WINhealth Partners http://www.winhealthpartners.org
2002 A Health Maintenance Organization
Serving: Laramie, Carbon, Big Horn, Park, Goshen and Platte
Counties in Wyoming
Enrollment in this Plan is limited. You must live
or work in our Geographic service area to enroll. See page 6 for requirements.
Enrollment codes for this Plan:
PV1 Self Only PV2 Self and Family
Special notice: This Plan is offered for the first time under the
Federal Employees Health Benefits Program during the 2001 Open Season.
RI 73-809 1
1 Page
2 3
2002 WINhealth Partners 2
Table of Contents
Table of Contents
Page
Introduction………………………………………………………………….
........................................................................................4
Plain Language
.......................................................................................................................................................................................4
Inspector General Advisory
....................................................................................................................................................................4
Section 1. Facts about this HMO plan
...................................................................................................................................................6
How we pay providers
..........................................................................................................................................................6
Your
Rights...........................................................................................................................................................................6
Service
Area..........................................................................................................................................................................6
Section 2. We Are a New
Plan...............................................................................................................................................................7
Section 3. How you get care
.................................................................................................................................................................8
Identification
cards................................................................................................................................................................8
Where you get covered
care..................................................................................................................................................8
Plan providers
.................................................................................................................................................................8
Plan facilities
..................................................................................................................................................................8
What you must do to get covered care
..................................................................................................................................8
Primary
Care...................................................................................................................................................................8
Specialty Care
................................................................................................................................................................8
Hospital care
..................................................................................................................................................................8
Circumstances beyond our
control........................................................................................................................................9
Services requiring our prior
approval....................................................................................................................................9
Section 4. Your costs for covered services
..........................................................................................................................................10
Copayments
..................................................................................................................................................................10
Deductible.....................................................................................................................................................................10
Coinsurance
..................................................................................................................................................................10
Your out-of-pocket
maximum.............................................................................................................................................10
Section 5. Benefits
...............................................................................................................................................................................11
Overview.............................................................................................................................................................................11
(a) Medical services and supplies provided by physicians and other health
care professionals ....................................12
(b) Surgical and
anesthesia services provided by physicians and other health care
professionals.................................19
(c) Services provided by a
hospital or other facility, and ambulance
services...............................................................22
(d) Emergency services/accidents
..................................................................................................................................24
(e) Mental health and substance abuse benefits
.............................................................................................................26
(f) Prescription drug
benefits.........................................................................................................................................27
(g) Special features
.......................................................................................................................................................29
Flexible benefits
option.....................................................................................................................................29
(h) Dental
benefits..........................................................................................................................................................30
Section 6. General exclusions --things we don't
cover........................................................................................................................31
2
2 Page 3 4
2002 WINhealth Partners 3 Table of Contents
Table of Contents
Page
Section 7. Filing a claim for
covered services
.....................................................................................................................................32
Section 8. The disputed claims
process................................................................................................................................................33
Section 9. Coordinating benefits with other coverage
........................................................................................................................35
When you have…
Other health coverage
..................................................................................................................................................35
Original
Medicare........................................................................................................................................................35
Medicare managed care plan
......................................................................................................................................37
TRICARE/Workers' Compensation/Medicaid
...................................................................................................................37
Other Government
agencies................................................................................................................................................38
When others are responsible for
injuries.............................................................................................................................38
Section 10. Definitions of terms we use in this
brochure......................................................................................................................39
Section 11. FEHB facts
........................................................................................................................................................................40
Coverage
information........................................................................................................................................................40
No pre-existing condition limitation
.........................................................................................................................40
Where you get information about enrolling in the FEHB Program
..........................................................................40
Types of coverage available for you and your
family...............................................................................................40
When benefits and premiums start
............................................................................................................................41
Your medical and claims records are confidential
....................................................................................................41
When you
retire........................................................................................................................................................41
When you lose benefits
.....................................................................................................................................................41
When FEHB coverage ends
......................................................................................................................................41
Spouse equity
coverage............................................................................................................................................41
Temporary Continuation of Coverage (TCC)
..........................................................................................................41
Converting to individual coverage
...........................................................................................................................42
Getting a Certificate of Group Health Plan
Coverage..............................................................................................42
Long term care insurance is coming later in 2002
................................................................................................................................43
Index ......... .....
.....................................................................................................................................................................................44
Summary of Benefits
............................................................................................................................................................................45
Rates
.......................................................................................................................................................................................Back
cover 3
3 Page 4 5
2002 WINhealth Partners 4 Introduction/Plain Language/Advisory
Introduction
WINhealth Partners 2515 Warren Avenue, Suite 504
Cheyenne, WY 82001
This brochure describes the benefits of WINhealth
Partners under our contract (CS 2859) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This brochure
is the official statement of benefits. No oral
statement can modify or
otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits that were available before
January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002 and
changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
“you” means the enrollee or family member; "we"
means WINhealth Partners.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel
Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure,
let us know. Visit OPM's "Rate Us" feedback area at www.opm.gov/insure or e-mail us at fehbwebcomments@opm.gov. You may also
write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E
Street, NW Washington, DC 20415-3650.
Inspector General Advisory
Fraud increases the cost of health care
for everyone. If you suspect that a physician, pharmacy, or hospital has charged
you for services you did not receive, billed you twice
for the same service,
or misrepresented any information, do the following:
Call the provider and
ask for an explanation. There may be an error. If the provider does not resolve
the matter, call us at (307) 638-7700 and explain the
situation. If we do
not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
Stop health care fraud! 4
4 Page 5 6
2002 WINhealth
Partners 5 Introduction/Plain Language/Advisory
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 WINhealth Partners 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.
HMO’s emphasize preventive care such as routine office visits, physical
exams, well-baby care, and immunizations, in addition to treatment for illness
and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan providers, you may
have to
submit claim forms.
You should join an HMO because you prefer the plan’s
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will
be available and/or remain under
contract with us.
