Serving: Stark, Carroll, Holmes, Tuscarawas and Wayne counties and
the Canton metropolitan area in Ohio
Enrollment in this Plan is limited; see page 6 for requirements.
Enrollment codes for this Plan:
3A1 Self Only 3A2 Self and Family
Error! Unknown switch argument.
RI 73-699
Error! Error! Unknown
switch
argument.
Error! Error! Unknown
switch argument. For changes in benefits
see page 8
For changes
in benefits
see page 8
Authorized for distribution by the:
United States
Office of Personnel Management
Retirement and Insurance Service
http:// www. opm. gov/ insure
RI 73-699
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since
benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care
options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost
this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and
on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all
reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal
employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive
outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated
services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the
FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not
immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep
health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your
family. We suggest you also visit our web site at www. opm. gov/ insure.
Sincerely,
Kay Coles James Director
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Notice of the Office of Personnel Management s
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.
By law, the Office of Personnel Management ( OPM) , which administers the Federal Employees Health Benefits ( FEHB) Program, is
required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how
OPM may use and give out ( disclose ) your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you ( your personal representative) , To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities ( such as fraud and abuse investigations) , For research studies that meet all privacy law requirements ( such as for medical research or education) , and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission ( an authorization ) to use or give out your personal medical information for any
purpose that is not set out in this notice. You may take back ( revoke ) your written permission at any time, except if OPM has
already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing,
and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical
information.
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5
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized
OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim.
Ask OPM to communicate with you in a different manner or at a different place ( for example, by sending materials to a P. O. Box instead of your home address) .
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-
606-0191 and ask for OPM s FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following
address:
Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the
Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical
information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change. The
privacy practices listed in this notice will be effective April 14, 2003.
4.
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2003 AultCare HMO 2
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . 4
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Service Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Section 2. How we change for 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Program-wide changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Changes to this Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Primary care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Specialty care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Hospital care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Circumstances beyond our control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Deductible. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Your catastrophic protection out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . 12
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
( c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
( d) Emergency services/ accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( f) Prescription drug benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Aultman Healthline
5.
5
Page 6
7
2003 AultCare HMO 3
I Can Cope
Common Ground
( h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
( i) Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Section 6. General exclusions --things we don' t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Section 7. Filing a claim for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
When you have other health coverage
What is Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Medicare managed care plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
TRICARE and CHAMPVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Workers' Compensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Other Government agencies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
When others are responsible for injuries ............................................................................................................................43
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Where you get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Types of coverage available for you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . 46
Children s Equity Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When you lose benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Spouse equity coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Converting to individual coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 48
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Long term care insurance is still available. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover
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2003 AultCare HMO 4 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of AultCare HMO under our contract ( CS2723) with the Office of Personnel Management
( OPM) , as authorized by the Federal Employees Health Benefits law. The address for AultCare HMO administrative offices is:
AultCare HMO
2600 Sixth Street SW
Canton, Ohio 44710
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure. It is your responsibility to be informed about your health benefits.
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, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and 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 AultCare.
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 plan s brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM' s " Rate Us"
feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650.
Stop Health Care Fraud
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program ( FEHBP) premium.
OPM s Office of Inspector General investigates all allegations of fraud, waste, and abuse in the FEHBP regardless of the agency that employs you or from which your retired.
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
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2003 AultCare HMO 5 Introduction/ Plain Language/ Advisory
Avoid using health care providers who tell you that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits ( EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a physician, pharmacy, or hospital has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 1-800-344-8858 and explain the situation.
If we do not resolve the issue:
CALL THE HEALTH CARE FRAUD HOTLINE 202-418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
Do not maintain as a dependent on your policy: Your former spouse after a divorce decree or annulment is final; or
Your child over age 22 unless he/ she is incapable of self support. If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM
if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHBP benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
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2003 AultCare HMO 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization ( HMO) . We require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to
treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments,
coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan s benefits, not because a particular provider is available. You cannot
change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.
How we pay providers
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.
AultCare HMO is an IPA model HMO, whereby the HMO has individual agreements with select physicians who have agreed to
provide care for AultCare HMO enrollees. Each family member must select a primary care doctor who coordinates care for the HMO
enrollee. There are approximately 251 primary care physicians from which to choose and nearly 642 specialists in our network.
