GHI Health Plan

http://www.ghi.com

2005

A Prepaid Comprehensive Medical Plan

with a High Option Point of Service Product

 

 

High Option Plan Serving:All of New York and

Northern New Jersey

 

For changes in benefits, see page 9.

Standard Option Plan Serving:New York City (the Boroughs of

Manhattan, Brooklyn, Bronx

Queens, and Staten Island),

all of Nassau, Suffolk,

Rockland and Westchester

Counties

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 full accreditation from URAC
See the 2005 Guide for more information on accreditation.

Enrollment codes for this Plan:

801 High Self Only

802 High Self and Family

804 Standard Self Only

805 Standard Self and Family

 

 

RI73-007

 

Dear Federal Employees Health Benefits Program Participant:

 

Welcome to the 2005 Open Season! By continuing to introduce pro-consumer health care ideas, the Office of Personnel Management (OPM) team has given you greater, cost effective choices. This year several national and local health plans are offering new options, strengthening the Federal Employees Health Benefits (FEHB) Program and highlighting once again its unique and distinctive market-oriented features. I remain firm in my belief that you, when fully informed as a Federal subscriber, are in the best position to make the decisions that meet your needs and those of your family. Plan brochures provide information to help subscribers make these fully informed decisions. Please take the time to review the plan's benefits, particularly Section 2, which explains plan changes.

 

Exciting new features this year give you additional opportunities to save and better manage your hard-earned dollars. For 2005, I am very pleased and enthusiastic about the new High Deductible Health Plans (HDHP) with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) component. This combination of health plan and savings vehicle provides a new opportunity to save and better manage your money. If an HDHP/HSA is not for you and you are not retired, I encourage you to consider a Flexible Spending Account (FSA) for health care. FSAs allow you to reduce your out-of-pocket health care costs by 20 to more than 40 percent by paying for certain health care expenses with tax-free dollars, instead of after-tax dollars.

 

Since prevention remains a major factor in the cost of health care, last year OPM launched the HealthierFeds campaign. Through this effort we are encouraging Federal team members to take greater responsibility for living a healthier lifestyle. The positive effect of a healthier life style brings dividends for you and reduces the demands and costs within the health care system. This campaign embraces four key "actions" that can lead to a healthy America: be physically active every day, eat a nutritious diet, seek out preventative screenings, and make healthy lifestyle choices. Be sure to visit HealthierFeds at www.healthierfeds.opm.gov for more details on this important initiative. I also encourage you to visit the Department of Health and Human Services website on Wellness and Safety, www.hhs.gov/safety/index.shtml, which complements and broadens healthier lifestyle resources. The site provides extensive information from health care experts and organizations to support your personal interest is staying healthy.

 

The FEHB Program offers the Federal team the widest array of cost-effective health care options and the information needed to make the best choice for you and your family. You will find comprehensive health plan information in this brochure, in the 2005 Guide to FEHB Plans, and on the OPM Website at www.opm.gov/insure. I hope you find these resources useful, and thank you once again for your service to the nation.

Sincerely,

 

Kay Coles James

Director

 

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[opm1] 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 [opm2] 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.

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 202-606-0745 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

United States 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 United States 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.

Introduction................................................................................................................................................................................................... 3

Plain language................................................................................................................................................................................................ 3

Stop Health Care Fraud!............................................................................................................................................................................... 3

Preventing Medical Mistakes.................................................................................... .............................................. 5

Section 1. Facts about this Prepaid Plan................................................................................................................................................... 7

We also have Point-of-Service (POS) benefits................................................................................................................... 7

How we pay providers........................................................................................................................................................... 7

Your rights............................................................................................................................................................................... 7

Service area.............................................................................................................................................................................. 8

Section 2. How we change for 2005........................................................................................................................................................... 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.................................................................................................................................... 11

Services requiring our prior approval................................................................................................................................ 11

Section 4. Your costs for covered services............................................................................................................................................ 12

· Copayments........................................................................................................................................................................ 12

