Serving: South Central Wisconsin
Enrollment codes for this Plan:
WJ1 Self Only
WJ2 Self and Family
RI 73-061
For changes in benefits
see page 9.
2004
Serving: South Central Wisconsin
Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 8 for requirements.
This Plan has Excellent
Accreditation from the NCQA.
See the 2004 Guide for more
information on the NCQA.
EX CELL ENT
1.
1
Page 2
3
United States
Office of Personnel Management
Washington, DC 20415-0001
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits (FEHB) Program plan brochure. The brochure
describes the benefits this plan offers you for 2004. Because benefits vary from year to year, you should review your
plan's brochure every Open SeasonÑ especially Section 2, which explains how the plan changed.
It takes a lot of information to help a consumer make wise healthcare decisions. The information in this brochure, our
FEHB Guide, and our web-based resources, make it easier than ever to get information about plans, to compare
benefits and to read customer service satisfaction ratings for the national and local plans that may be of interest. Just
click on www. opm. gov/ insure!
The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector
competition to keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in
1960, is sound and has stood the test of time. It enjoys one of the highest levels of customer satisfaction of any
healthcare program in the country.
I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health
benefits. We demand cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies
and departments to pay the full FEHB health benefit premium for their employees called to active duty in the Reserve
and National Guard so they can continue FEHB coverage for themselves and their families. Our carriers have also
responded to my request to help our members to be prepared by making additional supplies of medications available
for emergencies as well as call-up situations and you can help by getting an Emergency Preparedness Guide at
www. opm. gov. OPM's HealthierFeds campaign is another way the carriers are working with us to ensure Federal
employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain healthcare
costs and keep premiums down by living a healthy life style.
Open Season is your opportunity to review your choices and to become an educated consumer to meet your healthcare
needs. Use this brochure, the FEHB Guide, and the web resources to make your choice an informed one. Finally, if
you know someone interested in Federal employment, refer them to www. usajobs. opm. gov.
Sincerely,
Kay Coles James
Director
2.
2
Page 3
4
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 United States 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 health care 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.
3.
3
Page 4
5
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.
° 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 are effective April 14, 2003.
4.
4
Page 5
6
2 2004 Group Health Cooperative of South Central Wisconsin Table of Contents
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Preventing Medical Mistakes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
How we pay providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Who provides your health care? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Your Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
Section 2. How we change for 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Program-wide changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
° Plan providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
° Plan facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
What you must do to get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
° Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
° Specialty care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
° Hospital care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11
Circumstances beyond our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Services requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
° Copayments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
° Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
° Coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Your catastrophic protection out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . .15
(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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
° Services for deaf and hearing impaired
° Center of excellence
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
5.
5
Page 6
7
3 2004 Group Health Cooperative of South Central Wisconsin Table of Contents
Section 6. General exclusionsÑ things we don't cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39
Section 8. The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
° What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42
° Medicare + Choice plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
° TRICARE and CHAMPVA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45
° Workers' Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
° Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
When other Government agencies are responsible for your care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
° No pre-existing condition limitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
° Where you can get information about enrolling in the FEHB Program . . . . . . . . . . . . . . . . . . . . . . .48
° Types of coverage available for you and your family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
° Children's Equity Act . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
° When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
° When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49
When you lose benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
° When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
° Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
° Temporary Continuation of Coverage (TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
° Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
° Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
Two New Federal Programs Complement FEHB Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
° The Federal Flexible Spending Account Program -FSAFEDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52
° The Federal Long Term Care Insurance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Back cover
6.
6
Page 7
8
4 2004 Group Health Cooperative of South Central Wisconsin Introduction
Introduction
This brochure describes the benefits of Group Health Cooperative of South Central Wisconsin under our contract
(CS 1828) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. The address for the administrative offices is:
Group Health Cooperative of South Central Wisconsin
8202 Excelsior Drive
Madison, WI 53744-4971
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 in 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, 2004, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and are
summarized on page 9. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language 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 Group Health Cooperative of South Central Wisconsin.
° We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the
United States Office of Personnel Management. If we use others, we tell you what they mean first.
° Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to
OPM at the Office of Personnel Management, Insurance Services Program, Program Planning & Evaluation Group,
1900 E Street, NW, Washington, DC 20415-3650.
7.
7
Page 8
9
5 2004 Group Health Cooperative of South Central Wisconsin Stop Health Care Fraud!
CALLÑ THE HEALTHCARE FRAUD HOTLINE
202-418-3300
OR WRITE TO:
The United States Office of Personal Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.
Protect Yourself From FraudÑ Here are some things you can do to prevent fraud:
° Be wary of giving your plan identification (ID) 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.
° Avoid using health care providers who say 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 provider 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 608-828-4853 and explain the situation.
° If we do not resolve the issue:
° Do not maintain as a family member on your policy:
° Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
° Your child over age 22 (unless he/ she is disabled and incapable of self support).
° If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed,
with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled
under Temporary Continuation of Coverage.
° 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.
8.
8
Page 9
10
6
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical
mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most
tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer
recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can
improve the safety of your own health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
° Ask questions and make sure you understand the answers.
° Choose a doctor with whom you feel comfortable talking.
° Take a relative or friend with you to help you ask questions and understand answers.
2. Keep and bring a list of all the medicines you take.
° Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines.
° Tell them about any drug allergies you have
° Ask about side effects and what to avoid while taking the medicine.
° Read the label when you get your medicine, including all warnings.
° Make sure your medicine is what the doctor ordered and know how to use it.
° Ask the pharmacist about your medicine if it looks different than you expected.
3. Get the results of any test or procedure.
° Ask when and how you will get the results of test or procedures.
° Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
° Call your doctor and ask for your results.
° Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
° Ask your doctor about which hospital has the best care and results for your condition if you have more than one
hospital to choose from to get the health care you need.
° Be sure you understand the instructions you get about follow-up care when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
° Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
° Ask your doctor, "Who will manage my care when I am in the hospital?"
° Ask your surgeon:
Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
° Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications
you are taking.
