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2005 |
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RI 73-275 |
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Coventry Health Care of Kansas, Inc. (Wichita, Salina, and Central Kansas areas) |
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A Health Maintenance Organization with a High Deductible Health Plan Option |
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Serving: Wichita, Salina and Central Kansas areas Enrollment in this plan is limited. You must live or work in our Geographic service area to enroll. See page 8 for requirements. |
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For changes in benefits see page 9. |
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Enrollment code for this Plan: 7W1 High Option - Self Only 7W2 High Option - Self and Family 7W4 Standard Option - Self Only 7W5 Standard Option - Self and Family 7G1 HDHP - Self Only 7G2 HDHP - Self and Family |
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Special Notice: This plan is offering a High Deductible Health Plan (HDHP) option for the first time under the Federal Employees Health benefits Program during the 2004 open season. |
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 lifestyle 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 preventive 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,
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Kay Coles James
Director
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Notice of the United States 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.
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
Unites 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.
Section 5(a) Medical services and supplies provided by physicians and other health care professionals.......... 19
Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals..... 31
Transplant Network.................................................................................................................................................... 48
Section 5.1(a) Preventive care........................................................................................................................................... 56
Section 5.1(b)(1).Medical services and supplies provided by physicians and other health
care professionals............................................................................................................................................................... 59
This brochure describes the benefits of Coventry Health Care of Kansas, Inc.,under our contract (CS 2108) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. The address for Coventry Health Care of Kansas, Inc., administrative offices is:
Coventry Health Care of Kansas, Inc.
8301 East 21st North, Suite 300,
Wichita, KS 67206
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 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 Coventry Health Care of Kansas, Inc..
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 U.S. Office of Personnel Management, Insurance Services Programs, Program Planning & 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 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 that 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 866-320-0697and explain the situation.
If we do not resolve the issue:
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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 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 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 Healthcare 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.
1) Health Maintenance Organization
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 their 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 pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
2) High Deductible Health Plan
This Plan also offers a high deductible health plan (HDHP) with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) component. An HDHP is a new health plan product that provides traditional health care coverage and a tax advantaged way to help you build savings for future medical needs. An HDHP with an HSA or HRA is designed to give greater flexibility and discretion over how you use your health care benefits. As an informed consumer, you decide how to utilize your plan coverage with a high deductible and out-of-pocket expenses limited by catastrophic protection. And you decide how to spend the dollars in your HSA or HRA. You may consider:
Using the most cost effective provider
Actively pursuing a healthier lifestyle and utilizing your preventive care benefit
Becoming an informed health care consumer so you can be more involved in the treatment of any medical conditions or chronic illness.
The type and extent of covered services, and the amount we allow, may be different from other plans. Read our brochure carefully to understand the benefits and features of this HDHP. Internal Revenue Service (IRS) rules govern the administration of all HDHPs. The IRS Website at http://www.ustreas.gov/offices/public-affairs/hsa/faq1.html has additional information about HDHPs.
General features of an HDHP:
HDHP’s have higher annual deductibles and out-of-pocket maximum limits than other types of FEHB plans.
You are not required to select a primary care physician.
Preventive care services are generally paid as first dollar coverage or after a small deductible or copayment. First dollar coverage may be limited to a maximum dollar amount each year.
The annual deductible must be met before Plan benefits are paid for care other than preventive services.
You are eligible for a Health Savings Account (HSA) if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouses’s health plan, but does not include specific injury insurance and accident, disability, dental care, vision care, or long-term care coverage), not eligible for Medicare, and are not claimed as a dependent on someone else’s tax return.
- You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense. Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by a HDHP. You may withdraw money from your HSA for items other than qualified medical expenses, but will be subject to income tax and, if you are under 65 years old, an additional 10% penalty tax on the amount withdrawn.
- For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. In addition, your HSA dollars earn tax-free interest.
- You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.
If you are not eligible for an HSA or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although and HRA is similar to an HSA, there are major differences.
o An HRA does not earn interest.
o An HRA is not portable if you leave the Federal government or switch to another plan.