How we pay providers
We contract with individual
physicians, medical groups, and hospitals to provide the benefits in this
brochure. These Plan providers accept a negotiated payment from us, and you will
only be responsible for your copayments or coinsurance.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get
information about us, our networks, providers, and facilities. OPM’s FEHB
website (www.opm.gov/insure) lists the specific types of information that we
must
make available to you. Some of the required information is listed
below.
WINhealth Partners meets State Licensing requirements
WINhealth Partners has been in existence for 6 years
WINhealth Partners
is a not-for-profit organization
WINhealth Partners has initiated a thorough
procedure for handling complaints and grievance
If you want more information
about us, call (307) 638-7700, or write to 2515 Warren Avenue, Suite 504,
Cheyenne, WY 82001. You may also contact us by fax at (307) 638-7701 or visit
our website at www.winhealthpartners.org.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. This is where our providers practice. Our service area is:
Laramie, Carbon, Goshen, Platte, Big Horn and Park Counties in Wyoming.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will pay only for emergency care
benefits. We will not pay for any other health care services out of our service
area unless the services have prior
plan approval.
If you or a covered
family member move outside of our service area, you can enroll in another plan.
If your dependents live out of the area (for example, if your child goes to
college in another state), you should consider enrolling in a fee-for-service
plan or an HMO
that has agreements with affiliates in other areas. If you or
a family member move, you do not have to wait until Open Season to change plans.
Contact your employing or retirement office. 6
6
Page 7 8
2002
WINhealth Partners 7 Section 2
Section 2. We Are a New Plan
This Plan is new to the FEHB program. We are being offered for the first
time during the 2001 open season. 7
7 Page 8 9
2002 WINhealth
Partners 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it whenever you receive services from a Plan
provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use your copy
of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express
confirmation letter.
If you do not receive your ID card within 30 days after
the effective date of your enrollment, or if you need replacement cards, call us
at (307) 638-7700.
Where you get covered care You get care from “Plan providers” and
“Plan facilities.” You will only pay copayments, deductibles, and/or
coinsurance, and you will not have to file claims.
Plan providers
Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our members.
We credential Plan
providers according to national standards.
We list
Plan providers in the provider directory, which we update periodically. The list
is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in the provider directory, which
we update
periodically. The list is also on our website.
It depends on the type of
care you need. WINhealth Partners utilizes an integrated healthcare delivery
network that includes Physicians, Hospitals, allied health and
ancillary
service providers. You gain access to the network and its benefits by selecting
a contracted network Physician from the list of participating Wyoming
physicians. Your
local Physician will help coordinate your care within the
WINhealth Partners network.
Our Participating Provider Directory lists those
select Physicians, facilities, and ancillary service providers who participate
in our HMO. WINhealth Partners does strongly
encourage a long-term primary
relationship with a Physician or Physicians who understand the particular health
needs of each patient.
Primary care Your primary care physician can be any physician within
the WINhealth Partners' network of participating physicians. Your primary care
physician will provide most of
your health care.
WINhealth Partners is
an open access network. If you want to change primary care physicians or if your
primary care physician leaves the Plan, you do not need to notify us.
Specialty care WINhealth Partners is an open access system. You may
select any specialist physician within the WINhealth Partners' network of
participating physicians. You do not need a
referral to see a participating
specialist for needed care.
Hospital care Your Plan physician will
make necessary hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at (307) 638-7700. 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:
What you must do to get covered care 8
8
Page 9 10
2002
WINhealth Partners 9 Section 3
You are discharged, not merely
moved to an alternative care center; or
The day your benefits from your
former plan run out; or
The 92 nd day after you become a member of this
Plan, whichever happens first.
These provisions apply only to the benefits
of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable
efforts to provide you with the necessary care.
Your WINhealth Partners’
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 preauthorization. Your
physician must obtain preauthorization services such as:
All
transplants Durable medical equipment
Home health care Nursing home
admission
Infertility treatment Mental health/substance abuse
Magnetic
resonance imaging (MRI) CT scans
Any services outside of the WINhealth
Partners provider network
After your physician has obtained preauthorization
from us, a letter stating whether the requested service has been approved will
be sent to your physician and to you. Services
that are obtained without the
required physician referral and preauthorization may not be covered.
Services requiring our prior approval 9
9
Page 10 11
2002
WINhealth Partners 10 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 provider, facility, pharmacy, etc., when you receive services.
Example: When you see your physician you pay a copayment of $10 per office
visit.
Deductible A deductible is a fixed expense you must incur for
certain covered services and supplies before we start paying benefits for them.
Copayments do not count toward any
deductible.
The calendar year
deductible for the prescription drug benefit is $50 per person.
NOTE: If you
change plans during open season, you do not have to start a new deductible under
your old plan between January 1 and the effective date of your new
plan. If
you change plans at another time during the year, you must begin a new
deductible under your new plan.
And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your old
option to the
deductible of your new option.
Coinsurance
Coinsurance is the percentage of our negotiated fee that you must pay for
your care.
Example: In our Plan, you pay 20% of our allowance for durable
medical equipment.
After your copayment and coinsurance total $2,000 per
person or $4,000 per family enrollment in any calendar year, you do not have to
pay any more for covered services.
However, copayments for the following
services do not count toward your out-of-pocket maximum, and you must continue
to pay copayments for these services:
prescription drugs
Be sure to keep accurate records of your
copayments and coinsurance since you are responsible for informing us when you
reach the maximum.
Your out-of-pocket maximum for deductibles, coinsurance,
and
copayments 10
10 Page
11 12
2002 WINhealth Partners 11 Section 5
Section 5. Benefits
OVERVIEW
(See page 8 for how our benefits changed this year and
page 45 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain
claims forms, claims filing advice,
or more information about our benefits, contact us at (307) 638-7700
or at our website at www.winhealthpartners.org.
(a) Medical services and supplies provided by physicians and other health
care professionals........................................................ 12-18
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family
planning
Infertility services Allergy care
Treatment therapies Physical
and occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision
services (testing, treatment, and supplies) Foot care
Orthopedic and
prosthetic devices Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................................ 19-21
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..............................................................................
22-23
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/accidents
.................................................................................................................................................
