NALC Health
Benefit Plan http: / / www. nalc. org/ depart/ hbp
2002
A fee-for-service plan
with a preferred provider organization
RI 71-009
Sponsored and administered by the National Association of
Letter
Carriers ( NALC) , AFL-CIO
Who may enroll in this Plan: If you are a Federal or Postal employee
or annuitant eligible to enroll in the FEHB Program, you may become a
member of this Plan. To enroll, you must become a member of the
National
Association of Letter Carriers.
To become a member:
If you are a Postal Service employee, you must pay NALC local dues.
If
you are a non-postal employee or annuitant, you become an associate member of
NALC when you enroll in the NALC Health Benefit Plan.
Membership dues: NALC local dues vary by branch. NALC bills associate
members
$ 36 per year.
Enrollment codes for this Plan:
321 Self Only
322 Self and Family
For
changes
in benefits
see page
5.
Caremark Therapeutic Services and its 17
pharmacies are JCAHO accredited;
United
Behavioral Health is JCAHO accredited; and
First Health s
Clinical Management Services is
URAC accredited. See the 2002 Guide for
more information on accreditation. 1
1 Page 2 3
2 2002 NALC Health Benefit Plan
Table of Contents
Table of Contents
Introduction . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 3
Plain Language . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Inspector General Advisory . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 4
Section 1. Facts about this
fee-for-service plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 4
Section 2. How we
change for 2002 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Section 3. How you get care . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 6
Identification cards . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . 6
Where you
get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 6
Covered providers . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Covered facilities . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 6
What you must do to get covered care . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7
Your hospital stay ( precertification) . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Other services . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8
Section 4. Your costs for covered services . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 9
Copayments . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 9
Deductible . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . 9
Coinsurance . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 9
Differences between our allowance and the bill . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 9
Your out-of-pocket maximum
for coinsurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
When government facilities bill us . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
If we overpay you . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 10
When you are age 65 or older
and you do not have Medicare . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 11
When you have the Original Medicare Plan . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 12
When
you have a Medicare private contract . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 12
Section 5. Benefits . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Overview . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . 13
( a) Medical
services and supplies provided by physicians and other health care professionals
. . . . . . . . . . 14
( b) Surgical and anesthesia
services provided by physicians and other health care professionals . . . . . .
. 22
( c) Services provided by a hospital or other
facility, and ambulance services . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 26
( d) Emergency services/ accidents
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 29
( e) Mental health and substance
abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
( f) Prescription drug benefits . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 34
( g) Special features . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . 36
Flexible benefits option
24-hour nurse line
24-hour help line
for mental health and substance abuse
Services for
deaf and hearing impaired
Centers of excellence for
transplants/ heart surgery
Disease management programs
Discounts for durable medical equipment ( DME)
Worldwide coverage
( h)
Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
( i) Non-FEHB benefits available to Plan members . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 38
Section
6. General exclusions things we don t cover . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . 39
Section 7. Filing a
claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 40
Section 8.
The disputed claims process . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Section 9. Coordinating benefits with other coverage . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
When you have other health coverage . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
What is Medicare . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 43
The Original Medicare Plan . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Medicare managed care plan . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Private contract with your physician . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 45
If
you do not enroll in Medicare Part A or Part B . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 45 2
2 Page 3
4
3 2002 NALC Health Benefit Plan
TRICARE . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Workers Compensation . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 45
Medicaid . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 46
When other Government agencies are responsible for your care . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 46
When others are responsible for
injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 46
Section 10. Definitions of terms we use in
this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 47
Section 11. FEHB facts . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 49
Coverage information . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 49
No pre-existing condition limitation . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Where you get information about enrolling in the FEHB Program . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Types of coverage available for you and your family .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 49
When benefits and
premiums start . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 49
Your medical and claims records are
confidential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 49
When you retire . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
When you lose benefits . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 50
When FEHB coverage ends . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 50
Converting to individual
coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 51 Getting a Certificate of Group Health Plan
Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Long term care insurance is coming later in 2002 . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 52
Department of Defense/ FEHB Program Demonstration Project . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . 53
Index . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 54
Summary of
benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 55
Introduction
NALC Health Benefit Plan
20547 Waverly Court
Ashburn, VA 20149-0001
This brochure describes the benefits of the NALC Health Benefit Plan
under our contract ( CS 1067) with the Office
of Personnel Management (
OPM) , as authorized by the Federal Employees Health Benefits law. This brochure
is the
official statement of benefits. No oral statement can modify or
otherwise affect the benefits, limitations, and exclusions
of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 5. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For
instance, you means the enrollee or family member; we means NALC Health Benefit
Plan .
We limit acronyms to ones you know. FEHB is the Federal Employees
Health Benefits Program. OPM is the Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB
plans brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit
OPM s Rate Us feedback area at www. . opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation Division,
1900 E Street, NW, Washington, DC
20415-3650.
Table of Contents/ Introduction/ Plain Language 3
3 Page 4 5
4 2002 NALC Health Benefit Plan
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for
everyone. If you suspect that a
physician, pharmacy, or hospital has charged
you for services you did not
receive, billed you twice for the same service,
or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 703/ 729-4677
or 1-888-636-NALC ( 6252) and explain the situation.