Want more information on patient safety?
° www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide-ranging
list of topics not only to inform consumers about patient safety but also to help choose quality healthcare
providers and improve the quality of care you receive.
° www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and
your family.
° www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is dedicated to
improving communication about the safe, appropriate use of medicines.
° www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
° www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals
working to improve patient safety.
° www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent
mistakes in the nation's healthcare delivery system.
2004 Group Health Cooperative of South Central Wisconsin Preventing Medical Mistakes
9.
9
Page 10
11
7 2004 Group Health Cooperative of South Central Wisconsin 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. The Plan is solely responsible
for the selection of these providers in your area. Contact the Plan for a copy of its most recent provider directory.
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, and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept negotiated payments from us, and you will only be responsible for your copayments or
coinsurance.
Who provides your health care?
GHC is a Group-Practice Prepayment (GPP) plan. We select qualified, experienced doctors for our medical staff. The
group medical practice at GHC allows for in-house consultations, peer review, and regular staff audits of medical care so
that we can assure quality care for you and your family members.
The first and most important decision you must make is to select your primary care provider. Specialists who represent
every possible specialty area also serve GHC members. Your Primary Care Provider (PCP) makes any necessary
referrals, with the following exceptions: A woman may see her Plan gynecological provider for her annual routine
examination without a referral (certified nurse midwives are not covered providers under this Plan); Vision care; Dental
care; Mental Condition benefits; Substance Abuse benefits; and Chiropractic care.
GHC uses the facilities and services of four hospitals in the South Central Wisconsin area. Your primary care site
(clinic) determines the assigned hospital for your routine care. Most specialty care is referred to the University of
Wisconsin Hospital and Clinics, and Meriter Hospital in Madison. Babies are usually delivered at St. Marys Hospital in
Madison.
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: 27
° Profit status: Non-Profit
° Accreditation: Excellent rating from NCQA
If you want more information about us, call 608/ 828-4827, or write to the GHC Marketing Department, P. O. Box 44971,
Madison, WI 53744-4971. You may also contact us by fax at 608/ 828-9333 or visit our website at www. ghc-hmo. com.
10.
10
Page 11
12
8 2004 Group Health Cooperative of South Central Wisconsin Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service
area is:
In the State of Wisconsin, the entire counties of: Columbia, Dane, Dodge, Green, Iowa, Jefferson, Rock, and Sauk.
Ordinarily, you must get your health care from providers who contract with us. If you receive care outside of our service
area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another FEHB 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.
11.
11
Page 12
13
9 2004 Group Health Cooperative of South Central Wisconsin Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
° We added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible
Spending Account ProgramÑ FSAFEDS and the Federal Long Term Care Insurance Program. See page 52.
° We added information regarding Preventing medical mistakes. See page 6.
° We added information regarding enrolling in Medicare. See page 42.
° We revised the Medicare Primary Payer Chart. See page 44.
Changes to this Plan
° Your share of the non-Postal premium will increase by 1.6% for Self Only or decrease by -10.3% for Self and Family.
° The copayment for Durable Medical Equipment has changed from $20 per office visit to 20% coinsurance per item or
per rental period. See page 21.
° The Prescription drug benefit is changed as follows:
-The dispensing limitation has changed from a 34 day supply to a 30 day supply. See page 34.
-A limited number of drugs will be available in a 90-day supply subject to three copayments. This changed
from a 100 day supply for three copayments. See page 34.
-Injectable medications administered in a clinic setting will be subject to the prescription drug copayments.
See page 34.
-A patient will be able to purchase a formulary brand drug when a formulary generic drug is prescribed when
the name brand copayment and the difference between the generic and name brand are paid. See page 34.
° Physical and Occupational therapies will be limited to 40 visits (combined) per year. Previously the benefit limit was
60 consecutive days per condition. See page 19.
° Hospice Care: GHC will continue to cover in-home services only. If a member chooses in-patient services, the member
will be responsible for the difference in GHC's daily in-home allowance and the actual cost billed by the hospice
organization. See page 27.
12.
12
Page 13
14
10 2004 Group Health Cooperative of South Central Wisconsin 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
608-260-3170 or write to us at Group Health Cooperative, PO Box
44971, Madison, WI 53744-4971. You may also request replacement
cards through our website at www. ghc-hmo. com.
Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to
file claims.
° Plan providers Plan providers are physicians and other health care professionals in
our service area that we contract with to provide covered services
to our members. We credential Plan providers according to
national standards.
We list Plan providers in the GHC Provider Directory, which we
update periodically. The list is also on our website.
° Plan facilities Plan facilities are hospitals and other facilities in our service area
that we contract with to provide covered services to our members.
We list these in the provider directory, which we update periodically.
The list is also on our website.
What you must do It depends on the type of care you need. First, you and each family to get covered care 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. If you need assistance, please call the GHC
Member Services Department at 608-828-4853.
° Primary care Your primary care physician can be a family practitioner, an internist
or a pediatrician. (You may also select from affiliated nurse
practitioners or physicians assistants.) 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
13.
13
Page 14
15
11 2004 Group Health Cooperative of South Central Wisconsin Section 3
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 plan mental health and/ or substance abuse,
vision care, dental care or chiropractic providers without a referral,
and a woman may see her Plan gynecological provider for her annual
routine examination without a referral.
Here are other things you should know about specialty care:
° If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional referrals. Your
primary care physician will use our criteria when creating your
treatment plan (the physician may have to get an authorization or
approval beforehand).
° If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will
decide what treatment you need. If he or she decides to refer you to
a specialist, ask if you can see your current specialist. If your
current specialist does not participate with us, you must receive
treatment from a specialist who does. Generally, we will not pay for
you to see a specialist who does not participate with our Plan.
° If you are seeing a specialist and your specialist leaves the Plan,
call your primary care physician, who will arrange for you to
see another specialist. You may receive services from your
current specialist until we can make arrangements for you to see
someone else.
° If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than
cause; or
-drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.
° Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility.
14.