The first and most important decision each member must make is the selection of a primary care doctor. The decision is important
since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of
your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization. Services of other providers are covered only when there has been a referral by the member s
primary care doctor with the following exception( s) : a woman may see her Plan gynecologist for her annual routine examination
without a referral.
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.
Years in existence Profit status
If you want more information about us, call 330-438-6360, or write to AultCare HMO, 2600 Sixth Street SW, Canton, Ohio 44710.
You may also contact us by fax at 330-580-5527 or visit our website at www. aultman. com.
Service Area
To enroll with us, you must live in or work in our service area. This is where our providers practice. Our service area is:
Stark; Carroll;
Holmes; Tuscarawas;
Wayne Counties in Ohio.
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.
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2003 AultCare HMO 7 Section 1
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.
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2003 AultCare HMO 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that go to Section 5 Benefits. Also, we
edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
A Notice of the Office of Personnel Management s Privacy Practices is included.
A section on the Children s Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised.
Changes to this Plan
Your share of the non-Postal premium will increase by 72.2% for Self Only or 120.2% for Self and Family.
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2003 AultCare HMO 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification ( ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a
Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card,
use your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation ( for annuitants) , or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at
330-438-6360.
Where you get covered care You get care from Plan providers and Plan facilities. You will only pay copayments and you will not have to file claims.
Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list
is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory,
which we update periodically.
What you must do to get
covered care
It depends on the type of care you need. First, you and each family member must
choose a primary care physician. This decision is important since your primary care
physician provides or arranges for most of your health care.
Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to
see a specialist.
If you want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see your
obstetrician/ gynecologist once yearly without a referral.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating your
treatment plan ( the physician may have to get an authorization or approval
beforehand) .
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he
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2003 AultCare HMO 10 Section 3
or she decides to refer you to a specialist, ask if you can see your current specialist.
If your current specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see a specialist
who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive
services from your current specialist until we can make arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your specialist because we:
_ terminate our contract with your specialist for other than cause; or
_ drop out of the Federal Employees Health Benefits ( FEHB) Program and you
enroll in another FEHB Plan; or
_ reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your specialist
until the end of your postpartum care, even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise 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 330-438-6360. If you are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:
You are dis harged, not merely moved to an alternative are enter; 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.
Services requiring our prior
approval
Your primary care physician has authority to refer you for most services.
For certain services, however, your physician must obtain approval from us. Before
giving approval, we consider if the service is covered, medically necessary, and follows
generally accepted medical practice.
We call this review and approval process precertification. Precertification is required
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2003 AultCare HMO 11 Section 3
for all non-AultCare admissions and all Home Health Care programs. You must notify
the AultCare Utilization Management Department prior to any planned non-AultCare
admissions or to any Home Health Care program.
Other services requiring precertification include:
Partial hospitalization programs provided out-of-network; Intensive out patient programs provided out-of-network;
Rehabilitation facility admissions; Skilled nursing facility admissions;
Hospice care; Therapies, including physical, occupational, speech, cognitive and
growth hormone;
Mental Health and Substance Abuse; and Certain drugs.
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2003 AultCare HMO 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc. , when you receive services.
Example: When you see your primary care physician you pay a copayment of $ 10
per office visit.
Deductible We do not have a deductible.
Coinsurance We do not have coinsurance.
Your catastrophic protection out-of-
pocket maximum for coinsurance
and copayments
We do not have an catastrophic protection out-of-pocket maximum.
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2003 AultCare HMO 13 Section 5
Section 5. Benefits --OVERVIEW
( See page 8 for how our benefits changed this year and page 52 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 330-438-6360 or at our website at
www. aultman. com.
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14-23
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 occupation therapies
Speech therapies 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
( b) Surgical and anesthesia services provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23-25
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26-27
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28-29
Medical emergency Ambulance
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31-32
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Aultman Healthline I Can Cope
Common Ground
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
( i) Non-FEHB benefits available to Plan members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 3
16.
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Page 17
18
2003 AultCare HMO 14 Section 5( a)
Section 5 ( a) . Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician s office
In an urgent care center
Office medical consultations
Second surgical opinion
$ 10 per office visit
During a hospital stay Nothing
Lab, X-ray and other diagnostic tests
Such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services
during your office visit; otherwise, $ 10 per
office visit
17.
