefits (Continued)
Service
You pay up to
a maximum fee of
Prosthodontics, removable (Continued)
Denture rebase
Denture relines
Interim denture (complete or partial/ upper or lower)
Tissue conditioning
Prosthodontics, fixed
Bridge pontic
Metallic inlay/ onlay
Cast metal retainer for resin bonded prosthesis
Crown porcelain
Crown cast
Recement bridge
Post and core
Oral surgery
Extractions (nonsurgical and tissue impacted)
Anesthesia (general in office, first half-hour session)
$375
$325
$465
$110
$875
$815
$315
$860
$865
$85
$315
$475
$270
Periodontics (Gum treatment)
Gingivectomy per quadrant
Gingival curretage per quadrant
Periodontal surgery
Provisional
splinting
Scaling and root planing per quadrant
Periodontal maintenance
procedure
Endodontics (Root canal)
Therapeutic pulpotomy
Root canals
(anterior, bicuspid, molar) excluding final restoration
Apicoectomy
anterior
Orthodontics
Pre-orthodontic treatment visit
Fully banded case
(adult age 19 and over)
Fully banded case (child age 18 and under)
$315
$150
$760
$160
$150
$110
$125
$760
$510
$350
$5,625
$5,625
Specific fees vary by area of the country up to the stated maximum. Ask
your primary care dentist for a complete schedule of reduced fees.
Services not received from a participating dental provider are not
covered. We offer no other dental benefits than those shown above.
All
charges
When you have to file a claim Send your itemized bills to Aetna U. S.
Healthcare, One Imeson Place. 1 Imeson Park Drive, Bldg. 100, Mezz. Floor,
Jacksonville FL 32218. 44
44 Page 45 46
2002 Aetna U.
S. Healthcare HMO 45 Section 5( i)
Section 5 (i). Non-FEHB
benefits available to Plan members
The benefits and programs 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.
Intelihealth InteliHealth. com offers comprehensive health
information which is interactive and easy-to-use. Harvard
Medical School and
the University of Pennsylvania School of Dental Medicine help InteliHealth to
provide
trusted and credible health information to its users. InteliHealth
features include: a Drug Resource Center,
Disease and Condition Management
tools, Health Risk Assessments, the Harvard Symptom Scout (an
interactive
symptom checker that provides guidance about a variety of symptoms), Daily
Health News
and much more.
Vision One 1 You are eligible to receive substantial discounts on
eyeglasses, contact lenses, Lasik the laser vision
corrective procedure, and nonprescription items including sunglasses and
eyewear products through the Vision
One Program at more than 4,000 locations
across the country.
This eyewear discount enriches the routine vision care coverage provided in
your health plan, which includes
an eye exam from a participating provider.
If your health plan also includes coverage for eyewear such as
prescription
eyeglasses or contact lens, your out-of-pocket expense can be reduced when you
use Vision One
discount. You may purchase your eyewear at Vision One
locations at discounted rates, and your allowance will
automatically be
applied at point of purchase. You don't have to submit the receipt for
reimbursement. Your
allowance applies to prescription eyeglasses or
contact lenses only.
For more information on Vision One eyewear call toll free 1-800-793-8616. For
a referral to a Lasik provider,
call 1-800-422-6600.
Fitness Program Aetna U. S. Healthcare offers members access to
discounted fitness services provided by GlobalFit TM . Programs
offer Plan participants:
Low or discounted membership rates at
independent health clubs contracted with GlobalFit
Discounts on certain home
exercise equipment
To determine which program is offered in your area and to view a list of
included clubs, visit the GlobalFit
website at www. globalfit. com. If you
would like to speak with a GlobalFit representative, you can call the
GlobalFit Health Club Help Line at 1-800-298-7800.
1 Vision One is a registered trademark of Cole Vision. 45
45 Page 46 47
2002 Aetna U. S. Healthcare HMO 46 Section 6
Section 6. General exclusions things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not
cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness,
disease, injury, or condition and we agree, as discussed under
Services Requiring Our Prior Approval on
page 16.
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;
Procedures, 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;
Procedures, 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. 46
46 Page 47 48
2002 Aetna U.
S. Healthcare HMO 47 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your
identification card and pay your copayment, coinsurance,
or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital and
drug benefits In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance Claim Form. Facilities
will file on the UB-92 form. For claims questions and assistance, call us
at 1-800-537-9384.
When you must file a claim such as for out-of-area care submit it on
the HCFA-1500 or a claim form that includes the information shown
below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician or
facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer such as
the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your medical and
hospital claims to: Aetna U. S. Healthcare,
Inc., 1425 Union Meeting
Road, P. O. Box 1125, Blue Bell, PA 19422.
Submit your drug claims to: Aetna U. S. Healthcare, Pharmacy
Management, Claim Processing, P. O. Box 398106, Minneapolis, MN
55439-8106.
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. 47
47 Page
48 49
2002 Aetna U. S. Healthcare HMO
48 Section 8
Section