14
Page 15
16
12 2004 Group Health Cooperative of South Central Wisconsin Section 3
If you are in the hospital when your enrollment in our Plan begins,
call our Care Management department immediately at 608/ 257-5294.
If you are new to the FEHB Program, we will arrange for you to
receive care.
If you changed from another FEHB plan to us, your former plan will
pay for the hospital stay until:
° You are discharged, not merely moved to an alternative care
center; or
° The day your benefits from your former plan run out; or
° The 92nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized
person. If your plan terminates participation in the FEHB Program in
whole or in part, or if OPM orders an enrollment change, this
continuation of coverage provision does not apply. In such case, the
hospitalized family member's benefits under the new plan begin on
the effective date of enrollment.
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 prior approval. Your
physician must obtain prior approval for all services that require
prior authorization, such as, but not limited to:
Hospital care;
Referring you to a specialist;
Recommending follow-up care;
All surgical procedures;
All physical, speech and occupational therapy;
Infertility;
Breast reduction mammoplasty;
Plastic surgery;
Transplant of any organ;
All outpatient surgery; and
Growth hormone therapy (GHT).
GHC will not guarantee payment for services that require
prior authorization and were not prior authorized unless
emergent in nature.
15.
15
Page 16
17
13 2004 Group Health Cooperative of South Central Wisconsin Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
° Copayments A copayment is a fixed amount of money you pay to the provider,
facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician, you pay a
copayment of $20 per office visit.
° Deductible We do not have a deductible.
Note: If you change plans during open season, you do not have to
start a new deductible under your old plan between January 1 and
the effective date of your new plan. If you change plans at another
time during the year, you must begin a new deductible under your
new plan.
° Coinsurance Coinsurance is the percentage of our negotiated fee that you must
pay for your care.
Example: In our Plan, you pay 20% of our allowance for Durable
Medical Equipment and 50% of our allowances for sexual
dysfunction drugs and preventive dental care services if a non-participating
dentist is used.
Your catastrophic protection We do not have a catastrophic protection out-of-pocket maximum.
out-of-pocket maximum
16.
16
Page 17
18
14 2004 Group Health Cooperative of South Central Wisconsin Section 5
Section 5. Benefits Ñ OVERVIEW
(See page 9 for how our benefits changed this year and page 59 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind
at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in
the following subsections. To obtain claims filing advice or more information about our benefits, contact us at
608-828-4853 or at our website at www. ghc-hmo. com.
(a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . .15Ð 22
° Diagnostic and treatment services ° Speech therapy
° Lab, X-ray, and other diagnostic tests ° Hearing services (testing, treatment,
° Preventive care, adult and supplies)
° Preventive care, children ° Vision services (testing, treatment, and supplies)
° Maternity care ° Foot care
° Family planning ° Orthopedic and prosthetic devices
° Infertility services ° Durable medical equipment (DME)
° Allergy care ° Home health services
° Treatment therapies ° Chiropractic
° Physical and occupational therapies ° Alternative treatments
° Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . . . . .23Ð 25
° Surgical procedures ° Organ/ tissue transplants
° Reconstructive surgery ° Anesthesia
° Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26Ð 28
° Inpatient hospital ° Hospice care
° Outpatient hospital or ambulatory ° Ambulance
surgical center
° Extended care benefits/ skilled nursing
care facility benefits
(d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29Ð 30
° Medical emergency ° Ambulance
(e) Mental health and substance abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31Ð 32
(f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33Ð 35
(g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
° Services for deaf and hearing impaired
° Centers of excellence for transplants/ heart surgery/ etc.
(h) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Summary of benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .59
17.
17
Page 18
19
15 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Section 5 (a) Medical services and supplies provided by physicians and other
health care professionals
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they
are medically necessary.
° Plan physicians must provide or arrange your care.
° We have no calendar year deductible.
° Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians $20 per office visit
° In physician's office
° In an urgent care center
° Office medical consultations
° Second surgical opinion
° At home
Professional services of physicians Nothing
° During a hospital stay
° In a skilled nursing facility
18.
18
Page 19
20
16 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as: Nothing if you receive these
tests during your office
° Blood tests visit; otherwise, $20 per
° Urinalysis per day for lab and/ or
° Non-routine pap tests radiology visits.
° Pathology
° X-rays
° Non-routine Mammograms
° Cat Scans/ MRI
° Ultrasound
° Electrocardiogram and EEG
Preventive care, adult You pay
Routine screenings, such as: $20 per office visit
° Total Blood CholesterolÑ once every three years
° Colorectal Cancer Screening, including
Ð Fecal occult blood test
Ð Sigmoidoscopy, screeningÑ every five years starting at age 50
Routine Prostate Specific Antigen (PSA) testÑ one annually for men age 40
and older
Routine pap test
Routine mammogramÑ covered for women age 35 and older, as follows:
° From age 35 through 39, one during this five year period
° From age 40 and older, one every calendar year
Physical exams required for travel, or for attending school or camp
Note: Travel related immunizations may be provided in accordance with
CDC recommendations and GHC protocols.
Not covered: Physical exams required for obtaining or continuing All charges
employment, obtaining or continuing insurance, or other third-party requests.
Routine immunizations, limited to: $20 per office visit
° Tetanus-diphtheria (Td) boosterÑ once every 10 years, ages 19 and
over (except as provided for under Childhood immunizations)
° Influenza vaccines, annually
° Pneumococcal vaccine, age 65 and over
19.
19
Page 20
21
17 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Preventive care, children You pay
° Childhood immunizations recommended by the American Academy Nothing to age 5; $20 per
of Pediatrics office visit age 5 and older
° Well-child care charges for routine examinations, immunizations and care
(up to age 22)
° Examinations, such as:
Ð Eye exams through age 17 to determine the need for vision correction
Ð Ear exams through age 17 to determine the need for hearing correction
Ð Examinations done on the day of immunizations (up to age 22)
Physical exams required for travel, or for attending school or camp.
Note: Travel related immunizations may be provided in accordance with CDC
recommendations and GHC protocols.