17
Page 18
19
2003 AultCare HMO 15 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Physicals
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test Sigmoidos opy, s reening
$ 10 per office visit
Routine Prostate Spe ifi Antigen ( PSA) test $ 10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnostic and treatment services , above.
$ 10 per office visit
Routine mammogram covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years
Nothing
Routine immunizations, limited to:
Tetanus-diphtheria ( Td) booster once every 10 years, , ages 19 and over ( except as provided for under Childhood immunizations)
Influenza vaccine, annually
Pneumococcal vaccines, age 65 and over
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges.
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics Nothing
Well-child care charges for routine examinations, immunizations and care ( under age 22)
Examinations, such as:
_ Eye exams to determine the need for vision correction. ( see
Vision services )
_ Ear exams through age 17 to determine the need for hearing
correction.
_ Examinations done on the day of immunizations ( under age 22)
$ 10 per office visit
18.
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Page 19
20
2003 AultCare HMO 16 Section 5( a)
Maternity care You pay
Complete maternity ( obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery.
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. Surgical
benefits, not maternity benefits, apply to circumcision.
We pay hospitalization and surgeon services ( delivery) the same as for illness and injury. See Hospital benefits ( Section 5c) and
Surgery benefits ( Section 5b) .
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, such as:
Voluntary sterilization ( see Surgical Procedures Section 5( b) )
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
elective abortion
All charges.
19.
19
Page 20
21
2003 AultCare HMO 17 Section 5( a)
Infertility services You Pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
_ intravaginal insemination ( IVI)
_ intracervical insemination ( ICI)
_ intrauterine insemination ( IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.
$ 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
All charges.
Allergy care
Testing and treatment
Allergy injection
Allergy serum
Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges.
20.
20
Page 21
22
2003 AultCare HMO 18 Section 5( a)
Treatment therapies You Pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 25.
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 330-438-6360 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
Physical and occupational therapies
60 visits 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.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided.
$ 10 per outpatient visit
Nothing per visit during covered inpatient
admission
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
60 visits per condition for the services of speech therapists. $ 10 per office visit
21.
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Page 22
23
2003 AultCare HMO 19 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 through age 17 ( 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)
In addition to the medical and surgical benefits provided for diagnosis
and treatment of diseases of the eye, annual eye refractions ( to provide a
written lens prescription) may be obtained from Plan providers.
$ 10 per office visit
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
( such as for cataracts)
$ 10 per office visit
Eye exam to determine the need for vision correction for children and
adults ( see Preventive care, children )
Coverage includes:
one complete refractory eye examination by a Plan provider every 24 months; and
one set of prescribed frames with a $ 55 maximum Plan payment; or
one set of single vision lenses with a $ 35 maximum Plan payment; or
one set of bi-focal lenses with a $ 55 maximum Plan payment; or
one set of tri-focal lenses with a $ 150 maximum Plan payment; or
one set of prescribed contact lenses with a $ 150 maximum Plan payment.
$ 10 per office visit
All charges over the maximum Plan
payment
Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Eye exams from an optometrist
All charges.
22.
22
Page 23
24
2003 AultCare HMO 20 Section 5( a)
Foot care You Pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$ 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 ( two per calendar year) , including necessary replacements, following a
mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, 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.
Nothing
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
All charges.
23.
23
Page 24
25
2003 AultCare HMO 21 Section 5( a)
Durable medical equipment ( DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at 330-438-6360 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.
Nothing
Not covered:
Motorized wheelchairs
All charges.
Home health services
Home health care ordered by a Plan physician and provided by a registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational nurse ( L. V. N. ) , or home health aide.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the convenience of, the patient or the patient s family;
home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative
All charges.
Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
$ 10 per office visit
Not covered:
Maintenance care
All charges.
24.
24
Page 25
26
2003 AultCare HMO 22 Section 5( a)
Alternative treatments You pay
Not covered:
naturopathic services
hypnotherapy
biofeedback
massotherapy
acupuncture
All charges.
25.
25
Page 26
27
2003 AultCare HMO 23 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 subje t 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 Se tion 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.
The amounts listed below are for the charges billed by a physi ian or other health are professional for your surgical care. Look in Section 5( c) for charges asso iated with the facility ( i. e. hospital, surgical center, etc. ) .
YOUR NON-AULTCARE PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to Section 3 to be sure whi h services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies ( see Reconstructive surgery )
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.