We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and copayments, are limited to $5,000 for Self-Only enrollment, or $10,000 for family coverage.
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.
Coventry Health Care of Kansas, Inc., provides you with a comprehensive benefit package that covers many kinds of health services for a fixed payroll deduction and minimal copayments. As a participant of Coventry Health Care of Kansas, Inc., you will select a personal doctor for yourself and each member of your family. Depending on where you live, you will be able to choose from a directory of more than 320 primary care doctors whose offices are located throughout the Plan's service areas.
The first and most important decision each member must make is the selection of a primary care doctor. Your primary care doctor will be the manager and coordinator of your health care. If you require additional care, your primary care doctor, with your input, will select the specialist or hospital that best fits your needs. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization.
The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 1-866-320-0697. You can also find out if your doctor participates by calling this number. The list is also on our website. Visit www.chckansas.com to utilize our doctor search option. Our doctor search on the web is updated monthly.
If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in the Plan, services (except for emergency benefits) are provided through the Plan’s delivery system; the continued availability and/or participation of any one doctor, hospital, or other provider, cannot be guaranteed.
Should you decide to enroll, you will be asked to complete a primary care doctor selection and send it to the Plan, indicating the name of the primary care doctor(s) selected for you and each member of your family. Members may change their doctor selection by notifying the Plan or by visiting our website at www.chckansas.com .
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.
Coventry Health Care of Kansas, Inc., is a for profit domiciled Kansas health maintenance organization (HMO) with certificates of authority to operate in both Kansas and Missouri. Coventry Health Care of Kansas, Inc., has been existence since 1961, and has two unique service areas: Kansas City and Wichita for a combined total membership of over 170,000. We are dedicated to providing quality health care at an affordable price, and we provide our members the security of knowing they are being offered a health care delivery system supported by a long tradition of quality and service.
If you want more information about us, call 1-866-320-0697, or write to Coventry Health Care of Kansas, 8301 East 21st North, Suite 300, Wichita, KS 67206. You may also contact us by visiting our website at www.chckansas.com.
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: Butler, Cowley, Harvey, Lyon, McPherson, Montgomery, Pratt, Saline, Sedgwick and Sumner Counties.
You may also enroll with us if you live or work in the following places: Chase, Chautauqa, Coffey, Dickinson, Elk, Geary, Greenwood, Harper, Kingman, Lincoln, Marion, Morris, Ottawa, Reno, Riley, Wilson and Woodson 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.
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.
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.
This Plan is offering a high deductible health plan (HDHP) option for the first time under the Federal Employees Health Benefits Program during the 2004 Open Season.
High Option
Your share of the non-Postal premium will increase by 4.1% for Self Only or decrease by 5.1% for Self and Family.
Standard Option
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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. | |
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If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-866-320-0697or write to us at Coventry Health Care of Kansas, Inc., 8301 East 21st North, Suite 300, Wichita, KS 67206. You may also request replacement cards through our Web site at www.chckansas.com. | |
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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. | |
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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. Visit www.chckansas.com to utilize our doctor search option. Our doctor search on the web is updated monthly. | |
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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 www.chckansas.com. | |
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It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. The Plan’s provider directory lists primary care doctors (generally family practitioners, pediatricians, and internist), with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 1-866-320-0697. You can also find out if your doctor participates by calling these numbers If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. | |
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Your primary care physician will generally be a family practitioner, internist or pediatrician.Your primary care physician will provide most of your health care, or give you a referral to see a specialist. If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one. | |
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Your primary care physician will refer you to a specialist for needed care. You must receive a referral from your primary care doctor before seeing or obtaining special services, with the following exceptions:, (1) Female members may visit a participating gynecologist without a referral from their primary care doctor; (2) All members may visit the Plan's mental health providers for mental conditions and substance benefits without a referral from their primary care doctor (See "Mental Conditions /Substance Abuse Benefits"). Referral to a participating specialist is given at your primary care doctor's discretion; if specialists or consultants are required beyond those participating in the Plan, your primary care doctor will make arrangements for appropriate referrals. When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation. All follow-up care must be provided or arranged by the primary care doctor. On referrals, the primary care doctor will give specific instructions to the consultant as to what services are authorized. If the consultant suggests additional services or visits, you must first check with your primary care doctor. Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance. Here are some 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 workwith the specialist to 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 and 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 program 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. | |