Maternity care You pay
Complete maternity (obstetrical) care, such as: $20 for the initial maternity
° Prenatal care office visit; nothing for all
° Delivery other maternity related
° Postnatal care office visits.
Note: Here are some things to keep in mind:
° You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your inpatient stay
if medically necessary.
° We cover routine nursery care of the newborn child during the covered
portion of the mother's maternity stay. We will cover other care of an infant
who requires non-routine treatment only if we cover the infant under a
Self and Family enrollment.
° We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
° Circumcision is covered as a surgery benefit, not as a Maternity benefit.
See Section 5 (b).
Not covered: Routine sonograms to determine fetal age, size or sex All charges
20.
20
Page 21
22
18 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Family planning You pay
A broad range of voluntary family planning services, limited to: $20 per office visit
° Voluntary sterilization (see surgical procedures Section 5( b)
° Surgically implanted contraceptives
° Injectable contraceptive drugs (such as Depo provera)
° Intrauterine devices (IUDs)
° Diaphragms
Note: We cover oral and injectable contraceptives under
the prescription drug benefit.
Not covered: Reversal of voluntary surgical sterilization, genetic counseling All charges
Infertility services You pay
Diagnosis and treatment of infertility, such as: $20 per office visit
° Artificial inseminationÑ Intracervical insemination (ICI)
° Fertility drugs
Note: We only cover the oral fertility drug (clomiphene citrate) under the
prescription drug benefit.
Not covered: All charges
° Artificial insemination:
Ð Intravaginal insemination (IVI)
Ð Intrauterine insemination (IUI)
° Assisted reproductive technology (ART) procedures, such as:
Ð In vitro fertilization
Ð Embryo transfer, gamete GIFT and zygote ZIFT
Ð Zygote transfer
° Services and supplies related to excluded ART procedures
° Cost of donor sperm
° Cost of donor egg
° Injectable and oral fertility drugs, except for Clomiphene citrate
Allergy care You pay
Testing and treatment $20 per office visit
Allergy injection
Allergy serum Nothing
Not covered: Provocative food testing and sublingual All charges
allergy desensitization
21.
21
Page 22
23
19 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Treatment therapies You pay
° Chemotherapy and radiation therapy $20 per office visit
Note: High dose chemotherapy in association with autologous bone marrow
transplants is limited to those transplants listed under Organ/ Tissue Transplants
on page 25.
° Respiratory and inhalation therapy
° DialysisÑ hemodialysis and peritoneal dialysis
° Intravenous (IV)/ Infusion TherapyÑ 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 your
primary care physician for preauthorization. If we determine that 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.
Physical and occupational therapies You pay
° 40 visits per year combined benefit for the services of each of the following: $20 per initial visit per
Ð qualified physical therapists; and condition; nothing during
Ð occupational therapists. inpatient admission
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.
One follow-up visit six months after the date of your last physical or $20 per visit
occupational therapy treatment.
° Cardiac rehabilitation following a heart transplant, bypass surgery, a $20 for the initial visit
myocardial infarction, unstable angina pectoris, or angioplasty is provided
for up to 36 sessions.
Not covered: All charges
° Long-term rehabilitative therapy
° Exercise programs (except in therapy programs listed above)
Speech therapy You pay
° 60 consecutive days per condition for the services of qualified $20 per initial office visit
speech therapists. per condition; nothing during
inpatient admission
22.
22
Page 23
24
20 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Hearing services (testing, treatment, and supplies) You pay
° Hearing testing Nothing to age 5; $20 per
office visit for age 5 and older
Not covered: Hearing aids, testing and examinations for them All charges
Vision services (testing, treatment, and supplies) You pay
° Annual vision examinations Nothing to age 5; $20 per
office visit for age 5 and older
° Annual eye refractions $20 per office visit
° Lenses following intraocular surgery (such as for cataract removal) $20 per office visit
or for Keratoconus when there is a change in visual acuity requiring
a new prescription
Not covered: All charges
° Eyeglasses or contact lenses, except as above
° Eye exercises and orthoptics
° Radial keratotomy and other refractive surgery
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or $20 per office visit
peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe inserts.
Not covered: All charges
° 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)
23.
23
Page 24
25
21 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Orthopedic and prosthetic devices You pay
° Artificial limbs and eyes, stump hose $20 per office visit
° Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
° Internal prosthetic devices, such as artificial joints, pacemakers, and surgically
implanted breast implant following mastectomy. Note: See 5( b) for coverage
of the surgery to insert the device.
° Braces
° Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome
Not covered: All charges
° 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
° cost of a cochlear implanted device
° prosthetic replacements, unless the item is no longer useful and has exceeded
its reasonable lifetime under normal use; or the member's condition has
changed so as to make the original equipment inappropriate.
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable 20% coinsurance per
medical equipment prescribed by your Plan physician, such as oxygen and item (per purchase or per
dialysis equipment. Under this benefit, we also cover: rental period)
° hospital beds;
° standard wheelchairs;
° crutches;
° walkers; and
° blood glucose monitors
° insulin pumps
Note: Call us at 608-257-5294 as soon as your Plan physician prescribes any
of the above 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.
Not covered: All charges
° Motorized wheel chairs
° DME replacements, unless the item is no longer useful and has exceeded
its reasonable lifetime under normal use or the member's condition has
changed so as to make the original equipment inappropriate.
24.
24
Page 25
26
22 2004 Group Health Cooperative of South Central Wisconsin Section 5 (a)
Home health services You pay
° Home health care ordered by a Plan physician and provided by a registered Nothing
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.
Not covered: All charges
° 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.
Chiropractic You pay
° Chiropractic services, but only related to a specific injury. $20 per office visit
Not covered: All charges
° Chiropractic services for chronic problems or for maintenance.