24-25 Medical emergency Ambulance
(e) Mental health and substance abuse benefits
..................................................................................................................................26
(f) Prescription drug benefits
..............................................................................................................................................................27
(g) Special features
.............................................................................................................................................................................
29 Flexible benefits option
(h) Dental benefits
...............................................................................................................................................................................30
Summary of Benefits
............................................................................................................................................................................45
11
11 Page 12 13
2002 WINhealth Partners 12 Section 5(a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
Diagnostic and treatment services
Professional services of
physicians
In physician’s office
$10 per office visit
Professional services of physicians
In an urgent care center
Office
medical consultations
Second surgical opinion
$10 per office visit
At home $10 per home visit
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/MRI
Ultrasound
Electrocardiogram and EEG
Nothing 12
12 Page
13 14
2002 WINhealth Partners 13
Section 5(a)
Preventive care, adult You Pay
Routine
screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening – every five years
starting at age 50
Nothing
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Nothing
Routine pap test
Note: The office visit is covered if pap test
is received on the same day; see Diagnosis and Treatment, above.
Nothing
Routine mammogram –covered annually for adult women Nothing
Not
covered: Physical exams required for obtaining or continuing employment or
insurance, attending schools or camp, or travel. All charges.
Routine
Immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10
years, ages19 and over (except as provided for under Childhood immunizations)
Influenza/Pneumococcal vaccines, annually, age 65 and over
Nothing
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
Eye exams through age 17 to determine
the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (up to age 22)
$10 per office visit 13
13 Page 14 15
2002 WINhealth
Partners 14 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 need to precertify
your normal delivery; see page 22 for other circumstances, such as extended
stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend your
inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother’s maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits
(Section 5b).
$10 per office visit for the initial prenatal visit. Copayments will be
waived for
further prenatal visits.
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 under the prescription drug benefit.
$10 per office 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)
$10 per office visit
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization embryo transfer, gamete GIFT
and zygote ZIFT
Zygote transfer Services and supplies related to excluded ART
procedures
Cost of donor sperm Cost of donor egg
Oral and injectable fertility drug
All charges. 14
14 Page 15 16
2002 WINhealth
Partners 15 Section 5(a)
Allergy care You Pay
Testing
and treatment
Allergy injection
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges.
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 21.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous
(IV)/Infusion Therapy – Home IV and antibiotic therapy
Growth hormone
therapy (GHT)
NOTE: Growth hormone is covered under the prescription drug
benefit.
NOTE: We will only cover GHT when we preauthorize the treatment.
Call (307) 638-7700 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will only
cover GHT
services from the date you submit the information. If you do not ask or if we
determine GHT is not medically necessary, we will not
cover the GHT or
related services and supplies. See Services requiring our prior approval
in Section 3.
$10 per office visit
Not covered: All charges.
Physical and occupational therapies
Up to two consecutive months per condition for the services of each of
the following:
qualified physical therapists and occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to illness or injury.
$15 per office visit (physical therapy) $25 per office visit (occupational
therapy)
Nothing per visit during covered inpatient admission
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to $2,500 per year. $25 per visit
Not covered: long-term rehabilitative therapy
exercise
programs
All charges.
Speech therapy
Up to two consecutive months per condition. $25 per
visit. 15
15 Page
16 17
2002 WINhealth Partners 16
Section 5(a)
Hearing services (testing, treatment, and supplies)
You pay
First hearing aid and testing only when necessitated by
accidental injury
Hearing testing for children up to age 22 (see Preventive care, children)
$10 per office visit
Not covered: all other hearing testing
hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
Eye exam to
determine the need for vision correction for children through age 17 (see
Preventive care, children) $10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump
hose
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy. Note:
We pay
internal prosthetic devices as hospital benefits; see Section 5(c) for payment
information. See 5(b) for coverage of the surgery
to insert the device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
$10 per office visit
Orthopedic and prosthetic devices-Continued on next page 16
16 Page 17 18
2002 WINhealth Partners 17 Section 5(a)
Orthopedic and prosthetic devices (Continued) You pay
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel
cups
lumbosacral supports
corsets, trusses, elastic
stockings, support hose, and other supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
All charges.
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
oxygen
services and supplies
blood glucose monitors; and
insulin pumps.
NOTE: Durable medical equipment must be preauthorized. Call us at (307)
638-7700 as soon as your Plan physician prescribes this equipment.
We will arrange with a health care provider to rent or sell you durable
medical equipment at discounted rates and will tell you more about this
service when you call.
20% of charges up to plan maximum of $5,000 per calendar year
Not covered: Medical supplies used for comfort, personal hygiene,
convenience,
or first aid – support hose, bandages, adhesive tape gauze,
antiseptics.
All charges.
Home health services
Home health care ordered by a Plan physician
and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.),
licensed
vocational nurse (L.V.N.), or home health aide.
Services include oxygen
therapy, intravenous therapy and medications. Preauthorization is required
for home health services. Call (307)
638-7700 to notify us before your home health services begin.
Nothing
Home health services – continued on next page 17
17 Page 18 19
2002 WINhealth Partners 18 Section 5(a)
Home health services (Continued) You pay
Not
covered: nursing care requested by, or for the convenience of, the
patient or
the patient’s family; Private duty nursing
Transportation Home care primarily for personal assistance
that does not include a medical
component and is not diagnostic,
therapeutic, or rehabilitative.
All charges.
Chiropractic
Manipulation of the spine and extremities
X-rays
related to chiropractic services
$15 per office visit with a maximum annual benefit of $500
Not covered:
Adjunctive procedures such as ultrasound, electrical
muscle stimulation, vibratory therapy, and cold pack application
All charges.
Alternative treatments
Not covered: All services All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation. Drugs are not covered.
Diabetes self-management,
self-management training and education shall be limited to:
-A one-time evaluation and training program when medically necessary, within
one (1) year of diagnosis;
-Additional medically necessary self-management
training shall be provided upon a significant change in symptoms, condition or
treatment. This additional training shall be limited to three (3) hours per
year.