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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 1-866-320-0697. 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. |
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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. | |
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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 authorization. Your physician must obtain for example, prior authorization from the Plan for outpatient surgeries or inpatient hospitalization. You may call customer service at 1-866-320-0697to find out if a specific procedure treatment requires prior authorization. |
You must share the costs of some services. You are responsible for:
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A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services. You are responsible for paying copayments to providers at the time of service. Example: When you see your primary care physician you pay a copayment of $15 per office visit. When you go in the hospital, you pay $100 copay per day up to a $300 maximum per admission. | |
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A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible. High and Standard Option Plan - we have no deductible. High Deductible Health Plan - the individual deductible applies to members enrolled in Self Only. The family deductible applies collectively to all members enrolled in Self and Family. 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. | |
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Coinsurance is the percentage of our allowance that you must pay for your care. If your Plan has a deductible, Coinsurance doesn’t begin until you meet your deductible. Example: In our Plan, you pay 50% of our allowance for infertility services and 20% for covered durable medical equipment. | |
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After your copayments and coinsurance total the amounts listed below, you do not have to pay any more for covered services. Be sure to keep accurate records of your copayments since you are responsible for informing us when you reach the maximum. High and Standard Option Plans: After your copayments and coinsurance total the amounts listed below in the calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for : Dental Care Services and Prescription Drugs. High Option Plan - the out-of-pocket maximum for Self Only is $2,000 and $4,000 for Self and Family. Standard Option Plan - the out-of-pocket maximum for Self Only is $2,500 and $5,000 for Self and Family. High Deductible Health Plan:. After your copayments and coinsurance total the amounts listed below in the calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for : Dental Care Services. The individual out-of-pocket maximum applies to members enrolled in Self Only. The family out-of-pocket maximum applies collectively to all members enrolled in Self and Family. High Deductible Health Plan - the out-of-pocket maximum for Self Only is $5,000 and $10,000 for Self and Family. | |
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When Government facilities bill us |
Facilities of the Department of Veteran Affairs, the Department of Defense, and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. |
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If we overpay you |
We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. |
Section 5. High and Standard Option Benefits – OVERVIEW
(See page 9 for how our benefits changed this year and page 113 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 claim forms, claims filing advice, or more information about our benefits, contact us at 866-320-0697or at our Web site at www.chckansas.com.
Transplant Network.................................................................................................................................................................... 49
Section 5(a) Medical services and supplies provided by physicians and other health care professionals
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I M P O R T A N T |
Here are some important things you should 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. |
I M P O R T A N T |
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Benefit Description |
High Option You pay |
Standard Option You pay | ||||
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Professional services of physicians In a physician’s office
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$15 per visit to your primary care physician $30 per visit to a specialist
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$20 per visit to your primary care physician $35 per visit to a specialist
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Professional services of physicians In an urgent care center |
Nothing |
Nothing | ||||
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During a hospital stay Initial examination of a newborn child covered under a family enrollment In a skilled nursing facility |
Nothing |
Nothing | ||||
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Office medical consultations Second surgical opinion |
$15 per visit to your primary care physician $30 per visit to a specialist |
$20 per visit to your primary care physician $35 per visit to a specialist | ||||
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At home |
$25 per visit