Alternative treatments You pay
Not covered: All charges
° Acupuncture
° Naturopathic services
° Hypnotherapy
° Biofeedback
Educational classes and programs You pay
Coverage may include: Some fees requiredÑ contact
° Smoking Cessation GHC Health Education
° Diabetes self-management Department at 608-257-9705
° Nutrition for fees and schedules
° Weight Management
° Stress Management
° Prenatal
° First aid
° Fitness programs
25.
25
Page 26
27
23 2004 Group Health Cooperative of South Central Wisconsin Section 5 (b)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they
are medically necessary.
° Plan physicians must provide or arrange your care.
° We have no calendar year deductible.
° Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
° The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e., hospital, surgical center, etc.).
° YOUR PLAN DOCTOR MUST GET PRIOR APPROVAL OF SOME
SURGICAL PROCEDURES. Please refer to the prior approval information
shown in Section 3 to be sure which services require prior approval and
identify which surgeries require prior approval.
Benefit Description You pay
Surgical procedures
A comprehensive range of services such as: $20 per office visit;
° Operative procedures nothing for hospital visit
° 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 obesityÑ 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)Ð Orthopedic and prosthetic
devices for device coverage information.
° Voluntary sterilization (e. g., Tubal ligation, Vasectomy)
° 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.
Not covered: All charges
° Reversal of voluntary sterilization
° Routine treatment of conditions of the foot; see Foot care
26.
26
Page 27
28
24 2004 Group Health Cooperative of South Central Wisconsin Section 5 (b)
Reconstructive surgery You pay
° Surgery to correct a functional defect $20 per office visit;
° Surgery to correct a condition caused by injury or illness if: nothing for hospital visit
Ð the condition produced a major effect on the member's appearance and
Ð the condition can reasonably be expected to be corrected by such surgery
° Surgery to correct a condition that existed at or from birth and is a significant
deviation from the common form or norm. Examples of congenital anomalies
are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed
fingers; and webbed toes.
° All stages of breast reconstruction surgery following a mastectomy, such as:
Ð surgery to produce a symmetrical appearance on the other breast;
Ð treatment of any physical complications, such as lymphedemas;
Ð 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: All charges
° Cosmetic surgeryÑ 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
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to: $20 per office visit;
° Reduction of fractures of the jaws or facial bones nothing for hospital visit
° 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
° Other surgical procedures that do not involve the teeth or their
supporting structures
° Surgical removal of fully impacted teeth
° Dental treatment of Temporomandibular joint (TMJ) syndrome is limited to $20 per office visit
a maximum Plan payment of $1250 per person per calendar year.
Note: A Physical Therapy evaluation is required before an intraoral splint is
considered as a treatment option
Not covered: All charges
° Oral implants and transplants
° Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingival, and alveolar bone)
27.
27
Page 28
29
25 2004 Group Health Cooperative of South Central Wisconsin Section 5 (b)
Organ/ tissue transplants You pay
Limited to: $20 per office visit
° Cornea for evaluation;
° Heart nothing in hospital
° Heart/ lung
° Kidney
° Kidney/ Pancreas
° Liver
° Lung: SingleÐ Double
° Pancreas
° Allogeneic (donor) bone marrow transplants
° Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal
and ovarian germ cell tumors
° Intestinal transplants (small intestine) and the small intestine with the liver or
small intestine with multiple organs such as the liver, stomach, and pancreas
° National Transplant Program (NTP)Ñ UW Hospital & Clinics
Limited BenefitsÑ 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.
Not covered: All charges
° Donor screening tests and donor search expenses, except those performed
for the actual donor
° Implants of artificial organs
° Transplants not listed as covered
Anesthesia You pay
Professional services provided in Nothing
° Hospital (inpatient)
Professional services provided in $20 per visit
° Hospital outpatient department
° Skilled nursing facility
° Ambulatory surgical center
° Office
28.
28
Page 29
30
26 2004 Group Health Cooperative of South Central Wisconsin Section 5 (c)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services
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).
Benefit Description You pay
Inpatient hospital
Room and board, such as Nothing
° ward, semiprivate, or intensive care accommodations
° general nursing care
° 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.
Other hospital services and supplies, such as: Nothing
° Operating, recovery, maternity, and other treatment rooms
° Prescribed drugs and medicines
° Diagnostic laboratory tests and X-rays
° Administration of blood and blood products
° Blood or blood plasma, if not donated or replaced
° Dressings, splints, casts, and sterile tray services
° Medical supplies and equipment, including oxygen
° Anesthetics, including nurse anesthetist services
° Take-home items
° Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home
Not covered: All charges
° Custodial care
° Non-covered facilities, such as nursing homes, schools
° Personal comfort items, such as telephone, television, barber services,
guest meals and beds
° Private nursing care
29.
29
Page 30
31
27 2004 Group Health Cooperative of South Central Wisconsin Section 5 (c)
Outpatient hospital or ambulatory surgical center You pay
° Operating, recovery, and other treatment rooms Nothing
° 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.
Not covered: Blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care You pay
facility benefits
We provide a comprehensive range of benefits for up to 100 days per calendar Nothing
year 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.
Not covered: Custodial care All charges
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered if care is Nothing for in-home services.
provided in the home. Covered in-home services include: nursing services;
medical social services; dietary, bereavement and spiritual counseling services;
rehabilitative services; and home health aides.
Coverage for other hospice options, including but not limited to inpatient and You pay the difference in cost
residential care, will be at the same cost level as for in-home care with the cost between GHC's in-home
Member responsible for any difference in cost. allowance and actual costs as
as billed by the hospice
Hospice services are provided under the direction of a Plan physician and the organization
GHC Medical Director who certify that the Member is in the terminal stage
of an illness, with a life expectancy of six (6) months or less.
Not covered: Independent nursing, homemaker services All charges
30.
30
Page 31
32
28
Ambulance You pay
° Local professional ambulance service when medically appropriate Nothing
Not covered: Ambulance services to home following an inpatient stay All charges
2004 Group Health Cooperative of South Central Wisconsin Section 5 (c)
31.
31
Page 32
33
29 2004 Group Health Cooperative of South Central Wisconsin Section 5 (d)
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (d). Emergency services/ accidents
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
° We have no calendar year deductible.
° Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
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 emergenciesÑ what they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the nearest emergency system (e. g., the
911 telephone system) or go to the nearest hospital emergency room. Be sure to tell emergency room personnel that
you are a GHC Plan member so they can notify us. You or a family member must also notify us within 48 hours. It
is your responsibility to make certain that the Plan has been notified.
If you need to be hospitalized in a non-Plan facility, you or a family member must notify the Plan within 48 hours
or on the first working day following your admission, unless it is not reasonably possible to do so. If a GHC plan
doctor believes that you will receive better care in a Plan hospital, we will transfer you when it is medically feasible
and we will pay all ambulance charges for the transfer.
Benefits are available for care by non-Plan providers in a medical emergency only if delay in reaching a Plan
provider would result in death, disability or significant jeopardy to your condition.
Any follow up care recommended by non-plan providers in such a medical emergency must be approved by GHC or
provided by GHC plan providers.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness.
If you need to be hospitalized, you or a family member must notify the Plan within 48 hours or on the first working
day following your admission, unless it is not reasonably possible to do so. If a GHC Plan doctor believes you will
receive better care in a Plan hospital, we will transfer you when it is medically feasible and we will pay all
ambulance charges for that transfer.
Any follow up care recommended by non-plan providers in such a medical emergency must be approved by GHC or
provided by GHC plan providers.
32.
32
Page 33
34
30 2004 Group Health Cooperative of South Central Wisconsin Section 5 (d)
Benefit Description You pay
Emergency within our service area
° Emergency care at a doctor's office $20 per visit
° Emergency care at an urgent care center
° Emergency care as an inpatient at a hospital, including doctors' services Nothing
° Emergency care as an outpatient at a hospital, including doctors' services $50 per visit, waived if
admitted as an inpatient.
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
° Emergency care at a doctor's office $20 per visit
° Emergency care at an urgent care center
° Emergency care as an inpatient at a hospital, including doctors' services Nothing
° Emergency care as an outpatient at a hospital, including doctors' services $50 per visit, waived if
admitted as an inpatient.
Not covered: All charges
° Elective care or non-emergency care
° Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
° Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
Ambulance
Professional ambulance service, as well as air ambulance, when Nothing
medically appropriate.
See Section 5( c) for non-emergency service.
Not covered: Ambulance services to home following an inpatient stay All charges
33.
33
Page 34
35
31 2004 Group Health Cooperative of South Central Wisconsin Section 5 (e)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Section 5 (e). Mental health and substance abuse benefits
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.
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and Your cost sharing
contained in a treatment plan that we approve. The treatment plan may include responsibilities are no
services, drugs and supplies described elsewhere in this brochure. greater than for other
illnesses or conditions.
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.
° Professional services, including individual or group therapy by providers $20 per office visit
such as psychiatrists, psychologists, or clinical-social workers.
° Medication management
° Diagnostic tests Nothing if you receive
these services during your
office visit; otherwise,
$20 per day for such lab
and/ or radiology tests.
° Services provided by a hospital or other facility Nothing
° Services in approved alternative care settings such as partial hospitalization,
full-day hospitalization, facility based intensive outpatient treatment.
Mental health and substance abuse benefits continued on next page Mental health and substance abuse benefits continued on next page
34.
34
Page 35
36
32 2004 Group Health Cooperative of South Central Wisconsin Section 5 (e)
Mental health and substance abuse benefits (continued) You Pay
Not covered: Services we have not approved All charges
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order us to
pay or provide one clinically appropriate treatment plan in favor of another.
Preauthorization To be eligible to receive these benefits you must obtain a
treatment plan and follow all of our network authorization
processes.
° Patients may make their own appointments for mental health
and/ or substance abuse services as follows:
Outpatient Mental HealthÑ GHC Mental Health Department
Telephone: 608-441-3290 or 800-605-4327;
after hours: 608-257-9700
Inpatient Mental HealthÑ UW Hospital & Clinics
Substance AbuseÑ Outpatient and Inpatient Services
Gateway Recovery Services, Inc., 608-278-8200
Limitation We may limit your benefits if you do not obtain a
treatment plan.
35.
35
Page 36
37
33 2004 Group Health Cooperative of South Central Wisconsin Section 5 (f)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Section 5 (f). Prescription drug benefits
Here are some important things to keep in mind about these benefits:
° We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
° All benefits are subject to the definitions, limitations and exclusions
in this brochure and are payable only when we determine they are
medically necessary.
° Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
There are important features you should be aware of. These include:
° Who can write your prescription. A plan physician, referral doctor, or
licensed dentist must write the prescription.
° Where you can obtain them. You must fill the prescription at a plan
pharmacy.
° We use a formulary. A drug formulary is a list of prescription medications,
representing the current judgment of medical practitioners, for the treatment of
disease. Not all medications will be listed in the formulary, particularly when
there are several similar medications available. The formulary will include the
drugs covered by the plan's benefit. Your physician/ practitioner may request
coverage for non-formulary drugs when clinically necessary.
° These are the dispensing limitations. We cover the amount prescribed, up to
a 30-day supply maximum, or One (1) commercially prepared unit (such as
one vial ophthalmic drops, one inhaler, one tube of ointment, or one bottle of
insulin) per co-payment. A limited number of drugs are available for a 90-day
supply for three (3) co-payments. If coverage has been approved for a non-formulary
drug, you pay the applicable generic or brand name co-payment. For
non-formulary drugs when coverage has not been approved, the co-payment is
equal to the plan-calculated total prescription cost, which is generally lower
than the retail price.
° If you are a military reservist called to active duty or are a member
requiring a supply of medication during a national emergency, call us at
608-828-4853 for assistance with obtaining your medication.
° Why use generic drugs? Generic drugs offer a safe and economic way to
meet your prescription drug needs. The generic name of a drug is its chemical
name; the name brand is the name under which the manufacturer advertises
and sells a drug. Under federal law, generic and name brand drugs must meet
the same standards for quality. A generic prescription costs you less and helps
moderate the costs of providing healthcare.