· Deductible........................................................................................................................................................................... 12

· Coinsurance........................................................................................................................................................................ 12

Your catastrophic protection out-of-pocket maximum.................................................................................................... 12

Section 5. Benefits - Overview(see page 13 for how our benefits changed this year
and page 14 for a benefit summary).................................................................................................................... 13

Section 5 (a) Medical services and supplies provided by physicians and other health care professionals.......... 14

Section 5 (b) Surgical and anesthesia services provided by physicians and other health care professionals...... 31

Section 5 (c) Services provided by a hospital or other facility, and ambulance services.......................................... 38

Section 5 (d) Emergency services/accidents.................................................................................................................... 41

Section 5 (e) Mental health and substance abuse benefits............................................................................................ 44

Section 5 (f) Prescription drug benefits............................................................................................................................. 46

Section 5 (g) Special features.............................................................................................................................................. 50

· Flexible benefit options..................................................................................................................................................... 50

· Large Case Management.................................................................................................................................................. 50

· Customer Service AnswerLine......................................................................................................................................... 50

· Services for deaf and hearing impaired........................................................................................................................... 50

· High risk pregnancies........................................................................................................................................................ 50

· Centers of excellence for transplants/heart surgery/etc.............................................................................................. 51

· Travel benefit/services overseas..................................................................................................................................... 51

Section 5 (h) Dental benefits............................................................................................................................................... 52

Section 5 (i) Point of service product................................................................................................................................. 54

Section 5 (j) Non-FEHB benefits available to Plan members.......................................................................................... 56

Section 6. General exclusions -- things we don't cover........................................................................................................................ 57

Section 7. Filing a claim for covered services........................................................................................................................................ 58

Section 8. The disputed claims process.................................................................................................................................................. 59

Section 9. Coordinating benefits with other coverage......................................................................................................................... 61

When you have other health coverage

What is Medicare?................................................................................................................................................................ 61

· Should I enroll in Medicare?............................................................................................................................................ 61

· The original Medicare plan (Part A or Part B)............................................................................................................... 62

· Medicare Advantage......................................................................................................................................................... 64

TRICARE and CHAMPVA ................................................................................................................................................. 64

Workers' Compensation....................................................................................................................................................... 64

Medicaid................................................................................................................................................................................. 65

What other Government agencies are responsible for your care.................................................................................. 65

When others are responsible for injuries.......................................................................................................................... 65

Section 10. Definitions of terms we use in this brochure..................................................................................................................... 66

Section 11. FEHB facts.............................................................................................................................................................................. 68

Coverage information........................................................................................................................................................... 68

· No pre-existing condition limitation................................................................................................................................ 68

· Where you get information about enrolling in the FEHB Program............................................................................ 68

· Types of coverage available for you and your family.................................................................................................. 68

· Children's Equity Act........................................................................................................................................................ 68

· When benefits and premiums start................................................................................................................................. 69

· When you retire................................................................................................................................................................. 69

When you lose benefits....................................................................................................................................................... 69

· When FEHB coverage ends............................................................................................................................................. 69

· Spouse equity coverage................................................................................................................................................... 70

· Temporary Continuation of Coverage (TCC)................................................................................................................ 70

· Converting to individual coverage.................................................................................................................................. 70

· Getting a Certificate of Group Health Plan Coverage................................................................................................... 70

Section 12. Two Federal Programs complement FEHB benefits........................................................................................................... 72

The Federal Flexible Spending Account Program - FSAFEDS..................................................................................... 72

The Federal Long Term Care Insurance Program............................................................................................................. 75

Index.............................................................................................................................................................................................................. 77

Summary of benefits for the GHI Health Plan - 2005.............................................................................................................................. 78

2005 Rate Information for the GHI Health Plan...................................................................................................................... .Back cover

Introduction

 

 

This brochure describes the benefits of Group Health Incorporated under our contract (CS 1056) with the United States Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for GHI administrative offices is:

Group Health Incorporated

441 Ninth Avenue
New York, NY 10001

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, 2005, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2005, and changes are summarized beginning on page 9. Rates are shown at the end of this brochure.