$10 per office visit 18
18 Page 19 20
2002 WINhealth
Partners 19 Section 5(b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this
brochure and are payable only when we
determine they are medically necessary. Plan physicians must provide or arrange
your care.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional
for your surgical care. Look in Section 5(c) for
charges associated with the facility (i.e. hospital, surgical center, etc.).
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of
amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see
reconstructive surgery)
Surgical treatment of morbid obesity --a condition
in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible members must be
age 18 or over
Insertion of internal prosthetic devices. See 5(a) – Orthopedic and
prosthetic devices for device coverage information
$10 per office visit. Nothing for hospital visits
Voluntary sterilization
Treatment of burns
NOTE: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.
Nothing
Not covered: Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
All charges. 19
19 Page 20 21
2002 WINhealth Partners 20 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.
Nothing
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
NOTE:
If you need a mastectomy, you may choose to have the procedure performed on an
inpatient basis and remain in the hospital up
to 48 hours after the
procedure.
Nothing
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges.
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
$10 per office visit
Not covered: Oral implants and transplants
Procedures
that involve the teeth or their supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
TMJ surgery and medical
services.
All charges. 20
20 Page 21 22
2002 WINhealth
Partners 21 Section 5(b)
Organ/tissue transplants You pay
Limited to:
Cornea
Heart
Heart/Lung
Kidney
Kidney/Pancreas
Liver
Lung: Single – Double
Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow
transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic
or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma;
epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas National Transplant Program (NTP)
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-
approved clinical
trial at a Plan-designated center of excellence and if approved by the Plan’s
medical director in accordance with the
Plan’s protocols.
NOTE: We cover
related medical and hospital expenses of the donor when we cover the recipient.
Nothing
Anesthesia
Professional services provided in –
Hospital
(inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
Nothing 21
21 Page
22 23
2002 WINhealth Partners 22
Section 5(c)
Section 5 (c). Services provided by a hospital or
other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by the
facility (i.e., hospital or surgical center) or ambulance service for your
surgery or care. Any costs associated with the professional charge
(i.e., physicians, etc.) are covered in Sections 5(a) or (b).
YOUR
PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as: Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products Blood or blood plasma, if not donated or replaced
Dressings,
splints, casts, and sterile tray services Medical supplies and equipment,
including oxygen
Anesthetics, including nurse anesthetist services Take-home
items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home (NOTE: calendar year
deductible
applies.)
Nothing
Not covered: Custodial care
Non-covered facilities, such
as nursing homes, schools Personal comfort items, such as telephone,
television, barber
services, guest meals and beds Private nursing
care
All charges. 22
22 Page 23 24
2002 WINhealth
Partners 23 Section 5(c)
Outpatient hospital or ambulatory
surgical center You Pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives replaced by the member All
charges.
Extended care benefits/skilled nursing care facility
benefits
Skilled nursing facility (SNF): 100 days Nothing
Not covered: custodial care All charges.
Hospice care
Covered for up to 6 months Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically
appropriate $100 per trip with a maximum benefit of $4,000 per trip 23
23 Page 24 25
2002 WINhealth Partners 24 Section 5(d)
Section 5 (d). Emergency services/accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some problems
are emergencies
because, if not treated promptly, they might become more serious; examples
include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies – what they all have in
common is the need for quick action.
What to do in case of emergency:
In order to receive benefits, you
must contact your WINhealth Partners’ physician who is a participating WINhealth
Partners provider before you are treated in an emergency facility. You must then
inform WINhealth Partners of your visit. If your
physical condition demands
immediate treatment and time does not permit contacting a Physician, call 911 or
go to the nearest emergency facility, then contact your Physician and WINhealth
Partners within 48 hours.
Emergencies within our service area: Notify your physician of the
emergency and contact WINhealth Partners within 48 hours of the service, or as
soon as reasonably possible. The $35 copayment will be charged for emergency
room
treatment, but will be waived if you are hospitalized.
Emergencies outside our service area: Benefits are available
for emergencies that occur outside our service area. Notify WINhealth Partners
of the emergency room service within 48 hours or as soon as reasonably possible.
The $35
copayment will be charged for emergency room treatment, but will be waived
if you are hospitalized. If you are hospitalized outside the service area and
your physician believes care can be better provided in a Plan hospital, you will
be transferred
when medically feasible. Follow-up services after the
emergency room care must be rendered by a Plan physician.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
$10 per office visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $35 per outpatient hospital visit
Not covered: Elective
care or non-emergency care All charges. 24
24
Page 25 26
2002
WINhealth Partners 25 Section 5(d)
Emergency outside our
service area You Pay
Emergency care at a doctor's office Emergency care
at an urgent care center $10 per office visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $35 per outpatient hospital visit
Not covered:
Elective care or non-emergency care
Emergency care
provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5(c) for non-emergency service.
$100 per trip. Maximum
benefit per trip of $4,000
Not covered: ambulance service provided due to the absence of another form
of transportation or solely for your convenience. All charges. 25
25 Page 26 27
2002 WINhealth Partners 26 Section 5(e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for similar benefits for other
illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
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
$10 per visit
Diagnostic tests Nothing
Services provided by a hospital or other
facility Nothing
Not covered: Services we have not approved.
NOTE: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
Members access their mental health/substance abuse benefit by calling the
(307) 638-7700. It is not necessary to get approval from your physician to
obtain
preauthorization for mental health services, but you must notify
WINhealth Partners prior to seeking treatment.
Limitations We may limit your benefits if you do not obtain a
treatment plan. 26
26 Page
27 28
2002 WINhealth Partners 27
Section 5(f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
The prescription drug deductible is: $50 per person. The calendar year
deductible applies to almost all benefits in this Section. We added "(No
deductible)" to show when the calendar year deductible does not apply.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A plan physician must write the
prescription.
Where you can obtain them. You may fill the
prescription at a participating pharmacy, a non-network pharmacy, or by mail.
You must fill the prescription at a plan pharmacy, or by mail for a maintenance
medication.