If we do not resolve the issue, call or write:
THE HEALTH CARE
FRAUD HOTLINE 202/ 418-3300
The United States Office of Personnel
Management
Office of the Inspector General Fraud Hotline
1900 E Street,
NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if the person tries to obtain services for someone who is
not an eligible family member, or is no longer enrolled in the Plan and
tries to
obtain benefits. Your agency may also take administrative action against you.
Section 1. Facts about this fee-for-service plan
This Plan is a
fee-for-service ( FFS) plan. You can choose your own physicians, hospitals, and
other health care providers.
We reimburse you or your provider for your
covered services, usually based on a percentage of the amount we allow. The
type and extent of covered services, and the amount we allow, may be
different from other plans. Read brochures carefully.
We also have Preferred Provider Organizations ( PPO)
Our
fee-for-service plan offers services through a PPO. When you use our PPO
providers, you receive covered services
at reduced cost. Contact us for the
names of PPO providers and to verify their continued participation. You can also
go
to our web page, which you can reach through the FEHB web site, www. opm. gov/ insure. Do not call
OPM or your
agency for our provider directory.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider.
Provider networks may be more
extensive in some areas than others. We cannot guarantee the availability of
every specialty
in all areas. If no PPO provider is available, or you do not
use a PPO provider, the non-PPO benefits apply.
How we pay providers
When you use a PPO provider or facility, our
Plan allowance is the negotiated rate for the service. You are not
respon-
sible for charges above the negotiated amount.
Non-PPO facilities and providers do not have special agreements with us. Our
payment is based on our allowance for
covered services. You may be
responsible for amounts over the allowance.
We also obtain discounts from some non-PPO providers. When we obtain
discounts through negotiation with providers
( PPO or non-PPO) , we pass
along the savings to you.
Your Rights
OPM requires that all FEHB Plans provide certain
information to you. You may get information about us, our net-
works,
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:
The NALC Health Benefit Plan has been part of the FEHB Program since
July 1960.
We are a not-for-profit employee organization sponsored
health plan.
Our preferred provider organization ( PPO) is The
First Health Network.
Our network provider for mental health
and substance abuse benefits is United Behavioral Health.
Our
prescription drug retail network is the NALC CareSelect Network.
Our
mail order prescription program is through CAREMARK.
If you want more information about us, call 703/ 729-4677 or 1-888-636-NALC (
6252) , or write to NALC Health Benefit
Plan, 20547 Waverly Court, Ashburn,
VA 20149-0001. You may also visit our website at www. nalc. org/ depart/ hbp.
Inspector General Advisory/ Section 1 4
4
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5 2002
NALC Health Benefit Plan
Section 2. How we change for 2002
Do
not rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5.
Benefits . Also, we edited and
clarified language throughout the brochure; any language change not shown here
is a
clarification that does not change benefits.
Program-wide changes
Four states are added to the list of medically underserved areas:
Georgia, Montana, North Dakota, and Texas.
Louisiana is no longer medically
underserved. ( Section 3)
We changed the address for sending disputed claims to OPM. ( Section
8)
Changes to this Plan
Your share of the NALC Postal premium will decrease by 15.5% for Self
Only and decrease by 25.9% for Self and
Family.
Your share of the non-Postal premium will decrease by 6.4% for Self
Only or 10.9% for Self and Family.
We clarified the brochure to
better explain that the non-PPO benefits are the standard benefits of this Plan,
that PPO
benefits apply only when you use a PPO provider, and that when no
PPO provider is available, non-PPO benefits
apply.
We clarified the Preventive care, adult benefits by removing the entry
for blood lead level testing for adults because
it is a test more typically
done for children. ( Section 5( a) )
We no longer limit total blood cholesterol tests to certain age
groups. ( Section 5( a) )
We now cover routine screening for
chlamydial infection. ( Section 5( a) )
We added meningococcal
immunization coverage under Preventive care, children. ( Section 5( a) )
Your PPO copayment for amblyopia and strabismus examinations is now $
20. Previously your copayment was $ 15.
( Section 5( a) )
Your charges for physical and occupational therapy are now covered up
to a combined total of 50 visits per calendar
year. Previously the Plan
covered up to 90 visits for each. ( Section 5( a) )
We increased speech therapy benefits by removing the requirement that
services must be required to restore
functional speech. ( Section 5( a) )
Your charges for speech therapy are now covered up to a total of 30
visits per calendar year. Previously the Plan
covered up to 90 visits. (
Section 5( a) )
We now cover certain intestinal transplants. ( Section 5( b) )
Your hospital inpatient coinsurance is now 10% of the Plan allowance
at PPO hospitals and 30% of the Plan
allowance at non-PPO hospitals.
Previously you paid nothing at PPO hospitals and 20% of the Plan allowance at
non-PPO hospitals. ( Section 5( c) )
We changed how we determine our Plan allowance for non-PPO benefits.
In geographic areas where you have
adequate access to a PPO provider but do
not use one, our allowance is based on the average PPO negotiated rate
for that region. ( Section 10)
If you do not have adequate access to a PPO provider, our Plan
allowance will be based on the 80 th percentile of
data gathered by Ingenix,
Inc. Previously it was based on the 90 th percentile. ( Section 10)
Section 2 5
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6 2002 NALC Health Benefit Plan
Section 3. How you get care
Identification cards We will send
you an identification ( ID) card when you enroll. You should carry your
ID
card with you at all times. You must show it whenever you receive services
from a provider or fill a prescription at an NALC CareSelect retail pharmacy
. Until
you receive your ID card, use your copy of the Health
Benefits Election Form,
SF-2809; your health benefits enrollment
confirmation ( for annuitants) ; or your
Employee Express confirmation
letter. If you want to obtain a prescription at an
NALC CareSelect retail
pharmacy and have not received your identification card,
contact us at 703/
729-4677 or 1-888-636-NALC ( 6252) .