 

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 GHI Health Plan.

· We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.

· Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.

If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www.opm.gov/insure or e-mail OPM at fehbwebcomments@opm.gov. You may also write to OPM at the Office of Personnel Management, Insurance Services Program, Program Planning and Evaluation Group, 1900 E Street, NW Washington, DC 20415-3650

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program (FEHB) 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 Fraud - Here are some things you can do to prevent fraud:

· Be wary of giving your plan identification (ID) 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 1-888-456-3728 and explain the situation.

If we do not resolve the issue:

 

CALL ¾ THE HEALTH CARE FRAUD HOTLINE 202-418-3300 OR WRITE TO: United States Office of Personnel Management Office of the Inspector General Fraud Hotline 1900 E Street NW Room 6400 Washington, DC20415-1100

 

· 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 incapable of self support.)

· If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with your retirement office (such as OPM) if you are retired, or with the National Fiance 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 FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.

 

 

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?

Ø www.ahrq.gov/consumer/pathqpack.html. The Agency for Health Care Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.

Ø www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and your family.

Ø 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.

Ø www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.

Ø www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety.

Ø 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 health care delivery system.

 

Section 1. Facts about this Prepaid Plan with a High Option Point-of-Service product

 

This Plan offers two benefit packages. A High Option and a Standard Option. Within the Plan's network you are encouraged to select a personal doctor who will provide or arrange your care and you will pay minimal amounts for comprehensive benefits. The Plan is solely responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.

Because the Plan emphasizes care through participating providers and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a more comprehensive range of benefits than many insurance plans.

In addition to providing comprehensive health services and care for accidents, illness and injury, the Plan emphasizes preventive benefits such as routine office visits, physicals, immunizations and well-baby care. You are encouraged to get medical attention at the first sign of illness. Whenever you need services, you may choose to obtain them from your personal doctor within the Plan's provider network. Under the High Option benefit package, you may go outside the network for treatment. When you choose a non-Plan doctor or other non-Plan provider, you will pay a substantial portion of the charges, and the benefits available may be less comprehensive.

You should join a prepaid plan 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.

We also have a Point-of-Service (POS) benefits:

Our High Option benefit package offers Point-of-Service (POS) benefits. This means you can receive covered services from a participating provider without a required referral, or from a non-participating provider. These out-of-network benefits have higher out-of-pocket costs than our in-network benefits.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

When you use a participating hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, emergency room physicians, anesthesiologists, and pathologists, may not all be participating providers. If they are not, you will be reimbursed at 50% of the Plan's fee schedule under the High Option benefits package and nothing under the Standard Option benefits package.

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.

· GHI is URAC-accredited and is licensed under Article 43 of the New York State Insurance Law as a health services corporation.

· GHI has been in continuous existence for over sixty (60) years

· GHI is a not-for-profit New York corporation

If you want more information about us, call 212/501-4GHI (4444), or write to GHI, PO Box 1701, New York, NY 10023-9476. You may also visit our website at www.ghi.com.

Service area

To enroll with us in the High Option you must live or work in our service area. Our service area is: all of New York and the New Jersey counties of Bergen, Essex, Hudson, Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex and Union.

To enroll with us in the Standard Option you must live or work in our service area. Our service area is: New York City (the Boroughs of Manhattan, Brooklyn, Bronx, Queens, and Staten Island) all of Nassau, Suffolk, Rockland and Westchester Counties.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.

Section 2. How we change for 2005

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

· In Section 9, we revised the Medicare Primary Payer Chart and updated the language regarding Medicare Advantage plans (formerly called Medicare + Choice plans).

· In Section 12, we revised the language regarding the Flexible Spending Account Program ­ FSAFEDS and the Federal Long Term Care Insurance Program.

Changes to this Plan

· Your share of the non Postal High Option premium will increase by 9.5% for Self only and 9.8% for Self and Family, the Standard Option Premium will increase by 7.1% for Self only and decrease by 17.3% for Self and Family.