Voluntary sterilization
Treatment of burns
Note: Generally, we pay for internal prostheses ( devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.
$ 10 per office visit; nothing for hospital
visits
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges.
26.
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Page 27
28
2003 AultCare HMO 24 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.
$ 10 per office visit; nothing for hospital
visits
All stages of breast reconstruction surgery following a mastectomy, such as:
_ surgery to produce a symmetrical appearance on the other
breast;
_ treatment of any physical complications, such as
lymphedemas;
_ breast prostheses and surgical bras and replacements ( see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
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; nothing for hospital
visits
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures ( such as the periodontal membrane, gingiva, and alveolar bone)
All charges.
27.
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Page 28
29
2003 AultCare HMO 25 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
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
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges
Anesthesia
Professional services provided in
Hospital ( inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing
28.
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Page 29
30
2003 AultCare HMO 26 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 Section 5( a) or ( b) .
YOUR NON-AULTCARE 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
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
Nothing
Not covered:
Custodial care
Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care
All charges.
29.
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Page 30
31
2003 AultCare HMO 27 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 if replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care/ skilled nursing care benefit:
The Plan provides a comprehensive range of benefits, with no day or
dollar limit when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan. All necessary
services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan
doctor
Nothing
Not covered:
Custodial care
Rest cures
Domiciliary
Convalescent care
All charges
Hospice care
Supportive and palliative care
Inpatient and outpatient care
Family counseling
Note: limited to life expectancy of six ( 6) months or less
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing
30.
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Page 31
32
2003 AultCare HMO 28 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 and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.
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:
If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency system ( e. g. , the 911 telephone system) or go to the nearest hospital
emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You
or a family member should notify the Plan unless it is not reasonably possible to do so. It is your responsibility to ensure that
the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your
admission, unless it is not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities
and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with
any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider
would result in death, disability or significant jeopardy to your condition.
To be covered by this plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers.
Benefit Description You pay
Emergency within or outside our service area
Emergency care at a doctor' s office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services
Nothing
Emergency within or outside our service area ( Continued on next page)
31.
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Page 32
33
2003 AultCare HMO 29 Section 5( d)
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
All charges.
Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing
32.
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Page 33
34
2003 AultCare HMO 30 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:
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.
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 office visit
Diagnostic tests Nothing if you receive these services during your office visit; otherwise, $ 10 per
office visit
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan s clinical appropriateness. OPM will generally not order
us to pay of provide one clinically appropriate treatment plan in favor of
another.
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
All non-AultCare admissions, partial hospitalization programs and intensive out-patient
programs require preauthorization. For preauthorization, call 330-438-6360.
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2003 AultCare HMO 31 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 over pres ribed drugs and medi ations, as des ribed in the hart beginning on the next page.
All benefits are subje t to the definitions, limitations and exclusions in this bro hure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.
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
difference in cost between the name brand drug and the generic.
Certain drugs require prior authorization where your physician will submit a letter of medical necessity. For a list of these drugs, call 330-438-6360.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of :
Who can write your prescription. A plan physician or licensed dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy or a non-network pharmacy.
These are the dispensing limitations. Prescriptions are filled up to a 34 day supply per copay. Maintenance drugs are dispensed up to a 90 day supply for one copay at retail.
Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a brand name drug. The
U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand name drugs. You can save money by using generic drugs. However, you and
your physician have the option to request a brand name if a generic option is available. Using the most cost-effective
medication saves money.
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:
Drugs and medicines that by Federal law of the United States require a physician s prescription for their purchase, except as
excluded below.
Insulin; a copayment applies to each 34 day supply.
Diabetic supplies, including insulin syringes, needles, glucose test tablets and test tape, Benedict s solution or equivalent, and acetone
test tablets
Disposable needles and syringes for the administration of covered medications
Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits
Drugs for sexual dysfunction ( see Prior authorization)
Contraceptive drugs
Smoking cessation drugs up to an annual $ 200 maximum per member
Growth hormorne
$ 5 generic
$ 10 brand
Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay.
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2003 AultCare HMO 32 Section 5( f)
Covered medications and supplies ( Continued) You Pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements that can be purchased without a prescription
Nonprescription medicines
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
All Charges
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2003 AultCare HMO 33 Section 5( g)
Section 5 ( g) . Special Features
Feature Description
Aultman Healthline For any of your health concerns, 7 days a week, you may call 1-800-393-9337 and talk with a registered nurse who will discuss treatment options and answer your health
questions.