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 703/ 729-4677
or 1-888-
636-NALC ( 6252) .
Where you get covered care You can get care from any covered provider
or covered facility. How much
we pay and you pay depends on the type of
covered provider or facility you
use. If you use our preferred providers,
you will pay less.
Covered providers We consider the following to be covered providers
when they perform services within the scope of their license or certification:
A licensed doctor of medicine ( M. D. ) or osteopathy ( D. O. ) ; or,
for specified services covered by the Plan, a licensed dentist ( D. D. S. or D.
M. D. ) , or podia-
trist ( D. P. M. ) .
A nurse anesthetist ( C.
R. N. A. ) .
A community mental health organization: A nonprofit
organization or agency with a governing or advisory board representative of the
community that
provides comprehensive, consultative and emergency services for treatment of
mental conditions.
A qualified clinical psychologist, clinical social worker,
optometrist, nurse midwife, nurse practitioner/ clinical specialist, and
nursing-school-administered
clinic.
Other providers listed in Section 5. Benefits .
Note: When we use the term physician, it can mean any of the above providers.
.
Medically underserved areas. We cover any licensed medical
practitioner for
any covered service performed within the scope of that
license in states OPM
determines are medically underserved. For 2002, , the
states are: Alabama,
Georgia, Idaho, Kentucky, Mississippi, Missouri,
Montana, New Mexico,
North Dakota, South Carolina, South Dakota, Texas,
Utah, and Wyoming.
Covered facilities Covered facilities include:
Birthing center
: A freestanding facility that provides comprehensive maternity care in a
home-like atmosphere and is licensed or certified by the jurisdiction.
Hospice : A facility that 1) provides care to the terminally ill; 2)
is licensed or certified by the jurisdiction in which it operates; 3) is
supervised by a staff of
physicians ( M. D. or D. O. ) with at least one
such physician on call 24 hours a
day; 4) provides 24-hour-a-day nursing
services under the direction of a
registered nurse ( R. N. ) and has a
full-time administrator; and 5) provides an
ongoing quality assurance
program.
Hospital : 1) An institution that is accredited as a hospital under
the hospital accreditation program of the Joint Commission on Accreditation of
Healthcare
Organizations ( JCAHO) ; or 2) any other institution licensed as a hospital,
operating under the supervision of a staff of physicians with 24-hour-a-day
registered nursing service, and is primarily engaged in providing general
inpatient acute care and treatment of sick and injured persons through
medical,
diagnostic and major surgical facilities. All these facilities must
be provided on
its premises or under its control.
The term hospital does not include a convalescent home or extended care
facility, or any institution or part thereof which a) is used principally as
a
convalescent facility, nursing home, or facility for the aged; b)
furnishes
primarily domiciliary or custodial care, including training in the
routines of
daily living; or c) is operated as a school or residential
treatment facility.
Section 3 6
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7 2002 NALC Health Benefit Plan
Skilled nursing facility ( SNF) : A facility eligible for
Medicare payment, or a government facility not covered by Medicare, that
provides continuous non-
custodial inpatient skilled nursing care by a
medical staff for post-hospital
patients.
Treatment facility : A freestanding facility accredited by the Joint
Commission on Accreditation of Healthcare Organizations ( JCAHO) for treatment
of
substance abuse.
What you must do to It depends on the kind of
care you want to receive. You can go to any
get covered care provider
you want, but we must approve some care in advance.
Transitional care Specialty care. If you have a chronic or disabling
condition and
lose access to your specialist because we drop out of
the Federal Employees Health Benefits ( FEHB) Program and you enroll in another
FEHB Plan, or
lose access to your PPO specialist because we terminate our contract
with your specialist for other than cause,
you may be able to continue seeing your specialist and receiving any PPO
benefits 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 and any PPO benefits continue until the end of your
postpartum care,
even if it is beyond the 90 days.
Hospital care We pay for covered services from the effective date of
your enrollment. If you are in
the hospital, however, when your enrollment
in our Plan begins, call our customer
service department immediately at 703/
729-4677 or 1-888-636-NALC ( 6252) .
If you changed from another FEHB plan to us, your former plan will pay for
the
hospital stay until the earliest of these events:
You are discharged, not merely moved to an alternative care center;
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan.
These provisions apply only to the benefits of the hospitalized person.
How to Get Approval for
Your hospital stay Precertification is the process by which prior to
your inpatient hospital admis-sion we evaluate the medical necessity of your
proposed stay and the number of
days required to treat your condition. Unless we are misled by the
information
given to us, we won t change our decision on medical necessity.
Precertification is
not a guarantee of benefit payments.
In most cases, your physician or hospital will take care of precertification.
Because
you are still responsible for ensuring that we are asked to
precertify your care, you
should always ask your physician or hospital
whether they have contacted us.