Benefit changes to the GHI High Option Plan

1. Prescription Drug Benefit

· The current Retail Drug copay has been increased from $10 for a generic drug to $15 for a generic drug, and from $20 for name brand drug that is listed in the preferred prescription drug formulary to $25 for a name brand drug that is listed in the preferred prescription drug formulary.

· The Maintenance Drug Program copay has been increased as from $20 copay for a generic drug to $35 copay for a generic drug, from $40 for a name brand drug listed in the preferred prescription drug formulary to $60 for a name brand drug listed in the preferred prescription drug formulary and from $60 for a name brand drug which is not listed in the preferred prescription drug formulary to $75 for a name brand drug which is not listed in the preferred prescription drug formulary.

The following Prescription Drug Programs are added to the Prescription Drug Benefit:

a) Step Therapy Prior Authorization Program

b) Drug Quantity Management Program

c) Diabetic Supplies Close Category Program

d) Non-Sedating Antihistamines Program

2. Hospital Deductible

Effective January 1, 2005 there is a hospital deductible of $100 per inpatient admission up to a maximum of $200 per year. The hospital deductible is waived for maternity care.

 

Benefit changes to the GHI Standard Option Plan

1. Prescription Drug Benefit

In order to better control the continuing increase in drug costs and thereby preserve the existing benefit; GHI is proposing the same Prescription Drug Programs as stated under the High Option Plan.

2. Copay for Pediatric Visit Are Waived

The in physician office copy of $25 is waived for pediatric visits.

 

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 212/501-4GHI (4444). You may also request replacement cards through the GHI website, www.ghi.com
Where you get covered care	You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/or coinsurance, and you will not have to file claims. If you have the High Option Plan with our point-of-service program, you can also get care from non-Plan providers, but it will cost you more.
· Plan providers	Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.
	We list Plan providers in the provider directory, which we update periodically. The list is also on our website.
· Plan facilities	Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website.
What you must do to get covered care	Within the Plan's network, you are encouraged to select a personal doctor who will provide or arrange your care, in which case you will pay minimal amounts for comprehensive benefits under the High Option Plan. When you choose a non-Plan doctor or other non-Plan provider, you will pay a substantial portion of the charges, and the benefits available may be less comprehensive.
· Primary care	You may seek care from a doctor, dentist, podiatrist, qualified clinical psychologist, optometrists, chiropractor, nurse, certified midwife, nurse practitioner/clinical specialist, or qualified clinical social worker and any other duly-licensed, registered or certified practitioner or privately-operated facility permitted to perform or render care or service described in this brochure.
· Specialty care	You may see the specialist whenever you and your family feel you need care. Here are other things you should know about specialty care:
	· If you have a chronic or disabling condition and lose access to your specialist because we:
	- ­Terminate our contract with your specialist for other than cause; or
	- ­ Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or - ­ Reduce our service area and you enroll in another FEHB Plan.
	You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.
	If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days

 

· Hospital care	Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.
	If you are in the hospital when your enrollment in our Plan begins, call our Customer Service Department immediately at 212/501-4GHI (4444). 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 assist you with the necessary care.
Services Requiring our prior approval	For certain services, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, is medically necessary, and follows generally-accepted medical practice.
	Your physician must obtain prior approval for the following services:
	· High-tech radiology
	· High-tech nursing
	· Infusion therapy
	· Mental Health and Substance Abuse
	· Infertility Services
	If no one contacted us, we will not pay for those services.
	For certain services, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, is medically necessary, and follows generally accepted medical practice.
	Your physician must obtain precertification for the following services:
	· All inpatient hospital admission for maternity care and skilled nursing facilities
	· Non-emergency hospital admissions
	If no one contacted us, we will decide whether the hospital stay was medically necessary.
	· If we determine that the stay was medically necessary, we will pay for the covered inpatient hospital benefits less the $125 per day penalty, up to a maximum of $250 per admission
	· If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits.
	You do not need precertification in these cases
	· You have another group health insurance policy that is the primary payer for the hospital stay.
	· Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhauset your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payer and you do need precertification.