° When you have to file a claim. Generally you will not need to file a claim.
An exception would be a drug prescribed in an emergency or urgent situation
when you are out of the area. Forward such claims to GHC Claims
Department, PO Box 44971, Madison, WI 53744-4971. Be sure to include
your member number and an explanation of why you are submitting the claim.
Prescription drug benefits begin on the next page.
36.
36
Page 37
38
34 2004 Group Health Cooperative of South Central Wisconsin Section 5 (f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan A $6 copay for generic drugs
physician, referral doctor, or licensed dentist and obtained from a A $12 copay for name
Plan pharmacy. brand drugs
° Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase, except those listed as Note: if there is no generic
Not covered. equivalent available, you will
° Insulin still have to pay the name
° Diabetic supplies, including insulin syringes, needles, injection pens, brand copay.
glucose test tablets and test tape, Benedict's solution or equivalent and
acetone test tablets Note: Patients wishing to use
° Contraceptive drugs and devices a formulary brand name
° Smoking cessation drugs when participating in the Plan's behavior medication instead of a
modification program covered generic equivalent
° Pre-natal vitamins during pregnancy may choose to do so but
° Disposable needles and syringes for the administration of covered medications will pay the cost difference
° Oral fertility drug, Clomiphene citrate, limited to a lifetime maximum between the formulary brand
of one year and the formulary generic
in addition to the brand
copayment.
Note: Medications
administered in-clinic by a
professional health care
worker that could be self-administered
are subject to
the medication co-payment.
Injectable vaccines and
allergens are not considered
medications for the purpose
of medication co-payments.
° Drugs for sexual dysfunction are subject to dosage limits. 50%
Contact the Plan for details.
Continued on next page.
37.
37
Page 38
39
35
Covered medications and supplies (continued) You Pay
Not covered: All Charges
° Drugs and supplies for cosmetic purposes
° Non-formulary drugs
° Drugs to enhance athletic performance
° Fertility drugs, including drugs to maintain pregnancy (except clomiphene
citrateÑ see covered medications)
° Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
° Vitamins, nutrients and food supplements even If a physician prescribes or
administers them (except pre-natal vitaminsÑ see covered medications)
° Nonprescription medicines
° Drugs for which there is a nonprescription equivalent available
° Medical supplies such as dressings and antiseptics
° Smoking cessation drugs (except when participating in the Plan's behavior
modification program)
° Weight loss drugs, appetite suppressants, weight loss programs or classes,
when medically necessary for the treatment of morbid obesity
2004 Group Health Cooperative of South Central Wisconsin Section 5 (f)
38.
38
Page 39
40
36 2004 Group Health Cooperative of South Central Wisconsin Section 5 (g)
Section 5 (g). Special features
Feature Description
Services for deaf and Hearing impaired interpreter for non-emergency services can be reached at this hearing impaired TDD line: 608-257-7391.
Center of excellence Our local center of excellence is associated with the University of Wisconsin Hospital and Clinics in Madison, Wisconsin.
39.
39
Page 40
41
37 2004 Group Health Cooperative of South Central Wisconsin Section 5 (h)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T
Section 5 (h). Dental benefits
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they
are medically necessary.
° Plan dentists must provide or arrange your care.
° We have no calendar year deductible.
° We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the
health of the patient. See Section 5c for inpatient hospital benefits. We do not
cover the dental procedure unless it is described below.
° Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair but not Nothing up to $1500 per
replace sound natural teeth. The need for these services must result from an accident, all charges above
accidental injury. You must be seen within 48 hours of the accident; however, $1500 per accident
treatment may be delayed due to your medical condition. Damage to teeth
caused by chewing or biting does not constitute an accidental injury.
Dental benefits
Service You pay
° Prophylaxis or cleaning (one every six months) Nothing if you use a GHC
° Topical applications of fluoride through age fifteen (one every six months) Plan dentist; 50% of charges
if you use a non-participating
dentist
Not covered: all other dental services (i. e., fillings, extractions, crowns, All charges
orthodontics, etc.)
40.
40
Page 41
42
38 2004 Group Health Cooperative of South Central Wisconsin Section 6
Section 6. General exclusionsÑ 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
° Services, drugs, or supplies you receive without charge while in active military service
41.
41
Page 42
43
39 2004 Group Health Cooperative of South Central Wisconsin 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
or coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:
Medical, hospital and drug benefits In most cases, providers and facilities file claims for you. Physicians
must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 608-828-4853.
When you must file a claimÑ such as for services you receive
outside of the Plan's service areaÑ 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 (by code #)
° 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 payerÑ such as the Medicare Summary Notice (MSN)
° Receipts, if you paid for your services
Submit your claims to: Group Health Cooperative, Claims
Department, PO Box 44971, Madison, WI 53744-4971.
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.
42.
42
Page 43
44
40 2004 Group Health Cooperative of South Central Wisconsin 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: Group Health Cooperative Member Services, PO Box 44971, Madison, WI
53744-4971; 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 Ñ 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 usÑ 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, Insurance Services Programs, Health Insurance Group 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.
Step 4 continued on next page.
43.
43
Page 44
45
41 2004 Group Health Cooperative of South Central Wisconsin Section 8
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of
reasons beyond your control.
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the
suit against OPM in Federal court by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or
death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
608-828-4853 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 may call OPM's Health Insurance Group 3 at 202-606-0755 between 8 a. m. and 5 p. m. eastern time.
44.
44
Page 45
46
42 2004 Group Health Cooperative of South Central Wisconsin Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that
pays health care expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan normally pays its benefits
in full as the primary payer and the other plan pays a reduced benefit
as the secondary payer. We, like other insurers, determine which
coverage is primary according to the National Association of
Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in
this brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our
allowance, up to our regular benefit. We will not pay more than our
allowance.
What is Medicare? Medicare is a Health Insurance Program for: ° People 65 years of age and older.
° Some people with disabilities, under 65 years of age.