Warning We reduce our benefits for the inpatient hospital stay by $
500 if no one contacts us
for precertification. In addition, if we determine
the stay is not medically neces-
sary, we will not pay any inpatient hospital
benefits.
How to precertify You, your representative, your physician, or your
hospital must call us at 1-800-
an admission 622-6252 prior to
admission, unless your admission is related to a mental health
and substance
abuse condition. In that case, call 1-877-468-1016.
If you have an emergency admission due to a condition that you
reasonably believe puts your life in danger or could cause serious damage to
bodily
function, you, your representative, the physician, or the hospital must
telephone
us within two business days following the day of the emergency
admission,
even if you have been discharged from the hospital.
Provide the following information:
Enrollee s name and Member identification number;
Patient s name, birth
date, and phone number;
Reason for hospitalization, and proposed treatment
or surgery;
Name and phone number of admitting physician;
Name of
hospital or facility; and
Number of planned days of confinement.
Section 3
continues on next page 7
7
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8 2002
NALC Health Benefit Plan
We will tell the physician and/ or
hospital the number of approved inpatient days and send written confirmation of
our decision to you, your physician, and the
hospital.
Maternity care
You do not need to precertify a maternity admission for a routine delivery.
However, if your medical condition requires you to stay more than 48 hours
after a
vaginal delivery or 96 hours after a cesarean section, then your
physician or the
hospital must contact us for precertification of additional
days. Further, if your
baby stays after you are discharged, then your
physician or the hospital must contact
us within two business days for
precertification of additional days for your baby.
If your hospital stay If your hospital stay including for maternity
care needs to be extended, you,
needs to be extended your
representative, your physician or the hospital must ask us to approve the
additional days.
What happens when you When we have precertified the admission but you
remain in the hospital
do not follow the beyond the number of days we
approved, and you do not get the additional
precertification rules
days precertified, then:
for any part of the admission that we determine was medically necessary, we
pay inpatient benefits, but
for the part of the admission that we
determine was not medically necessary,
we pay only for medical services and
supplies otherwise payable on an
outpatient basis and do not pay inpatient
benefits.
If no one contacted us, we decide whether the hospital stay was
medically necessary.
If we determine that the stay was medically necessary,
we pay the inpatient
charges, but reduce benefits by $ 500.
If we
determine that it was not medically necessary for you to be an inpatient,
we
will not pay inpatient hospital benefits. We will pay only for covered
medical supplies and services that would be otherwise payable on an
outpatient basis.
If we denied the precertification request, we will not pay inpatient
hospital benefits. We pay only for covered medical supplies and services that
would be
otherwise payable on an outpatient basis.
Exceptions You do not
need precertification in these cases:
You are admitted to a hospital outside the United States.
You have another group health insurance including Medicare Part A
that is the primary payer for the hospital stay.
Note: If you exhaust your Medicare hospital benefits and do not want to use
your
Medicare lifetime reserve days, you need to precertify with us by
calling 1-800-
622-NALC ( 6252) .
Other services Some other services require precertification, prior
authorization or a referral.
Growth hormone therapy ( GHT) : We cover
GHT only when we preauthorize the treatment. Call 1-800-433-NALC ( 6252) for
preauthorization. See Section
5( a) . Treatment therapies.
Some drugs, such as those for
sexual dysfunction, require prior authorization. Call us at 1-800-433-NALC (
6252) for information.
Organ/ tissue transplants and donor expenses: The Plan participates in
the First Health National Transplant Program. Before your initial
evaluation as a
potential candidate for a transplant procedure, you or your
physician must
contact First Health at 1-800-622-6252 and speak to a
Transplant Case
Manager. See Section 5( b) . Organ/ tissue transplants
.
Mental health and substance abuse care: United Behavioral Health (
UBH) provides the Plan s mental health and substance abuse benefits. Call
1-877-468-1016 for
preauthorization. See Section 5( e) . Mental health and substance abuse
benefits .
Durable medical equipment ( DME) : Although DME does
not require prior authorization, you should call us at 1-800-433-NALC ( 6252)
before you
purchase or rent DME so we can give you information on discounted rates. See
Section 5( a) . Durable medical equipment .
Section 3 8
8 Page
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9 2002 NALC Health Benefit Plan
Section 4. Your costs for covered services
This is what you
will pay out-of-pocket for your covered care:
Copayments A copayment
is a fixed amount of money you pay to the provider, facility, pharmacy, etc. ,
when you receive services. Copayments are not the same for
all services. See Section 5. Benefits .
Example: When you see your
PPO physician you pay a $ 20 copayment per
office visit.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those expenses. The family deductible is satisfied when the combined
covered expenses applied to the calendar year deductible for family members
total the amounts shown. Copayments do not count toward any deductible.
The PPO calendar year deductible is $ 250 per person ( $ 500 per
family) . If you use non-PPO providers, your calendar year deductible is
increased to
a maximum of $ 300 per person ( $ 600 per family) . Whether or not you
use PPO providers your deductible will not exceed $ 300 per person ( $ 600
per family) .
The calendar year drug deductible of $ 25 per person or $ 50 per
family applies only to non-network benefits.
The calendar year deductible for in-network mental health and
substance abuse benefits is $ 250 per person ( $ 500 per family) .
The calendar year deductible for out-of-network mental health and
substance abuse inpatient and outpatient professional services is $ 300 per
person ( $ 600 per family) .