 

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 a participating provider you pay a copayment of $15 per office visit under the High Option and a $25 per office visit under the Standard Option and when you go in the hospital, you pay nothing.

 

Deductible

A deductible is a fixed expense you must pay for certain covered services and supplies before we start paying benefits for them. Copayments do not count towards any deductible. The calendar year deductible for certain services is: · For nursing service, you pay an annual deductible of $150 per individual or family. · For appliances, oxygen or equipment, you pay an annual deductible of $100 per individual or family. · For referred ambulatory, laboratory tests and diagnostic x-rays, which is only available under the High Option Plan, you pay a $25 deductible per referral. · The Standard Option coverage has a $50 prescription drug deductible that you must meet each calendar year and a $250 per day maximum $750 per admission hospital deductible. The hospital deductible is waived for maternity care. Note: If you change plans during Open Season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan. And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

 

Coinsurance

Any amount in excess of 50% of the High Option Plan's fee schedule for POS services provided by non-participating providers.

 

Your catastrophic protection out-of-pocket maximum for deductibles, coinsurance,and copayments

Under the High Option Plan, after your out-of-pocket expenses total $10,000 per person in any calendar year for covered services provided by a non-participating provider, GHI will then pay catastrophic benefits at 100% of reasonable and customary charges as determined by the Plan. Out-of-pocket expenses are calculated based upon the reasonable and customary charge for covered catastrophic services. Covered catastrophic services include: 1) surgery, 2) administration of anesthesia, 3) chemotherapy and radiation therapy, 4) covered in-hospital service and diagnostic services, and 5) maternity. However, expenses for the following services do not count toward your catastrophic protection out-of-pocket maximum: · Home and office visits and related diagnostic services · Nursing, Appliances, Oxygen and Equipment · Dental services · Vision services · Prescription drugs

Section 5. Benefits -- OVERVIEW (See page 8 for how our benefits changed this year and page 78 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 212/501- 4444 or at our website at www.ghi.com.

Section 5 (a) Medical services and supplies provided by physicians and other health care
professionals............................................................................................................ 14-30

· Diagnostic and treatment services · Lab, X-ray, and other diagnostic tests · Preventive care, adult · Preventive care, children · Maternity care · Family planning · Infertility services · Allergy care · Treatment therapies · Physical and occupational therapies

· Speech therapy · Hearing services (testing, treatment, and supplies) · Vision services (testing, treatment, and supplies) · Foot care · Orthopedic and prosthetic devices · Durable medical equipment (DME) · Home health services · Chiropractic · Alternative treatments · Educational classes and programs

Section 5 (b) Surgical and anesthesia services provided by physicians and other health care professionals.......... 31-37

· Surgical procedures · Reconstructive surgery

· Oral and maxillofacial surgery · Organ/tissue transplants · Anesthesia

Section 5 (c) Services provided by a hospital or other facility, and ambulance services................. 38-40

· Inpatient hospital · Outpatient hospital or ambulatory surgical center

· Extended care benefits/skilled nursing care facility benefits · Hospice care · Ambulance

Section 5 (d) Emergency services/accidents......................................................................................................................... 41-43

· Emergency Within Our Service Area · Ambulance · Emergency Outside Service Area

Section 5 (e) Mental health and substance abuse benefits................................................................................................ 44-45

· Mental health & substance abuse benefits

Section 5 (f) Prescription drug benefits................................................................................................................................. 46-50

· Covered Medications and Supplies

Section 5 (g) Special features........................................................................................................................................................ 50

· Flexible benefit options · Large Case Management · Customer Service AnswerLine · Services for deaf and hearing impaired

· High risk pregnancies · Centers of excellence for transplants/heart surgery/etc. · Travel benefit/services overseas

Section 5 (h) Dental benefits................................................................................................................................................... 52-53

· Accidental Injury Benefit · Dental Benefits

Section 5 (i) Point of service benefits..................................................................................................................................... 54-55