We use a formulary. We cover non-formulary drugs
prescribed by a Plan doctor. The formulary represents a preferred drug list that
has been selected to meet patient's needs at a lower cost. Benefits for
prescription
drugs are determined using the formulary. Those covered brand and generic
prescriptions that are listed on the formulary will be subject to the lowest
applicable brand or generic copayment. Those covered
prescriptions that are
not listed on the formulary will be subject to the highest copayment.
We
have an open formulary. If your physician believes a name brand product is
necessary or there is no generic available, your physician may prescribe a name
brand drug from a formulary list. This list of name
brand drugs is a preferred list of drugs that we select to meet patient needs
at a lower cost. To order a prescription drug brochure, call (307) 638-7700.
These are the dispensing limitations. Prescriptions may be obtained
from a retail pharmacy in a 34-day supply. A 90-day supply is available through
the mail-order option. A generic equivalent will be dispensed if
it is
available, unless your physician specifically requires a name brand. If you
receive a name brand drug when a Federally-approved generic drug is available,
and your physician has not specified Dispense as
Written for the name brand
drug, you have to pay the applicable brand copayment plus the difference in cost
between the name brand drug and the generic.
Why use generic drugs? Generic drugs offer a safe and economic way to
meet your prescription drug needs. The generic name of a drug is its chemical
name; the name brand is the name under which the manufacturer
advertises and
sells a drug. Under federal law, generic and name brand drugs must meet the same
standards for safety, purity, strength, and effectiveness. A generic
prescription costs you --and us --less than a name
brand prescription.
Generic drugs are less expensive than brand name drugs; therefore, you may
reduce your out-of-pocket costs by choosing to use a generic drug.
When you have to file a claim. Participating pharmacies will file
claims for you. Should you have to file a claim, contact us and we will assist
you with your claim. 27
27 Page 28 29
2002 WINhealth
Partners 28 Section 5(f)
Benefit Description You pay After the
calendar year deductible
NOTE: The calendar year deductible applies to
almost all benefits in this Section. We say "(No deductible)" when it does not
apply.
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan physician and obtained from a Plan
pharmacy or through our mail order
program: Drugs and medicines that by Federal law of the United States
require a physician’s prescription for their purchase, except those listed
as Not covered.
Insulin Disposable needles and syringes for the
administration of covered
medications Drugs for sexual dysfunction (see
Prior authorization below)
Contraceptive drugs and devices
Preauthorization Requirements:
Some prescription drugs need
preauthorization before benefits will be available. A drug is authorized for the
length of treatment not to exceed
a one-year period of time. Call us at (307) 638-7700 when your physician
prescribes these drugs to assure the preauthorization is in
place. Drugs
needing Preauthorization by WINhealth Partners include: Injectable medications
Impotency Agents Interferon/Intron/Avonex
Growth Hormones Accutane
Drugs for adult acne ADD/ADHD medication such as Ritalin for adults over 19
years of age
Drugs exceeding $500 per month (or $750 when using mail
service) Prescriptions written by a non-participating provider except in
emergency situations
$50 deductible per year, per member, and
$ 10 per prescription for
generic
$ 15 per prescription for preferred brand
$ 40 per prescription
for non-preferred drugs
Mail order drugs are covered for a 90-day supply subject to the following
copayments:
No deductible
$20 member copayment for generic drugs
$30 member copayment for preferred brand drugs
$80 member copayment for
non-preferred drugs
NOTE: If there is no generic equivalent available, you will still have to pay
the
brand name copay.
Not covered:
Oral and injectable fertility drugs
Drugs and supplies for cosmetic purposes
Vitamins,
nutrients and food supplements even if a physician prescribes or administers
them
Nonprescription drugs
Smoking cessation drugs and medications,
including nicotine patches
Drugs to enhance athletic performance
Drugs obtained at a
non-Plan pharmacy except for out-of-area emergencies
All charges. 28
28 Page 29 30
2002 WINhealth
Partners 29 Section 5(g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
High risk pregnancies Our nurses will work with you through the course
of your pregnancy to assure that you get the necessary medical care. If you have
a high risk pregnancy, call our medical management department at (307) 638-7700.
Centers of excellence for transplants We offer transplant candidates
access to a national network of transplant centers. 29
29 Page 30 31
2002 WINhealth Partners 30 Section 5(h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We do not cover
hospitalization for dental procedures; we do not cover the dental procedure
unless it is described below.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but
not replace) sound natural teeth. The need for these services must
result from an accidental injury.
$10 office visit
Dental benefits
We have no other dental benefits. 30
30 Page 31 32
2002 WINhealth Partners 31 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury,
or condition.
We do not cover the
following:
Care by non-Plan providers except for authorized referrals or
emergencies (see Emergency Benefits);
Services, drugs, or supplies you
receive while you are not enrolled in this Plan;
Services, drugs, or
supplies that are not medically necessary;
Services, drugs, or supplies not
required according to accepted standards of medical, dental, or psychiatric
practice;
Experimental or investigational procedures, treatments, drugs or
devices;
Services, drugs, or supplies related to abortions except when the
life of the mother would be in danger if the fetus were carried to term or when
the pregnancy is a result of active rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program. 31
31 Page
32 33
2002 WINhealth Partners 32
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 In most cases, providers and facilities file
claims for you. Physicians must file on the Drug benefits form HCFA-1500,
Health Insurance Claim Form. Facilities will file on the UB-92 form.
For
claims questions and assistance, call us at (307) 638-7700.
When you must
file a claim --such as for out-of-area care --submit it on the HCFA-1500 or a
claim form that includes the information shown below. Bills and receipts should
be
itemized and show:
Covered member’s name and ID number;
Name and
address of the physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to:
WINhealth Partners, 2515 Warren Ave., Suite 504, Cheyenne, WY 82001
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. 32
32 Page
33 34
2002 WINhealth Partners 33
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: P. O. Box 652, Cheyenne, WY
82003; and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request—go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us --if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs
Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
The Disputed Claims process (Continued)
Send OPM the
following information:
A statement about why you believe our decision was
wrong, based on specific benefit provisions in this brochure;
Copies of
documents that support your claim, such as physicians' letters, operative
reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim. 33
33 Page 34 35
2002 WINhealth
Partners 34 Section 8
Note: You are the only person who has a
right to file a disputed claim with OPM. Parties acting as your representative,
such as medical providers, must include a copy of your specific written consent
with the review request.