° People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant)
Medicare has two parts:
° Part A (Hospital Insurance). Most people do not have to pay for
Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who was a federal
employee on January 1, 1983, or since automatically qualifies.)
Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.
° Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
Should I enroll in Medicare? The decision to enroll in Medicare is yours. We encourage you to
apply for Medicare benefits 3 months before you turn age 65. It's
easy. Just call the Social Security Administration toll-free number 1-
800-772-1213 to set up an appointment to apply. If you do not apply
for one or both Parts of Medicare, you can still be covered under the
FEHB Program.
If you can get premium-free Part A coverage, we advise you to enroll
in it. Most Federal employees and annuitants are entitled to Medicare
Part A at age 65 without cost. When you don't have to pay
premiums for Medicare Part A, it makes good sense to obtain the
coverage. It can reduce your out-of-pocket expenses as well as costs
to the FEHB, which can help keep FEHB premiums down.
45.
45
Page 46
47
43 2004 Group Health Cooperative of South Central Wisconsin Section 9
Section 9. Coordinating benefits with other coverage (continued)
Everyone is charged a premium for Medicare Part B coverage. The
Social Security Administration can provide you with premium and
benefit information. Review the information and decide if it makes
sense for you to buy the Medicare Part B coverage.
If you are eligible for Medicare, you may have choices in how you
get your health care. Medicare + Choice 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 Medicare, depending on the type of
Medicare + Choice plan you have.
The Original Medicare Plan The Original Medicare Plan is available everywhere in the
(Part A or Part B) United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B
benefits now. You may go to any doctor, specialist or hospital that
accepts Medicare. The Original Medicare Plan pays its share and you
pay your share. Some things are not covered under Original
Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this plan,
you still need to follow the rules in this brochure for us to cover your
care. Your care must continue to be authorized by your Plan primary
care physician.
Claims process when you have the You probably will never have to file a claim form when you have
Original Medicare Plan 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 claim will be
coordinated automatically and we will then provide secondary
benefits for covered charges. You will not need to do anything.
To find out if you need to do something to file your claim, call
us at 608-251-4138.
We do not waive any costs if the Original Medicare Plan is your
primary payer.
(Primary payer chart begins on next page.)
46.
46
Page 47
48
44 2004 Group Health Cooperative of South Central Wisconsin Section 9
Medicare always makes the final determination as to whether they are the primary payer. The following chart illustrates
whether 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 youÑ or your covered spouseÑ are age 65 or over and have Then the primary payer isÉ
Medicare and youÉ Medicare This Plan
1) Are an active employee with the Federal government and...
° You have FEHB coverage on your own or through your spouse who
is also an active employee
° You have FEHB coverage through your spouse who is an annuitant
2) Are an annuitant and...
° You have FEHB coverage on your own or through your spouse who is
also an annuitant
° You have FEHB coverage through your spouse who is an active employee
3) Are a reemployed annuitant with the Federal government and your position
is excluded from the FEHB (your employing office will know if this *
is the case)
4) Are a reemployed annuitant with the Federal government and your position
is not excluded from the FEHB (your employing office will know if
this is the case) and...
° You have FEHB coverage on your own or through your spouse who is
also an active employee
° You have FEHB coverage through your spouse who is an annuitant
5) 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)
6) Are enrolled in Part B only, regardless of your employment status for Part B for other
services services
7) 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)
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and... ° It is within the first 30 months of eligibility for or entitlement to
Medicare due to ESRD (30-month coordination period)
° It is beyond the 30-month coordination period and you or a family member
are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare for 30-month
beneficiary and... coordination
° This Plan was the primary payer before eligibility due to ESRD period
° Medicare was the primary payer before eligibility due to ESRD
C. When either you or your spouse are eligible for Medicare solely due to disability and you
1) Are an active employee with the Federal government and...
° You have FEHB coverage on your own or through your spouse who is
also an active employee
° You have FEHB coverage through your spouse who is an annuitant
2) Are an annuitant and...
° You have FEHB coverage on your own or through your spouse who is
also an annuitant
° You have FEHB coverage through your spouse who is an active employee
D. Are covered under the FEHB Spouse Equity provision as a former spouse
*Unless you have FEHB coverage through your spouse who is an active employee
** Workers' Compensation is primary for claims related to your condition under Workers' Compensation
47.
47
Page 48
49
45 2004 Group Health Cooperative of South Central Wisconsin Section 9
° Medicare + Choice plan If you are eligible for Medicare, you may choose to enroll in and get
your Medicare benefits from a Medicare + Choice plan. These are
health care choices (like HMOs) in some areas of the country. In
most Medicare + Choice plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare + Choice
plans provide all the benefits that Original Medicare covers. Some
cover extras, like prescription drugs. To learn more about enrolling in
a Medicare + Choice plan, contact Medicare at 1-800-MEDICARE
(1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare + Choice plan, the following options are
available to you:
This Plan and another plan's Medicare + Choice plan: You may
enroll in another plan's Medicare + Choice plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare + Choice plan is primary, even out of the managed care
plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments or coinsurance. If you
enroll in a Medicare + Choice plan, tell us. We will need to know
whether you are in the Original Medicare Plan or in a Medicare +
Choice plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare + Choice
plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare + Choice plan, eliminating
your FEHB premium. (OPM does not contribute to your Medicare +
Choice 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 + Choice plan's service area.
° If you do not enroll in If you do not have one or both parts of Medicare, you can still be
Medicare Part A or Part B 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 their eligible dependents. If TRICARE or
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 TRICARE or
CHAMPVA: 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 lost coverage under the
program.
48.
48
Page 49
50
46 2004 Group Health Cooperative of South Central Wisconsin Section 9
Workers' Compensation We do not cover services that:
° you need because of a workplace-related illness or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
° OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
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 suspect your FEHB coverage to
enroll in 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 voluntarily lose coverage under the State program.
When other Government agencies We do not cover services and supplies when a local, state,
are responsible for your care or federal government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for
for injuries medical or hospital care for injuries or illness caused by another
person, you mu