The calendar year deductible for
out-of-network substance abuse treat-ment in a treatment facility is $ 300 per
person.
Note: If you change plans during Open Season, you do not have to start a
new deductible under your old plan between January 1 and the effective date
of your new plan. If you change plans at another time during the year, you
must begin a new deductible under your new plan.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. Coinsurance doesn t begin until you meet your
deductible.
Example: When you see a non-PPO physician, your coinsurance is 30% of
our
allowance for office visits.
Note: If your provider routinely waives ( does not require you to pay) your
copayments, deductibles, or coinsurance, the provider is misstating the fee
and may be violating the law. In this case, when we calculate our share, we
reduce the provider s fee by the amount waived.
For example, if your physician ordinarily charges $ 100 for a service but
routinely waives your 30% coinsurance, the actual charge is $ 70. We pay
$ 49 ( 70% of the actual charge of $ 70) .
Differences between Our Plan allowance is the amount we use to
calculate our payment for our allowance and covered services.
Fee-for-service plans arrive at allowances in different ways,
the bill so our allowances vary. For more information about how we
determine our
Plan allowance, see the definition of Plan allowance in
Section 10.
Often, the provider s bill is more than a fee-for-service plan s allowance.
Whether or not you have to pay the difference between our allowance and
the bill depends on the provider you use.
PPO providers agree to limit what they will bill you. Because of that,
when you use a preferred provider, your share of covered charges consists
only of your copayment, deductible, and coinsurance. Here is an example
about coinsurance: You see a PPO physician who charges $ 150, but our
allowance is $ 100. If you have met your deductible, you are only
responsible for your coinsurance. That is, you pay just 15% of our $ 100
allowance ( $ 15) . Because of the agreement, your PPO physician will not
bill you for the $ 50 difference between our allowance and his/ her bill.
Section 4
continues on next page 9
9
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10
2002 NALC Health Benefit Plan
Non-PPO providers , on the other
hand, have no agreement to limit what they will bill you. When you use a non-PPO
provider, you pay your
copayment, deductible, and coinsurance, plus
any difference between our
allowance and charges on the bill. Here is an
example: You see a non-
PPO physician who charges $ 150 and our allowance is
again $ 100.
Because you ve met your deductible, you are responsible for
your
coinsurance, so you pay 30% of our $ 100 allowance ( $ 30) . Plus,
because
there is no agreement between the non-PPO physician and us, he/ she
can
bill you for the $ 50 difference between our allowance and his/ her
bill.
The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician.
The table uses our example of a service for which the physician charges
$ 150 and our allowance is $ 100, and shows the amount you pay if you have
met your calendar year deductible.
PPO physician
$ 150
We set it at: 100
85% of our
allowance: 85
15% of our allowance: 15
No: 0
$ 15
EXAMPLE
Physician s charge
Our allowance
We pay
You
owe:
Coinsurance
+ Difference up to charge
TOTAL YOU PAY
Your catastrophic protection For those services with coinsurance (
excluding mental health and substance
out-of-pocket maximum abuse
care) , we pay 100% of the Plan allowance for the remainder of the
for
coinsurance calendar year after coinsurance expenses total these amounts:
$ 3000 per person or family for services of PPO providers/ facilities
$ 3500 per person or family for services of PPO and non-PPO
providers/ facilities, combined
For mental health and substance abuse benefits, we pay 100% of the Plan
allowance for the remainder of the calendar year after coinsurance expenses
total these amounts:
$ 3000 per person or family for services of network mental health and
substance abuse providers/ facilities
$ 8000 per person for out-of-network mental health and substance abuse
inpatient hospital treatment ( to a maximum of 50 days)
Note: Your out-of-pocket maximum does not apply to these benefits:
Skilled nursing care
Prescription drugs
Any
out-of-network outpatient mental health and substance abuse professional care
Note: The following cannot be counted toward out-of-pocket expenses:
Deductibles
Copayments
Expenses incurred under
Prescription Drug Benefits
Expenses in excess of the Plan allowance
or maximum benefit limitations
Any out-of-network expenses for mental
health and substance abuse professional care, except inpatient hospital stays
Amounts you pay for non-compliance with this Plan s cost containment
requirements
Coinsurance for skilled nursing care
You are
responsible for these amounts even after the out-of-pocket
maximum has been
met.
When government Facilities of the Department of Veterans Affairs, the
Department of
facilities bill us Defense, and the Indian Health
Service 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.
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 4
Non-PPO physician
$ 150
We set it at: 100
70% of our
allowance: 70
30% of our allowance: 30
Yes: 50
$ 80 10
10
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11
2002 NALC Health Benefit Plan
When you are age 65 or older and you
do not have Medicare
Under the FEHB law, we must limit our payments for
those benefits you would be entitled to if you had Medicare. And,
your
physician and hospital must follow Medicare rules and cannot bill you for more
than they could bill you if you had
Medicare. The following chart has more
information about the limits.
If you
are age 65 or older, and
do not have Medicare
Part A, Part B, or both; and
have this Plan as an annuitant or as a
former spouse, or as a family member of an annuitant or former spouse;
and
are not employed in a position that gives FEHB coverage ( Your
employing office can tell you if this applies. )
Then, for your inpatient hospital care in a Medicare participating
hospital,
the law requires us to base our payment on an amount the
equivalent Medicare amount set by Medicare s rules for what Medicare would pay,
not on the actual charge;
you are responsible for your coinsurance and any applicable
deductibles or copayments you owe under this Plan;
you are not
responsible for any charges greater than the equivalent Medicare amount; we show
that amount on the Explanation of Benefits ( EOB) form that we send you; and
the law prohibits a hospital from collecting more than the Medicare
equivalent amount.