Section 5 (j) Non-FEHB benefits available to Plan members.................................................................................................... 56

Summary of benefits for the GHI Health Plan - 2005................................................................................................................ 78

2005 Rate Information for GHI Health Plan................................................................................................................................. 81

 

Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
	I M P O R T A N T	Here are some important things to keep in mind about these benefits: · Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. · Plan providers under the High Option benefit package non-Plan providers can provide or arrange your care. Limit out-of-pocket costs by using participating providers. · The calendar year deductible for certain services is: · For nursing services, you pay an annual deductible of $150 per individual or family. · For appliances, oxygen or equipment, you pay an annual deductible of $100 per     individual or family. · For referred ambulatory laboratory test and diagnostic x-rays, which are available only under the High Option Plan, you pay a $25 deductible per referral. We added asterisks - * - to show when the calendar year deductible does not apply. · Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.			I M P O R T A N T
Benefit Description			High Option	Standard Option
Diagnostic and treatment services*			You pay	You pay
Professional services of physicians · In physician's office			$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. Waived for Pediatric visits All charges for non-participating providers.
Professional services of physicians · In an urgent care center · Office medical consultations · Second surgical opinion			$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. Waived for pediatric visits All charges for non-participating providers.

 

 

Diagnostic and treatment services* (continued)	High Option You pay	Standard Option You pay
· During a hospital stay · In a skilled nursing facility · Initial examination of a newborn child covered under a family enrollment	Nothing for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	Nothing for participating providers. All charges for non-participating providers.
At home	$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. All charges for non-participating providers.
Lab, X-ray and other diagnostic tests*
Tests, such as: · Blood tests · Urinalysis · Non-routine Pap tests · Pathology · X-rays · Non-routine Mammograms · CAT Scans/MRI · Ultrasound · Electrocardiogram and EEG	$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service. POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount.	$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service. All charges for non-participating providers.

Preventative care, adult*	High Option You pay	Standard Option You pay
Routine screenings, such as: · Total Blood Cholesterol - once every three years · Colorectal Cancer Screening, including - Fecal occult blood test · Osteoporosis screening	$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount	$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service All charges for non-participating providers.
- Sigmoidoscopy, screening - every five years starting at age 50	$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. All charges for non-participating providers.
Routine Prostate Specific Antigen (PSA) test - one annually for men age 40 and older	$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount	$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service All charges for non-participating providers.

Preventative care, adult* (continued)	High Option You pay	Standard Option You pay
Routine Pap test	$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount.	$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service All charges for non-participating providers.
Routine mammogram -covered for women age 35 and older, as follows: · From age 35 through 39, one during this five year period · From age 40 through 64, one every calendar year · At age 65 and older, one every two consecutive calendar years	$15 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service POS: For non-participating providers, you pay any difference between our fee schedule and the billed amount.	$25 per each diagnostic x-ray + laboratory test performed by a participating provider. A maximum of two diagnostic copays will apply per date of service All charges for non-participating providers.
Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.	All charges	All charges
Routine immunizations, limited to: · Tetanus-diptheria (Td) booster - once every 10 years, ages 19 and over (except as provided for under Childhood immunizations) · Influenza vaccine annually · Pneumococcal vaccine, age 65 and over	$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. All charges for non-participating providers.

Preventative care, children*	High Option You pay	Standard Option You pay
· Childhood immunizations recommended by the American Academy of Pediatrics	Nothing for participating providers. POS: 50% of the Plan's fee schedule for non participating providers, and any difference between our fee schedule and the billed amount	Nothing for participating providers. All charges for non-participating providers.
· Well-child care charges for routine examinations, immunizations and care (up to age 22)	Nothing for participating providers. 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	Nothing for participating providers. All charges for non-participating providers.
· Examinations, such as: - Eye exams to determine the need for vision correction - Ear exams to determine the need for hearing correction	$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. All charges for non-participating providers.