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$25 per visit | ||||
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High Option You pay |
Standard Option You pay | |
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Laboratory tests, such as: Blood tests Urinalysis Non-routine pap tests Pathology |
$15 per visit to your primary care physician; $30 per visit to your specialist. You only pay the office visit copayment when the test is performed during your office visit. |
$20 per visit to your primary care physician; $35 per visit to your specialist. You only pay the office visit copayment when the test is performed during your office visit. |
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Radiology and other diagnostic tests, such as: X-rays Electrocardiogram and EEG CAT Scans/MRI Ultrasound |
10% of our allowance |
$100 per test |
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Non-routine Mammograms |
Nothing |
Nothing |
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Routine screenings, such as: Total Blood Cholesterol Colorectal Cancer Screening, including - Fecal occult blood test - Sigmoidoscopy, screening – every five years starting at age 50
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$15 per visit to your primary care physician $30 per visit to a specialist
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$20 per visit to your primary care physician $35 per visit to a specialist
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Routine Prostate Specific Antigen (PSA) test – one annually for men age 40 and older |
$15 per visit to your primary care physician $30 per visit to a specialist
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$20 per visit to your primary care physician $35 per visit to a specialist
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Preventive care, adult - continued on next page | |
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Preventive care, adult (continued) |
High Option You pay |
Standard Option You pay |
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Routine pap test Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above. |
$15 per visit to your primary care physician $30 per visit to a specialist
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$20 per visit to your primary care physician $35 per visit to a specialist
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Routine mammogram – covered for women age 35 and older, as follows: From age 35 through 39, one during this five year period From age 40 through 64, one every calendar year At age 65 and older, one every two consecutive calendar years |
Nothing |
Nothing |
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Routine immunizations, limited to: Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations) Influenza vaccine, annually Pneumococcal vaccine, age 65 and older |
$15 per office visit to your primary care physician $30 per visit to a specialist Nothing if you receive these services during your office visit |
$20 per office visit to your primary care physician $35 per visit to a specialist Nothing if you receive these services during your office visit |
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Childhood immunizations recommended by the American Academy of Pediatrics Examinations done on the day of immunizations (under age 22) |
$15 per office visit to your primary care physician $30 per visit to a specialist Nothing if you receive these services during your office visit |
$20 per office visit to your primary care physician $35 per visit to a specialist Nothing if you receive these services during your office visit
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Preventive care, children (continued) |
High Option You pay |
Standard Option You pay |
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Well-child care charges for routine examinations, immunizations and care (up to age 22) Examinations, such as: - Eye exams through age 17 to determine the need for vision correction - Ear exams through age 17 to determine the need for hearing correction
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$15 per visit to your primary care physician $30 per visit to a specialist |
$20 per visit to your primary care physician $35 per visit to a specialist
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Complete maternity (obstetrical) care, such as: Prenatal care Delivery Postnatal care Note: Here are some things to keep in mind: You do not need to precertify your normal delivery; see page 13 for other circumstances, such as extended stays for you or your baby. You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary. We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment. We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and Surgery benefits (Section 5b). |
$15 for initial office visit to your primary care physician to confirm pregnancy. $30 for initial office visit to a specialist to confirm pregnancy. All other copayments for prenatal visits during the course of pregnancy are waived.
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$20 for initial office visit to your primary care physician to confirm pregnancy. $35 for initial office visit to a specialist to confirm pregnancy. All other copayments for prenatal visits during the course of pregnancy are waived |
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Not covered: Routine sonograms to determine fetal age, size or sex. |
All charges. |
All charges. |
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High Option You pay |
Standard Option You pay | |
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A range of voluntary family planning services, limited to: 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 contraceptives under the prescription drug benefit.
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$50 copayment
$15 per visit to your primary care physician or $30 per visit to a specialist..
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$200 copayment
$20 per visit to your primary care physician or $35 per visit to a specialist applies to implanted or injectable contraceptive devices.