And, for your physician care, the law requires us to base our payment
and your coinsurance on
an amount set by Medicare and called the
Medicare approved amount, or
the actual charge if it is lower than
the Medicare approved amount.
Section 4
If your physician
Participates with Medicare
or accepts
Medicare assignment for the claim,
Does not participate with Medicare,
Then you are responsible for
your deductibles, coinsurance, and
copayments.
your deductibles, coinsurance, copayments, and
any balance up to 115% of
the Medicare
approved amount.
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are
permitted to collect only up
to the Medicare approved amount.
Our explanation of benefits form will tell you how much the physician or
hospital can collect from you. If your physi-
cian or hospital tries to
collect more than allowed by law, ask the physician or hospital to reduce the
charges. If you
have paid more than allowed, ask for a refund. If you need
further assistance, call us. 11
11 Page 12 13
12 2002 NALC
Health Benefit Plan
When you have the Original We limit our
payment to an amount that supplements the benefits that
Medicare Plan
Medicare would pay under Medicare Part A ( Hospital insurance) and
(
Part A, Part B, or both) Medicare Part B ( Medical insurance) , regardless
of whether Medicare pays.
Note: We pay our regular benefits for emergency services to an institutional
provider, such as a hospital, that does not participate with Medicare and is
not
reimbursed by Medicare.
When you are covered by Medicare Part B and it is primary, you pay no
out-
of-pocket expenses for services both we and Medicare Part B cover.
If your physician accepts Medicare assignment, then you pay nothing
for
covered charges.
If your physician does not accept Medicare assignment, then you pay
nothing for covered charges because we include payment up to the
limiting charge.
Note: The physician who does not accept Medicare assignment may not bill
you for more than 115% of the amount Medicare bases its payment on,
called the limiting charge. The Medicare Summary Notice ( ( MSN) that
Medicare will send you will have more information about the limiting
charge. If your physician tries to collect more than allowed by law, ask the
physician to reduce the charges. If the physician does not, report the
physician to your Medicare carrier who sent you the MSN form. Call us if
you need further assistance.
When you have a Medicare A physician may ask you to sign a private
contract agreeing that you can
private contract with a be billed
directly for services Medicare ordinarily covers. Should you sign
physician an agreement, Medicare will not pay any portion of the
charges, and we will
not increase our payment. We will limit our payment to
the amount we
would have paid after Medicare s payment.
Please see Section 9. Coordinating benefits with other coverage , for
more
information about how we coordinate benefits with Medicare.
Section 4 12
12 Page
13 14
13 2002 NALC Health Benefit Plan
Section 5. Benefits OVERVIEW
( See page 5 for how our
benefits changed this year and page 55 for a benefits summary. )
NOTE : This Benefits section is divided into subsections.
Please read the important things you should keep in mind at
the beginning of
each subsection. Also read the General exclusions in Section 6; they apply to
the benefits in the
following subsections. To obtain claims forms, claims
filing advice, or more information about our benefits, contact
us at 703/
729-4677 or 1-888-636-NALC ( 6252) .
( a) Medical services and supplies provided by physicians and other health
care professionals . . . . . . . . . . . . . . . . . . . 14-21
Diagnostic
and treatment services
Lab, X-ray, and other diagnostic tests
Preventive
care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical
and occupational therapy
Speech therapy
Hearing services ( testing, treatment, and
supplies)
Vision services ( testing, treatment, and
supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment
( DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
( b) Surgical and anesthesia services provided by physicians and other health
care professionals . . . . . . . . . . . . . . . . 22-25
Surgical procedures
Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and
maxillofacial surgery
( c) Services provided by a hospital or other facility, and ambulance
services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . 26-28
Inpatient hospital Skilled nursing care facility benefits
Outpatient hospital or ambulatory Hospice care
surgical center Ambulance
( d) Emergency services/ Accidents . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29-30
Accidental injury Ambulance
Medical emergency
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 31-33
In-Network Benefits
Out-of-Network Benefits
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 34-35
Covered medications and supplies
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . 36
Flexible benefits option
24-hour nurse line
24-hour help line for mental health and
substance abuse
Services for deaf and hearing impaired
Centers of excellence for transplants/ heart surgery
Disease management
programs
Discounts for durable medical equipment ( DME)
Worldwide
coverage
( h) Dental benefits ( No benefit) . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 37
( i) Non-FEHB benefits available to Plan members . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
SUMMARY OF
BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Section 5 13
13 Page
14 15
14 2002 NALC Health Benefit Plan
Section 5( a) . Medical services and supplies provided by physicians
and other health care professionals
I
M
P
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T
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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.
The PPO calendar year deductible is $ 250 per person ( $ 500 per family) . If
you use non-PPO providers, your calendar year deductible is $ 300 per person ( $
600 per family) . Whether you
use PPO or non-PPO providers, your deductible
will not exceed $ 300 per person ( $ 600
per family) . The calendar year
deductible applies to almost all benefits in this Section.