I Can Cope Weekly cancer education sessions are presented by doctors, nurses and other professionals. The sessions are held by the Aultman Cancer Center and co-sponsored
by the American Cancer Society. For information/ registration, you may call
330-438-6290. Free parking is available.
Common Ground A cancer support group for cancer patients and their caregivers. It s led by an Aultman oncology social worker. For information, call 330-438-6290. Free parking
is available.
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2003 AultCare HMO 34 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 subje t to the definitions, limitations, and ex lusions in this bro hure and are payable only when we determine they are medically necessary.
Plan dentists must provide or arrange your are.
We over hospitalization for dental pro edures only when a nondental physi al impairment exists whi h makes hospitalization necessary to safeguard the health of the patient; we do not cover the dental procedure unless it is
des ribed below.
Be sure to read Section 4, Your costs for covered services , for valuable information about how ost sharing works. Also read Se tion 9 about oordinating benefits with other overage, in luding with Medi are.
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.
Nothing
Dental Benefits
Preventive and Diagnostic
Oral exam ( one per year) Prophylaxis or cleaning ( one per year)
Annual application of fluoride up to age 12 Sealants
X-rays, including bite wings ( limited to once per year) and panoramic ( limited to once every 5 years)
Vitality test Oral cancer exam
Study models Emergency treatment, limited to the relief of pain, bleeding, swelling
or life threatening conditions
Diagnostic services
Basic Restorative
Restorative Endodontics
Periodontics Oral surgery
Prosthodontics
Major Restorative
Full and partial dentures Fixed bridges
Crowns Inlays
30%
Not covered: other dental services not shown as covered All Charges
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2003 AultCare HMO 35 Section 5( i)
Section 5 ( i) . Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about
them.
Aultman Aulternatives
Aultman Aulternatives is committed to health promotion and disease prevention. Programs are offered to individuals and
businesses designed to help participants learn to control risk factors and make healthier decisions. Weight management, healthy
nutrition, teen nutrition, smoking cessation and stress management programs are developed and presented by medical
professionals and are approved by a physician steering committee. Day and evening sessions are available for most classes. Call
330-363-6209 for fee and registration information.
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2003 AultCare HMO 36 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 endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service.
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2003 AultCare HMO 37 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay your copayment.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us
directly. Check with the provider. If you need to file the claim, here is the process:
Medical, hospital & drug benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claims questions and assistance, call us at 330-438-6360.
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: AultCare HMO
2600 Sixth Street SW
Canton, Ohio 44710
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.
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2003 AultCare HMO 38 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: AultCare HMO, 2600 Sixth Street SW, Canton, Ohio 44710; 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, Health Benefits Contracts Division 3,
1900 E Street, NW, Washington, D. C. 20415-3630.
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits ( EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify which documents apply to which claim.
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2003 AultCare HMO 39 Section 8
Disputed Claims ( Continued)
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such
as medical providers, must provide 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.
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 330-438-6360 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.
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2003 AultCare HMO 40 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) .
Medi are 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 Medi are-overed employment, you should be able to
qualify for premium-free Part A insurance. ( Someone who was a Federal employee on
January 1, 1983 or sin e automati ally 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 So ial Se urity he k or your retirement he k.
If you are eligible for Medi are, you may have hoi es in how you get your health are. Medicare
managed care plan is the term used to describe the various health plan choices available to
Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits
with Medi are, depending on the type of Medi are managed are plan you have.
The Original Medicare Plan ( Part A or Part B) The Original Medicare Plan ( Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medi are benefits and is the way most people get their Medi are Part
a and Part B benefits now. You may go to any do tor, specialist, or hospital that accepts Medicare.
The Original Medi are Plan pays its share and you pay your share. Some things are not overed
under Original Medi are, like pres ription 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.
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 1-800-344-
8858 or visit our website at www. aultman. com.
We do not waive any costs when you have Medicare.
( Primary payer chart begins on next page. )
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2003 AultCare HMO 41 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member has
Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
A. When either you --or your covered spouse --are age 65 or over and Then the primary payer is
Original Medicare This Plan
1) Are ana tive employee with theFederalgovernment( including whenyou or a
familymember are eligibleforMedicaresolely becauseof adisability) , .
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,
.