Note: The above deadlines may be extended if you
show that you were unable to meet the deadline because of reasons beyond your
control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM’s decision,
your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in
which you received the disputed services, drugs, or supplies or from the year in
which you were denied precertification or prior approval. This is the only
deadline that may not
be extended.
OPM may disclose the information it
collects during the review process to support their disputed claim decision.
This information will become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was before OPM when
OPM decided to
uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/prior approval, then call us at (307) 638-7700 or (800)
868-7670 and we will expedite our review; or
(b) We denied your initial
request for care or preauthorization/prior approval, then:
If we expedite
our review and maintain our denial, we will inform OPM so that they can give
your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/606-0737
between 8 a.m. and 5 p.m. eastern time. 34
34
Page 35 36
2002
WINhealth Partners 35 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health care expenses
without regard to
fault. This is called “double coverage.”
When you have
double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary payer. We, like
other insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will
not pay more than our allowance.
What is
Medicare? Medicare is a Health Insurance Program for:
People 65 years of
age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring
dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was
a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if
you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement
check.
If you are eligible for Medicare, you may have choices
in how you get your health care. Medicare + Choice is the term used to describe
the various health plan choices available
to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and is
the way most people
get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay
your share. Some things
are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care.
The Original Medicare Plan 35
35 Page 36 37
2002 WINhealth
Partners 36 Section 9
The following chart illustrates whether
the Original Medicare Plan or this Plan should be the primary payer for
you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly
Primary Payer Chart
Then the primary payer is… A. When either you
--or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Areanactiveemployee with
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability), !
2) Are an annuitant, !
!
3) Are a reemployed annuitant with the Federal government when…
a)
The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.) !
4) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court
judge who retired under Section 7447 of title 26, U.S.C. (or if your
covered spouse is this type of judge), !
5) Are enrolled in Part B only,
regardless of your employment status, ! (for Part B services) ! (for other
services)
6) Are a former Federal employee receiving Workers’ Compensation
and the Office of Workers’ Compensation Programs has determined that
you are
unable to return to duty,
!
(except for claims related to Workers’
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD, !
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD, !
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision, !
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or !
b) Are an active employee, or !
c) Are a former spouse of an annuitant,
or !
d) Are a former spouse of an active employee !
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare 36
36
Page 37 38
2002 WINhealth Partners 37 Section 9
Claims process when
you have the Original Medicare Plan --You probably will never have to file a
claim form when you have both our Plan and the Original Medicare Plan.
When
we are the primary payer, we process the claim first.
When Original Medicare
is the primary payer, Medicare processes your claim first.
In most cases,
your claims will be coordinated automatically and we will pay the balance of
covered charges. You will not need to do anything. To find out if you
need to do something about filing your claims, call us at (307) 638-7700
We waive some costs when you have the Original Medicare Plan--When
Original Medicare is the primary payer, we not waive any out-of-pocket costs.
Medical services and supplies provided by physicians and other health care
professionals. We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+Choice plan --a Medicare managed care plan.
These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you can only go to doctors, specialists, or hospitals that
are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care
plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www.medicare.gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You
may enroll in our Medicare managed care plan and also remain enrolled in our
FEHB plan. In this case, we do/do not
waive any of our copayments,
coinsurance, or deductibles for your FEHB coverage. {HMO-Add only if you have
one--tailor waiver text}
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan’s Medicare managed care plan and also remain enrolled in
our FEHB plan.
We will still provide benefits when your Medicare managed
care plan is primary, even out of the managed care plan's network and/or service
area (if you use our Plan
providers), but we will not waive any of our
copayments, coinsurance, or deductibles. If you enroll in a Medicare managed
care plan, tell us. We will need to know whether you
are in the Original
Medicare Plan or in a Medicare managed care plan so we can correctly coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a
Medicare managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your Medicare managed care plan premium.) For information
on
suspending your FEHB enrollment, contact your retirement office. If you
later want to reenroll in the FEHP program, generally you may do so only at the
next open season
unless you involuntarily lose coverage or move out of
Medicare managed care plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare Part B
and, if you can't
get premium-free Part A, we will not ask you to enroll in
it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.
If you do not enroll in Medicare Part A or Part B 37
37 Page 38 39
2002 WINhealth Partners 38 Section 9
Workers’ Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers’
Compensation Programs (OWCP) or a similar Federal or State agency determines
they
must provide; or
OWCP or a similar agency pays for through a third party
injury settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible for injuries When you receive money to
compensate you for medical or hospital care for injuries or illness caused by
another person, you must reimburse us for any expenses we paid.
However, we
will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 38
38 Page
39 40
2002 WINhealth Partners 39
Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same
year.
Coinsurance
Coinsurance is the percentage of our allowance that you must pay for your
care. See page 10.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 10.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Custodial care is defined to be non-medically necessary care that has been
determined to be primarily for your maintenance or care that has been designed
essentially to assist you
in meeting your activities of daily living.
Activities of daily living include, but are not limited to, bathing, turning,
dressing, walking, taking oral medications, and feeding.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for those services. See page 10.
The Plan’s Medical Director and Board of
Directors review experimental or investigational cases based on specific
information. Consultation with other outside
physicians within a specialty
is often sought as a part of the review process. The
experimental/investigational status of a treatment, procedure, or technique is
evaluated
based on publications and research. The Plan’s Pharmacy and
Therapeutics committee reviews information on a regular basis regarding new
experimental/investigational
medical technologies to determine potential
treatments which should be made available to you.
Group health coverage A body of subscribers who are eligible for
health care insurance by virtue of some common identifying attribute such as
employment by an employer, or membership in a
union, association, or other
such organization who can purchase health care insurance as a group. Generally,
all members of such a body of subscribers has similar health care
benefits
or may receive a core benefit package, similar exclusions, and have similar
health care benefits or may receive a core benefit package, similar exclusions,
and have
the ability to purchase riders of additional areas of coverage such
as prescription drugs or eyeglasses.