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Not covered: Reversal of voluntary surgical sterilization Genetic counseling. |
All charges. |
All charges. |
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Diagnosis and treatment of infertility such as: Artificial insemination: - intravaginal insemination (IVI) - intracervical insemination (ICI) - intrauterine insemination (IUI) |
50% of our allowance |
50% of our allowance |
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Not covered: Assisted reproductive technology (ART) procedures, such as: - in vitro fertilization - embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT) - zygote transfer Services and supplies related to ART procedures Cost of donor sperm Cost of donor egg
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All charges. |
All charges. |
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High Option You pay |
Standard Option You pay | |
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Testing Treatment/Allergy injections
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50% of our allowance $15 per visit to your primary care physician or $30 to a specialist |
50% of our allowance $20 per visit to your primary care physician or $35 to a specialist |
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Allergy serum |
Nothing |
Nothing |
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Not covered: Provocative food testing and sublingual allergy desensitization |
All charges. |
All charges. |
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High Option You pay |
Standard Option You pay | |
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Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 48. |
$15 per visit to your primary care physician $30 per visit to a specialist; or nothing for outpatient test |
$20 per visit to your primary care physician $35 for office visit; or $100 for outpatient test
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Respiratory and inhalation therapy |
$15 copayment |
$20 copayment |
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Dialysis – hemodialysis and peritoneal dialysis |
Nothing |
Nothing |
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Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy |
$15 per visit to your primary care physician $30 per visit to a specialist; Nothing when provided in the home |
$20 per visit to your primary care physician $35 office visit or; Nothing when provided in the home |
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Growth hormone therapy (GHT) Note: Growth hormone is covered under the medical benefit. Note: – We only cover GHT when we preauthorize the treatment. Call 1-866-320-0697 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3. |
Nothing |
Nothing |
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High Option You pay |
Standard Option You pay | ||
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60 days per condition for the services of each of the following: qualified physical therapists occupational therapists chiropractors (coverage limited to subluxation and manipulation) Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury. Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 60 sessions. |
$15 per visit to a specialist Nothing per visit during covered inpatient admission |
$20 copay for each outpatient session; Nothing per visit during covered inpatient admission
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Not covered: Long-term rehabilitative therapy Exercise programs |
All charges. |
All charges. | |
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60 days per condition
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$15 per visit to a specialist Nothing per visit during covered inpatient admission |
$20 copay for each outpatient session; Nothing per visit during covered inpatient admission | |
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First hearing aid and testing only when necessitated by accidental injury Hearing testing for children through age 17 (see Preventive care, children) |
$15 per visit to your primary care physician $30 per visit to a specialist |
$20 per visit to your primary care physician $35 per visit to a specialist | |
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Not covered: All other hearing testing Hearing aids, testing and examinations for them |
All charges. |
All charges. | |
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High Option You pay |
Standard Option You pay | ||
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One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts) Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children) |
$15 per visit to your primary care physician $30 per visit to a specialist |
$20 per visit to your primary care physician $35 per visit to a specialist | |
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Annual eye refractions Note: See Preventive care, children for eye exams for children. |
$10 per office visit |
$20 per office visit | |
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Not covered: Eyeglasses or contact lenses and after age 17, examinations for them Eye exercises and orthoptics Radial keratotomy and other refractive surgery |
All charges. |
All charges. | |
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Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts. |
$15 per visit to your primary care physician $30 per visit to a specialist |
$20 per visit to your primary care physician $35 per visit to a specialist | |
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Not covered: Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery) |
All charges. |
All charges. | |
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High Option You pay |
Standard Option You pay | ||
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We limit coverage to $1,000 per member per calendar year. Orthopedic devices such as braces Artificial limbs and eyes; stump hose Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy. External prosthetic devices, except those associated with reconstructive surgery after a mastectomy, are limited to one per member per lifetime. Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy. Note: See 5(b) for coverage of the surgery to insert the device. Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome. |
20% of our allowance |
20% of our allowance | |
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Not covered: Orthopedic and corrective shoes Arch supports Foot orthotics Heel pads and heel cups Lumbosacral supports Corsets, trusses, elastic stockings, support hose, and other supportive devices prosthetic replacements provided less than 3 years after the last one we covered
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All charges. |
All charges. | |
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High Option You pay |
Standard Option You pay | ||
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We limit coverage to $1,000 per member per calendar year. Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover: Hospital beds; Wheelchairs; Crutches; Walkers; Insulin pumps; and |
20% of our allowance |
20% of our allowance | |
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Blood glucose monitors for those members with diabetes. Note: Call us at 866-795-3995 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call. |
Nothing. |
Nothing. | |
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Not covered: Motorized wheelchairs
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All charges. |
All charges. | |
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Home health care ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aid. Services include oxygen therapy, intravenous therapy and medications. |
Nothing |
Nothing | |
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Not covered: Nursing care requested by, or fo | |||