We say ( No
deductible) to show when the calendar year deductible does not apply. .
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. When no PPO provider is available,
non-PPO benefits apply.
Please keep in mind that when you use a PPO hospital, the professionals who
provide services to you in the hospital, such as emergency room physicians,
radiologists,
anesthetists, and pathologists, may not all be
preferred providers. If they are not, they
will be paid by this Plan as
non-PPO providers.
Be sure to read Section 4. Your costs for covered services, for
valuable information about cost sharing, with special sections for members who
are age 65 or older. Also read
Section 9. Coordinating benefits with other coverage .
I
M
P
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A
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Benefit Description
You pay
After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this
Section. We say ( No deductible)
when it does not apply.
Diagnostic and treatment services
Professional services of physicians
Office or outpatient visits
PPO:
$ 20 copayment per visit
( No deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between
our
allowance and the billed amount
Professional services of physicians
Hospital care
Skilled nursing
facility care
Initial examination of a newborn child covered under a family
enrollment
Medical consultations
Second surgical opinions
Home visits
Note: For routine post-operative surgical care, see
Section 5( b) .
Surgical procedures .
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Not covered:
Routine physical checkups and related tests
Routine eye and hearing examinations
Services by
chiropractors, except in those states designated as
medically underserved
areas
Nonsurgical treatment for weight reduction or obesity
All charges
Section 5( a) 14
14 Page 15 16
15 2002 NALC
Health Benefit Plan
Lab, X-ray and other diagnostic tests
Tests and their interpretation, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
Non-routine Mammograms
CAT
Scans/ MRI
Ultrasound
Electrocardiogram ( EKG)
Electroencephalogram
( EEG )
You pay
PPO: 15% of the Plan allowance
Non-PPO: 30% of the
Plan allowance
and the difference, if any, between our
allowance and the
billed amount
Note: When tests are performed during
an inpatient confinement no
deductible
applies.
Plan pays for preadmission testing within 7 days of admission or
outpatient surgery. Screening tests, limited to:
Chest X-rays
Electrocardiograms
Urinalysis
Blood work
Note: Diagnostic tests, such as magnetic resonance imaging, throat
cultures or similar studies are not considered as preadmission testing.
PPO: Nothing ( No deductible)
Non-PPO: 20% of the Plan allowance
( No
deductible) , and the difference, if
any, between our allowance and the
billed amount
Preventive care, adult
Routine screenings, limited to:
Total
blood cholesterol one every three years
Chlamydial infection
Colorectal
cancer screening, including Fecal occult blood test one annually, age 40 and
older
PPO: $ 5 copayment ( No deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between our
allowance and the billed amount
Routine Sigmoidoscopy, screening one every five
years, age 50 and older
Routine Prostate Specific Antigen ( PSA test) one annually for men age 40 and
older
Routine pap test
Note: We cover the office visit if it is on the same day
as the
pap test. See Diagnostic and treatment services in this
Section.
Routine mammogram for women age 35 and older, as follows:
Ages 35 through
39, , one during this five year period
Ages 40 through 64, , one every
calendar year
Age 65 and older, , one every two consecutive calendar years
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between the
Plan allowance and the billed amount
PPO: $ 25 copayment ( No deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between our
allowance and the billed amount
PPO: Nothing for first $ 35 in charges ( No
deductible) , then 15% of the
Plan allowance
Non-PPO: Nothing for first $ 35 in charges
( No deductible) , then 30% of
the Plan
allowance and the difference, if any, between
our allowance and
the billed amount
PPO: $ 25 copayment ( No deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between our
allowance and the billed amount
Routine immunizations, limited to:
Tetanus-diphtheria ( Td) booster one
every 10 years, age 19 and older ( except as provided for under Preventive
care, children )
Influenza/ Pneumococcal vaccines, one annually, age 65 and older
PPO: $ 5 copayment ( No deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between our
allowance and the billed amount
Section 5( a)
Not covered: Routine tests, except listed under Preventive care, adult
All charges
in this Section 15
15
Page 16 17
16
2002 NALC Health Benefit Plan
Preventive care, children
Childhood immunizations, ages 3 through 21, limited to:
Immunizations recommended by the American Academy of Pediatrics
Meningococcal immunization lifetime limit of two vaccinations
PPO: Nothing ( No deductible)
Non-PPO: The difference, if any, between
our allowance and the billed amount ( No
deductible)
PPO: Nothing ( No deductible)
Non-PPO: The difference, if any, between
our allowance and the billed amount ( No
deductible)
PPO: $ 20 copayment ( No deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between our
allowance and the billed amount
Well-child care routine examinations and immunizations, through age 2
Note: For the coverage of the initial newborn exam see Diagnos-
tic
and treatment services in this Section.
Examinations, limited to:
Examinations for amblyopia ( lazy eye) and
strabismus
( crossed eyes) limited to one screening examination,
ages 2
through 6
Examinations done on the day of immunizations, ages 3
through 21
You pay
Maternity care
Complete maternity ( obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Amniocentesis
Group B streptococcus infection screening
Sonograms
Fetal monitoring
Other tests medically indicated for the unborn child
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see
Section 3. How
to get approval for 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
cover an extended stay, if medically necessary, but you, your
representative, your physician, or your hospital must
precertify.