Medical necessity "Medical Necessity" means those Health Care Services
and supplies, as determined by WINhealth Partners on a case-by-case basis, that
are appropriate and necessary to meet
the basic health needs of a Member. To
qualify as Medically Necessary, a health care service or supply must be:
consistent with the diagnosis of and prescribed course of treatment for the
Member's condition;
consistent with sound and valid standards for preventive
care; required to prevent the Member's condition from worsening;
consistent
with the local medical standards of the community and considered appropriate for
the Member's condition; and
performed in the most cost-efficient type of
setting appropriate for the condition.
Plan allowance Plan allowance
is the amount we use to determine our payment and your coinsurance for covered
services. Plans determine their allowances in different ways. We determine our
allowance the reasonable and customary charge. Participating Plan
providers will accept the plan allowance as payment in full.
Us/We Us and we refer to WINhealth Partners.
You You refers
to the enrollee and each covered family member.
Experimental or investigational services 39
39 Page 40 41
2002 WINhealth Partners 40 Section 11
Section 11. FEHB facts
No pre-existing condition limitation
We will not refuse to cover the treatment of a condition that you had before
you enrolled in this Plan solely because you had the condition before you
enrolled.
Where you can get information about enrolling in the
FEHB Program
See www.opm.gov/insure. Also, your employing or retirement office can answer
your questions, and give you a Guide to Federal Employees Health Benefits
Plans, brochures
for other plans, and other materials you need to make
an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don’t determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your employing or
retirement office.
Types of coverage available for you and your family Self Only coverage
is for you alone. Self and Family coverage is for you, your spouse, and your
unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for.
Under certain circumstances, you may also continue coverage for a disabled child
22 years of age or
older who is incapable of self-support.
If you have a Self Only
enrollment, you may change to a Self and Family enrollment if you marry, give
birth, or add a child to your family. You may change your enrollment 31
days
before to 60 days after that event. The Self and Family enrollment begins on the
first day of the pay period in which the child is born or becomes an eligible
family
member. When you change to Self and Family because you marry, the
change is effective on the first day of the pay period that begins after your
employing office receives your
enrollment form; benefits will not be
available to your spouse until you marry.
Your employing or retirement
office will not notify you when a family member is no longer eligible to
receive health benefits, nor will we. Please tell us immediately when
you
add or remove family members from your coverage for any reason, including
divorce, or when your child under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another FEHB
plan. 40
40 Page
41 42
2002 WINhealth Partners 41
Section 11
When benefits and premiums start The benefits in
this brochure are effective on January 1. If you joined this Plan during Open
Season, your coverage begins on the first day of your first pay period that
starts on
or after January 1. Annuitants’ coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing
office will tell you the effective
date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the following records are confidential
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
Law enforcement officials when investigating and/or
prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse
equity coverage If you are divorced from a Federal employee or annuitant,
you may not continue to get benefits under your former spouse’s enrollment. But,
you may be eligible for your own
FEHB coverage under the spouse equity law. If you are recently divorced or
are anticipating a divorce, contact your ex-spouse’s employing or retirement
office to get RI
70-5, the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage
choices.
Temporary Continuation
If you leave Federal service, or if you lose coverage because you no longer
qualify as a of coverage (TCC) family member, you may be eligible for
Temporary Continuation of Coverage (TCC).
For example, you can receive TCC
if you are not able to continue your FEHB enrollment after you retire, if you
lose your job, if you are a covered dependent child and you turn 22
or
marry, etc.
You may not elect TCC if you are fired from your Federal job due
to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which
describes TCC, and the RI 70-5, the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage
and Former Spouse
Enrollees, from your employing or retirement office or from
www.opm.gov/insure. It explains what you have to do to enroll. 41
41 Page 42 43
2002 WINhealth Partners 42 Section 11
Converting to
You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled
your coverage or did not pay your premium, you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days after you receive
this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us
within 31 days
after you are no longer eligible for coverage.
Your
benefits and rates will differ from those under the FEHB Program; however, you
will not have to answer questions about your health, and we will not impose a
waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of Group Health Plan
Coverage
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a
Federal law that offers limited Federal protections for health coverage
availability and continuity
to people who lose employer group coverage. If
you leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have
been enrolled with us. You can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting periods,
limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If
you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB
Program. See also the FEHB web site
(www.opm.gov/insure/archive/health); refer
to the "TCC and HIPAA" frequently asked question. These highlight HIPAA rules,
such as the requirement that Federal employees must
exhaust any TCC
eligibility as one condition for guaranteed access to individual health coverage
under HIPAA, and have information about Federal and State agencies you can
contact for more information. 42
42 Page 43 44
2002 WINhealth Partners 43 Long Term Care Insurance
Long
Term Care Insurance Is Coming Later in 2002!
The Office of Personnel
Management (OPM) will sponsor a high-quality long-term care insurance program
effective in October 2002. As part of its educational effort, OPM asks you to
consider these questions:
It’s insurance to help pay for long term care
services you may need if you can’t take care of yourself because of an extended
illness or injury, or an age-related disease
such as Alzheimer’s. LTC
insurance can provide broad, flexible benefits for nursing home care, care in an
assisted living facility, care in your home, adult day care, hospice care,
and more. LTC insurance can supplement care provided by family members, reducing
the
burden you place on them.
Welcome to the club! 76% of Americans
believe they will never need long term care, but the facts are that
about
half them will. And it’s not just the old folks. About 40% of people needing
long-term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc. We hope you will
never need long term care, but everyone should have a plan just in
case.
Many people now consider long-term care insurance to be vital to their financial
and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that’s
before inflation! Long-term care can easily exhaust your savings.
Long-term care insurance can
protect your savings.