( exceptfor 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. .
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2003 AultCare HMO 42 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from another type of Medicare+ Choice plan --a Medicare managed care plan.
These are health care choices ( like HMOs) in some areas of the country. In most
Medicare managed 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 plans cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare at 1-800-
MEDICARE ( 1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are available to
you:
This Plan and another plan s Medicare managed care plan: You may enroll in
another plan s Medicare managed care plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare managed care plan is primary, even
out of the managed care plan' s network and/ or service area ( if you use our Plan
providers) , but we will not waive any of our copayments. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare managed care plan so we can correctly coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a
Medicare managed care plan, eliminating your FEHB premium. ( OPM does not
contribute to your Medicare managed care plan premium. ) For information on
suspending your FEHB enrollment, contact your retirement office. If you later want to
re-enroll in the FEHB Program, generally you may do so only at the next open season
unless you involuntarily lose coverage or move out of the Medicare managed care
plan s service area.
If you do not enroll in Medicare Part A or Part B If you do not have one or both parts of Medicare, you can still be covered under the FEHB Program. We will 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 and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and eligible dependents. If TRICARE
and CHAMPVA and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these programs.
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 one of
these programs, eliminating your FEHB premium. ( OPM does not contribute to any
applicable plan premiums. ) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next open season unless you involuntarily lose
coverage under these programs.
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.
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2003 AultCare HMO 43 Section 9
Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in any one of these State programs, eliminating
your FEHB premium. For information on suspending your FEHB enrollment, contact
your retirement office. If you later want to re-enroll in the FEHB Program, generally
you may do so only at the next Open Season unless you involuntarily lose coverage
under the State program.
When other Government agencies
are responsible for your care
We do not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.
When others are responsible for
injuries
When you receive money to compensate you for medical or hospital care for injuries or
illness caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you received in
the settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our subrogation procedures.
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2003 AultCare HMO 44 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. We do not have coinsurance.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care provided primarily for maintenance of the patient or which is designed essentially to assist the patient in meeting his activities of daily living and which is not primarily
provided for its therapeutic value in the treatment of an illness, disease, bodily injury or
condition.
Custodial care includes, but is not limited to, help in walking, bathing, dressing,
feeding, preparation of special diets and supervision over self-administration of oral
medications not requiring constant attention of trained medical personnel.
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. We do not have
deductibles.
Experimental or investigational
services The Plan s Utilization Management team gathers information from various sources before making an independent evaluation to determine medical appropriateness and/ or
the experimental/ investigational nature of new technology, i. e. , the application of
existing technology or new medical procedures, drugs, or devices. The Plan s decision
is made in good faith, following a detailed factual background investigation of the claim
and proposed service and interpretation of the Plan provisions. Sources the Plan may
use include the Federal Drug Administration, Medicare guidelines, published scientific
articles, and related medical society guidelines. If the plan decides that a service or
supply is not medically appropriate and/ or is experimental/ investigational, that service
or supply will not be eligible.
Group health coverage Coverage provided by the Company for the Plan participant and dependents, if applicable.
Medical necessity A service or supply given by a Provider that is required to diagnose or treat your condition, illness or injury and which we determine is:
Appropriate with regard to standards of good medical practice; Not solely for the convenience of you or a provider;
The most appropriate supply or level or service which can be safely provided to you. When applied to the care of an Inpatient, this means that
your medical symptoms or conditions require that the services cannot be
safely provided to you as an Outpatient.
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 as follows: a Provider s charge is considered Usual,
Customary and Reasonable when it is comparable to the fee usually charged for the
same or similar service rendered by other Providers in the same geographical area
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2003 AultCare HMO 45 Section 10
whose training, education, and professional standing is equivalent to that of the
Provider making the charge.
Us/ We Us and we refer to AultCare HMO
You You refers to the enrollee and each covered family member.
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2003 AultCare HMO 46 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 your FEHB coverage. These materials tell you:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment begins.
We don t determine who is eligible for coverage and, in most cases, cannot change
your enrollment status without information from your employing or retirement office.
Types of coverage available for
you and your family
Self Only coverage is for you alone. Self and Family coverage is for
you, your spouse, and your unmarried dependent children under age 22, including any
foster children or stepchildren for whom 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.
Children s Equity Act OPM has implemented the Federal Employees Health Benefits Children s Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits ( FEHB) Program, if you are an employ