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2005 |
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RI 73-543 |
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Heart of America Health Plan |
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A Health Maintenance Organization |
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Serving: North Central North Dakota Enrollment in this plan is limited. You must live in our Geographic service area to enroll. See page 6 for requirements. |
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For changes in benefits see page 7. |
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Enrollment code for this Plan: RU1 Self Only RU2 Self and Family |
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-orientated 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 component. This combination of health plan and savings vehicle provides a new opportunity to save and better manage your money. If an HDHP/HAS 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 iniative. 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 compliments and broadens healthier lifestyle resources. The site provides extensive information from health care experts and organizations to support your personal interest in 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 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.
Preventing medical mistakes. 4
Section 1. Facts about this HMO plan. 6
Section 2. How we change for 2005. 7
Section 3. How you get care. 8
What you must do to get covered care. 8
Circumstances beyond our control 10
Services requiring our prior approval 10
Section 4. Your costs for covered services. 11
Your catastrophic protection out-of-pocket maximum.. 11
Section 5(c) Services provided by a hospital or other facility, and ambulance services. 25
Section 5(d) Emergency services/accidents. 28
Section 5(e) Mental health and substance abuse benefits. 30
Section 5(f) Prescription drug benefits. 32
Section 5(g) Dental benefits 35
Section 6. General exclusions – things we don’t cover 36
Section 7. Filing a claim for covered services. 37
Section 8. The disputed claims process. 38
Section 9. Coordinating benefits with other coverage. 40
When you have other health coverage. 40
Should I enroll in Medicare?. 40
The Original Medicare Plan (Part A or Part B) 40
When other Government agencies are responsible for your care. 43
When others are responsible for injuries. 44
Section 10. Definitions of terms we use in this brochure. 45
No pre-existing condition limitation. 46
Where you can get information about enrolling in the FEHB Program.. 46
Types of coverage available for you and your family. 46
When benefits and premiums start 47
Temporary Continuation of Coverage (TCC) 48
Converting to individual coverage. 48
Getting a Certificate of Group Health Plan Coverage. 48
Two Federal Programs complement FEHB benefits. 49
The Federal Flexible Spending Account Program – FSAFEDS. 49
The Federal Long Term Care Insurance Program.. 52
Summary of benefits for the Heart of America Health Plan - 2005. 54
2005 Rate Information for Heart of America Health Plan. 55
This brochure describes the benefits of Heart of America Health Plan under our contract (CS 2606) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. The address for Heart of America Health Plan administrative offices is:
Heart of America Health Plan
810 South Main
Rugby, ND 58368
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 xx. 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 Heart of America Health Plan.
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 776-5848 or 1-800-525-5661 and 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 tests 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.
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.
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.
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 Web site (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.
We are Federally qualified
We have been in existence for 22 years
We are a non-profit organization
If you want more information about us, call 701-776-5848 or 1-800-525-5661, or write to Heart of America Health Plan, 810 South Main, Rugby, ND 58368. You may also contact us by fax at 701-776-5425.
To enroll in this Plan, you must live in our Service Area. This is where our providers practice. Our service area is:
All of Pierce, Rolette, Bottineau, McHenry, Towner, Ward and Renville counties in North Dakota and the portions of Benson, Wells, Sheridan, McLean, Mountrail and Burke Counties represented by the following zip codes:
58310 58329 58348 58365 58418 58704 58754 58736 58750 58763 58778 58789
58313 58331 58353 58366 58422 58705 58722 58737 58752 58768 58779 58790
58316 58332 58356 58367 58423 58710 58723 58739 58756 58769 58781 58792
58317 58337 58357 58368 58438 58711 58725 58740 58758 58770 58782 58793
58318 58339 58359 58369 58450 58712 58731 58741 58759 58772 58783
58320 58341 58360 58384 58451 58713 58733 58744 58760 58773 58784
58324 58343 58362 58385 58540 58716 58734 58746 58761 58775 58785
58325 58346 58363 58386 58701 58718 58735 58747 58762 58776 58789
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.
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 premium will increase by 5.7% for Self Only or 5.7% for Self and Family.
We have changed our name from Heart of America HMO to Heart of America Health Plan, and our logo has changed.