Not FEHB. Look
at the "Not covered" blocks in sections 5(a) and 5(c) of your FEHB
brochure. Health plans don’t cover custodial care or a stay in an assisted
living facility or a continuing need for a home health aide to help you get
in and out of bed and with other activities of daily living. Limited stays in
skilled nursing
facilities can be covered in some circumstances. Medicare
only covers skilled nursing home care (the highest level of nursing care)
after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100-day limit.
Medicaid covers long term care for
those who meet their state’s poverty guidelines, but has restrictions on covered
services and where they can be received. Long-term
care insurance can
provide choices of care and preserve your independence.
Employees will
get more information from their agencies during the LTC open enrollment period
in the late summer/early fall of 2002.
Retirees will receive information at
home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you can
learn more about the program on our web site at www.opm.gov/insure/archive/ltc.
Many FEHB enrollees think that their health plan and/or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care (LTC) insurance?
I’m healthy. I won’t need long
term care. Or, will I?
Is long term care expensive?
But won’t my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for this new
insurance coverage?
How can I find out more about the program NOW? 43
43 Page 44 45
2002 WINhealth Partners 44 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury 30
Allergy tests 15
Alternative treatment 18 Allogenetic (donor) bone marrow
transplant 21 Ambulance 23
Anesthesia 19 Autologous bone marrow
transplant 21
Biopsies 19 Birthing centers 14
Blood and blood plasma 22
Breast cancer screening 13
Casts 22 Catastrophic protection 45
Changes
for 2002 43 Chemotherapy 15
Childbirth 14 Chiropractic 18
Cholesterol
tests 13 Circumcision 14
Claims 32 Coinsurance 39
Colorectal cancer
screening 13 Congenital anomalies 19
Contraceptive devices and drugs 14
Coordination of benefits 36
Covered charges 37 Covered providers 6
Crutches 17 Deductible 10
Definitions 39 Dental care 30
Diagnostic
services 12 Disputed claims review 33
Donor expenses (transplants) 21
Dressings 22
Durable medical equipment (DME) 17 Educational classes and
programs 18
Effective date of enrollment 39 Emergency 24
Experimental or
investigational 39 Eyeglasses 16
Family planning 14 Fecal occult blood test
13
General Exclusions 31 Hearing services 16
Home health services 17 Hospice
care 23
Home nursing care 23 Hospital 8
Immunizations 13
Infertility 14
Inhospital physician care 22 Inpatient Hospital Benefits 22
Insulin 28 Laboratory and pathological
services 22 Machine diagnostic
tests 12
Magnetic Resonance Imagings (MRIs) 12
Mail Order Prescription
Drugs 27
Mammograms 12 Maternity Benefits 14
Medicaid 38 Medically
necessary 39
Medicare 43 Mental Conditions/Substance
Abuse Benefits 26
Neurological testing 12
Newborn care 14 Non-FEHB Benefits 42
Nurse Licensed Practical Nurse 17
Nurse Anesthetist 17 Nurse Midwife 17
Nurse Practitioner 17 Psychiatric Nurse 17
Registered Nurse 17 Nursery
charges 14
Obstetrical care 14 Occupational therapy 15
Ocular injury 16
Office visits 6
Oral and maxillofacial surgery 20 Orthopedic devices 16
Ostomy and catheter supplies 17
Out-of-pocket expenses 10 Outpatient facility care 22
Oxygen 22 Pap test
13
Physical examination 13 Physical therapy 15
Physician 8
Precertification 22
Preventive care, adult 13 Preventive care, children 13
Prescription drugs 27 Preventive services 13
Prior approval 22 Prostate
cancer screening 13
Prosthetic devices 16 Psychologist 26
Psychotherapy
26 Radiation therapy 15
Renal dialysis 15 Room and board 22
Second
surgical opinion 12 Skilled nursing facility care 21
Smoking cessation 18
Speech therapy 15
Splints 22 Sterilization procedures 14
Subrogation 38
Substance abuse 26
Surgery 19 Anesthesia 19
Oral 20 Outpatient 23
Reconstructive 20 Syringes 28
Temporary continuation of coverage
41
Transplants 21 Treatment therapies 15
Vision services 16 Well child
care 13
Wheelchairs 17 Workers’ Compensation 38
X-rays 12 44
44 Page 45 46
2002 WINhealth Partners 45 Summary
Summary of benefits for the WINhealth Partners
-2002
Do not rely on this chart alone. All benefits
are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize
specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover on
your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Below, an asterisk (*) means the item is subject to the $50
calendar year deductible.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $10 12
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing 24
25
Emergency benefits:
In-area
.............................................................................................
Out-of-area
......................................................................................
$35 per visit 26
27
Mental health and substance abuse
treatment...................................... Regular cost sharing. 28
Prescription drugs
.................................................................................
*Retail Pharmacy:
$10 generic prescriptions $15 preferred brand
prescriptions
$40 non-preferred prescriptions
Mail Order (90-day supply) $20 generic
$30 preferred brand prescriptions $80 non-preferred brand prescriptions
31
Dental Care
.......................................................................................
No benefit. 33
Vision Care
.......................................................................................
No benefit. 17
Protection against catastrophic costs (your out-of-pocket
maximum) ........................................................ Nothing
after $2,000/Self Only or $4,000/Family enrollment per year
Some costs do
not count toward this protection
10
Maximum Benefit $2,000,000 benefit maximum excluding mental health/substance
abuse and prescription drug benefits. 45
45
Page 46 47
46
46 Page 47
2002 WINhealth Partners 46 Premium Page
2002 Rate
Information for WINhealth Partners Benefit Plan
Non-Postal rates apply
to most non-Postal enrollees. If you are in a special enrollment category, refer
to the FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal
Service employees. Most employees should refer to the FEHB Guide for United
States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are published for
Postal Service Nurses, RI 70-2B; and
for Postal Service Inspectors and Office of Inspector General (OIG) employees
(see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov’t Share Your Share Gov’t Share Your Share USPS Share Your
Share
High Option
Self Only PV1 $86.39 $28.79 $187.17 $62.39 $102.22 $12.96
High Option
Self and Family PV2 $223.41 $88.45 $484.06 $191.64 $263.75
$48.11 47