Preventive care, children continued on next page

 

Preventative care, children* (continued)	High Option You pay	Standard Option You pay
· Examinations done on the day of immunizations (up to age 22)	Nothing for participating providers.   POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	Nothing for participating providers.   All charges for non-participating providers.
Maternity care*
Complete maternity (obstetrical) care, such as: · Prenatal care · Delivery · Postnatal care Note: Here are some things to keep in mind: · You must precertify your normal delivery. Maternity admissions should be precertified no later than the second trimester. · You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary. · We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. Surgical Benefits, not maternity benefits, apply to circumcision if this is the case. · We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b).	A single $15 copay for all pre- and post-natal care from a participating provider. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	A single $25 copay for all pre- and post-natal care from a participating provider. All charges for non-participating providers.
Not covered: Routine sonograms to determine fetal age, size or sex.	All charges	All charges

 

Family planning*	High Option You pay	Standard Option You pay
A range of voluntary family planning services, limited to: Voluntary sterilization (See Surgical procedures Section 5b) · Surgically implanted contraceptives (such as Norplant) · Injectable contraceptive drugs (such as Depo provera) · Intrauterine devices (IUDs) · Diaphragms Note: We cover oral contraceptives under the prescription drug benefit.	$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. All charges for non-participating providers.
Not covered: reversal of voluntary surgical sterilization, genetic counseling.	All charges	All charges
Infertility services*
Diagnosis and treatment of infertility, such as: · In vitro fertilization (limited to three transfers per lifetime) · Embryo transfer · Artificial insemination - Intravaginal insemination (IVI) - Intracervical insemination (ICI) - Intrauterinal insemination (IUI) · Fertility drugs Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.	$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. All charges for non-participating providers.
Not covered: Cost of donor sperm	All charges	All charges

 

Allergy care*	High Option You pay	Standard Option You pay
Testing and treatment Allergy injections Treatment materials (such as allergy serum)	$15 per visit for participating providers. POS: 50% of the Plan's fee schedule for non-participating providers, and any difference between our fee schedule and the billed amount.	$25 per visit for participating providers. All charges for non-participating providers.
Not covered: Provocative food testing and sublingual allergy desensitization	All charges	All charges
Treatment therapies*
· Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under Organ/Tissue Transplants on page 35. · Respiratory and inhalation therapy · Dialysis - hemodialysis and peritoneal dialysis	In a doctor's office, nothing for a participating provider. POS: In a doctors office, 50% of the Plan's fee schedule, for non-participating providers, and any difference between our fee schedule and the billed amount.	In a doctor's office, nothing for a participating provider. All charges for non-participating providers.
· High-tech nursing and infusion therapy - IV infusion therapy - Parenteral and enteral therapy - Other home IV therapies Note: Contact us at (212) 615-4662 prior to receiving services to ensure coverage. · Intermittent home nursing service - Provided by a Registered Nurse or Licensed Practitioner - Authorized and supervised by a doctor - Intermittent visits less than 2 hours per day	Nothing for a participating provider. POS: All charges for non-participating providers.	Nothing for a participating provider. All charges for non-participating providers.

Treatment therapies continued on next page

 

Treatment therapies* (continued)	High Option You pay			Standard Option You pay
· Growth hormone therapy (GHT). This benefit is provided under our Prescription Drug Benefits. You must fill the prescription at a pharmacy that participates under the program Express Scripts PERxCare Retail Pharmacy Program.	Generic drug: $10 copay per prescription or refill Name brand drug, listed on formulary: $20 copay per prescription or refill Name brand drug not on formulary: $50 copay per prescription or refill			After a $50 annual deductible per person Generic drug: $10 copay per prescription or refill   Name brand drug, listed on formulary: $25 copay per prescription or refill Name brand drug not on formulary: $50 copay per prescription or refill
Not covered: · Treatment for experimental or investigational procedures. · Therapy necessary for transsexual surgery.	All charges			All charges
Physical and occupational therapies*
· 60 visits per condition for the services of each of the following: - qualified physical therapist; - occupational therapist.   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. Occupational therapy is limited to services