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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 701-776-5848 or write to us at 810 South Main Avenue, Rugby, ND 58368. |
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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 list Plan providers in the provider directory, which we update periodically. All doctors of the Johnson Clinic Professional Corporation and Trinity Medical Group and affiliated clinics are available to HAHP members. The doctors of the Johnson Clinic, P.C. are available to provide health care from offices located in Towner, Maddock, Dunseith and Rugby, North Dakota. The doctors of the Trinity Medical Group are available to provide health care from offices located in Minot, Garrison, Mohall, Velva, Newtown, Kenmare, Parshall, Sherwood and Westhope, North Dakota. Your plan doctor will coordinate your health care needs including referrals to specialists when necessary. Services of specialists other Johnson Clinic and Trinity Medical Group primary care doctors are covered only when there has been a referral by the member’s primary care doctor with the following exception: a woman may see her plan gynecologist for an annual routine examination without a referral |
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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. |
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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. Provider directories are available at the time of enrollment or upon request by calling the Heart of America Health Plan at 701-776-5848 or 1-800-525-5661. |
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Your primary care physician can be afamily practitioner, internist, pediatrician or an OB-GYN.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. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see your plan gyncolegist for your routine examinationwithout a referral. 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 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 701-776-5848 or 1-800-525-5661. 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 physician must get our approval before sending you to a hospital, referring you to a specialist, or recommending follow-up care. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. |
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. Example: When you see your primary care physician you pay a copayment of $10 per office visit. |
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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. We have a $600 per member calendar year deductible for prescription drugs. |
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Coinsurance is the percentage of our allowance that you must pay for your care. Example: In our Plan, you pay 20% of charges up to a maximum coinsurance of $500 per year for prosthetic devices that exceed $25. |
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The copayment and coinsurance maximum is 50% of your annual premium per calendar year for services rendered by in network providers. When the copayment and coinsurance maximum applicable to your contract has been fulfilled, copayment and coinsurance will no longer be applied to the following services: Emergency Room services Outpatient hospital services Inpatient hospital services Outpatient mental health services Outpatient chemical dependency services Inpatient mental health services Inpatient chemical dependency services Durable equipment and prosthetic devices Referral services provided by participating providers |
Section
5. Benefits – OVERVIEW
(See page 7 for how our benefits changed this year and page 54 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 701-776-5848 or 1-800-525-5661.
Diagnostic and treatment services. 14
Lab, X-ray and other diagnostic tests. 15
Physical and occupational therapies. 18
Hearing services (testing, treatment, and supplies) 18
Vision services (testing, treatment, and supplies) 19
Orthopedic and prosthetic devices. 19
Durable medical equipment (DME) 20
Educational classes and programs. 20
Oral and maxillofacial surgery. 23
Section 5(c) Services provided by a hospital or other facility, and ambulance services. 25
Outpatient hospital or ambulatory surgical center 26
Extended care benefits/Skilled nursing care facility benefits. 26
Section 5(d) Emergency services/accidents. 28
Emergency within our service area. 29
Emergency outside our service area. 29
Section 5(e) Mental health and substance abuse benefits. 30
Mental health and substance abuse benefits. 30
Section 5(f) Prescription drug benefits. 32
Covered medications and supplies. 33
Section 5(g) Dental benefits 36
Summary of benefits for the Heart of America Health Plan - 2005. 54
2005 Rate Information for Heart of America Health Plan. 55
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. 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 |
You pay |
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Professional services of physicians In physician’s office |
$10 per office visit No copaymenta for visits to a plan specialist See note below for authorized non-plan specialist visits. |
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Professional services of physicians In an urgent care center During a hospital stay In a skilled nursing facility Office medical consultations Second surgical opinion |
$10 per office visit |
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At home – doctors house call |
Nothing |
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Note: When you receive authorized services from a Non-Plan specialist, you pay 20% of charges up to a maximum coinsurance of $3,000 per year. |
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Diagnostic and treatment services – continued on next page
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You pay |
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Diagnosis and treatment of infertility such as: Artificial insemination: intrauterine insemination (IUI) |
$10 per office visit |
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Not covered: Intracervical insemination ( ICI) Intravaginal insemination (IVI) Assisted reproductive technology (ART) procedures, such as: in vitro fertilization embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT) Services and supplies related to ART procedures Cost of donor sperm Cost of donor egg Fertility drugs |
All charges. |
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Testing and treatment Allergy injections |
$10 per office visit |
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Allergy serum |
Nothing |
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Not covered: Provocative food testing and sublingual allergy desensitization |
All charges. |
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You pay |
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Up to two consecutive months per condition. Note: We cover speech therapy in all situations where it is medically necessary. |
$10 per outpatient visit Nothing per visit during covered inpatient admission. |
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Hearing testing for children through age 17 (see Preventive care, children) |
$10 per office visit |
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Not covered: All other hearing testing Hearing aids, testing and examinations for them |
All charges. |
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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) Note: See Preventive care, children for eye exams for children. |
$10 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. |
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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. |
$10 per office visit |
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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. |
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You pay |
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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 aide. Services include oxygen therapy, intravenous therapy and medications. |
$10 per office visit |
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Not covered: Nursing care requested by, or for the convenience of, the patient or the patient’s family; Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative. |
All charges. |
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Manipulation of the spine and extremities Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application |
$10 per office visit |
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No Benefit |
All charges |
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Coverage is limited to: Smoking Cessation – Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs. Diabetes self management |
$10 per office visit |
Section 5(b) Surgical and anesthesia services 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. Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5© for charges associated with the facility (i.e. hospital, surgical center, etc.). |
I M P O R T A N T |
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Benefit Description |
You pay After the calendar year deductible… |
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A comprehensive range of services, such as: Operative procedures Treatment of fractures, including casting Normal pre- and post-operative care by the surgeon Correction of amblyopia and strabismus Endoscopy procedures Biopsy procedures Removal of tumors and cysts Correction of congenital anomalies (see Reconstructive surgery) |
$10 per office visit (nothing for hospital visits) |
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Surgical procedures - continued on next page
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Surgical procedures(continued) |
You pay |
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Surgery to correct a functional defect Surgery to correct a condition caused by injury or illness if: the condition produced a major effect on the member’s appearance and the condition can reasonably be expected to be corrected by such surgery Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes. All stages of breast reconstruction surgery following a mastectomy, such as: surgery to produce a symmetrical appearance of breasts; treatment of any physical complications, such as lymphedemas; breast prostheses and surgical bras and replacements (see Prosthetic devices) Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. |
$10 per office visit |
Not covered: Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury Surgeries related to sex transformation |
All charges. |
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You pay |
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Limited to: Cornea Heart Kidney Liver Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non-lymphocytic leukemia; advanced Hodgkin’s lymphoma; advanced non-Hodgkin’s lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors Intestinal transplants (small intestine) National Transplant Program (NTP) – LifeTrac Network Limited Benefits – Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer is subject to approval by the Plan’s Medical Director in accordance with the Plan’s protocols. Note: We cover related medical and hospital expenses of the donor when we cover the recipient. |
Nothing |
Organ/tissue transplants (continued) |
You pay |
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Diagnostic Tests |
Nothing |
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Services provided by a hospital or other facility Services in approved alternative care settings such as partial hospitalization, residential treatment (under 21 years of age) and full-day hospitalization. Note: When you receive authorized services from a non-Plan facility, you pay 20% of charges up to a maximum coinsurance of $3,000 per year |
Nothing |
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Not covered: Services we have not approved. Note: OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another. |
All charges. |
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Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following network authorization processes: Inpatient service and outpatient therapy services must be directed by your primary care physician and approved by the HAHP Medical Director. Available providers for Mental Health and Substance Abuse benefits are listed on your Provider Directory that you receive when you enroll or you may call the HAHP office at 701-776-5848 or 1-800-525-5661 to obtain one. |
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Limitation We may limit your benefits if you do not obtain a treatment plan. |
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I M P O R T A N T |
Here are some important things to keep in mind about these benefits: We cover prescribed drugs and medications, as described in the chart beginning on the next page. All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary. The calendar year deductible is $600 per member. The calendar year deductible applies to almost all benefits in this Section. 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. Plan members called to active military duty (or members in time of national emergency) who need to obtain prescribed medications should call our Member Services Department at 800-525-5661. |
I M P O R T A N T |
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There are important features you should be aware of. These include: Who can write your prescription. A licensed physician must write the prescription Where you can obtain them. You may fill the prescription at any pharmacy. We do not have a network pharmacy. Why use generic drugs? To reduce your out of pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name drugs; therefore, you may reduce your out of pocket costs by choosing to use a generic drug. When you have to file a claim. See Section seven (7) – Filing a claim for covered services. |
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Prescription drug benefits begin on the next page
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Benefit Description |
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