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 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 Section 5( c) . Inpatient
hospital and Section 5( b) . Surgical procedures.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges
Section 5( a)
Not covered: Routine sonograms to
determine fetal age, size or sex 16
16 Page 17 18
17 2002 NALC
Health Benefit Plan
Family planning
Voluntary family planning
services, limited to:
Voluntary sterilization
Implanted contraceptives (
such as Norplant)
Intrauterine devices ( IUDs)
Injectable contraceptive drugs ( such as Depo provera)
Diaphragms
Note: We cover oral contraceptives only under the Prescription drug
benefit. See Section 5( f) . Prescription drug benefits.
Not covered: Reversal of voluntary surgical sterilization, genetic
counseling
You pay
PPO: 10% of the Plan allowance
Non-PPO: 30% of the
Plan allowance
and the difference, if any, between our
allowance and the
billed amount
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges
Infertility services
Diagnosis and treatment of infertility,
except as shown in Not covered .
Note: For surgical services see
Section 5( b) .
Note: Prescription drugs for infertility are covered only
under the
Prescription drug benefit. See Section 5( f) . Prescription
drug benefits.
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges Not covered:
Infertility services after voluntary
sterilization Assisted reproductive technology ( ART) procedures, such
as:
Artificial insemination
In vitro fertilization
Embryo transfer and gamete intrafallopian tube transfer ( GIFT)
Services and supplies related to ART procedures Cost of donor sperm
Cost of donor egg
Allergy care
Testing
Treatment, except for allergy injections
Allergy serum
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
PPO: $ 5 copayment each ( No deductible)
Non-PPO: 30% of the Plan
allowance
and the difference, if any, between our
allowance and the
billed amount
All charges
Allergy injections
Not covered:
Provocative food testing
and sublingual allergy desensitization Environmental control units, such
as air conditioners, purifiers,
humidifiers, and dehumidifiers
Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in
association with autologous bone
marrow transplants is limited to those
transplants listed in Section 5( b) .
Organ/ tissue transplants .
Dialysis Hemodialysis and peritoneal dialysis Intravenous ( IV) / Infusion
Therapy Home IV and antibiotic therapy
Respiratory and inhalation therapies Growth hormone therapy ( GHT)
Note: We cover GHT only when it is preauthorized through our disease
management program. Call 1-800-433-NALC ( 6252) for preauthorization.
If
you do not preauthorize, we will not cover the GHT or related services
and
supplies.
Note: The growth hormone is covered under the Prescription drug benefit.
See Section 5( f) . Prescription drug benefits.
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Section 5( a)
All charges Not covered: Chelation therapy, except as
treatment for acute arsenic,
gold, lead or mercury poisoning 17
17 Page 18 19
18 2002 NALC Health Benefit Plan
Physical and occupational therapies
A combined total of 50
visits per calendar year for treatment provided by a licensed registered
therapist or physician for the following:
Physical therapy
Occupational therapy
Therapy is covered when the attending physician:
Orders the care;
Identifies the specific professional skills the patient
requires and the medical necessity for skilled services; and
Indicates the length of time the services are needed.
Note: We cover
physical and occupational therapy only to restore bodily
function when there
has been a total or partial loss of bodily function due
to illness or
injury.
Not covered:
Maintenance therapy, including cardiac
rehabilitation and exercise programs
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between
our allowance and the billed amount
All charges
Hearing services ( testing, treatment, and supplies)
Hearing
testing for covered diagnoses, such as otitis media and mastoiditis
First hearing aid and examination, limited to services necessitated by
accidental injury
Not covered:
Routine hearing testing
Hearing aid and
examination, except when necessitated by accidental injury
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between
our allowance and the billed amount
All charges
Vision services ( testing, treatment, and supplies)
Eye
examinations for covered diagnoses, such as cataract and glaucoma PPO: $ 20
copayment per visit ( No deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between
our
allowance and the billed amount
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
One pair of eyeglasses or contact lenses to correct an impairment directly
caused by accidental ocular injury or intraocular surgery ( such
as for
cataracts)
Note: For examinations for amblyopia and strabismus, see
Preventive
care, children in this Section .
Not covered:
Eyeglasses or contact lenses and examinations for
them Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
Refractions
All charges
Section 5( a)
Speech therapy
Up to 30 visits per calendar year for treatment
provided by a licensed registered speech therapist or physician
Therapy is covered when the attending physician:
Orders the care;
Identifies the specific professional skills the patient requires and the
medical necessity for skilled services; and
Indicates the length of time
the services are needed.
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Not covered: Maintenance therapy All charges
You pay 18
18 Page
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19 2002 NALC Health Benefit Plan
Foot care
Nonsurgical routine foot care when you are under
active treatment for a
metabolic or peripheral vascular disease, such as
diabetes
You pay
PPO: 15% of the Plan allowance
Non-PPO: 30% of the
Plan allowance
and the difference, if any, between our
allowance and the
billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges
Surgical procedures for routine foot care when you are under active
treatment for a metabolic or peripheral vascular disease, such as
diabetes
Open cutting, such as the removal of bunions or bone spurs
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)
Foot orthotics, arch supports, heel pads and cups
Orthopedic
and corrective shoes
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Custom-made durable braces for
legs, arms, neck and back
Externally worn breast prostheses and surgical
bras, including neces-
sary replacements following a mastectomy
Note: Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implants following
mastectomy are paid as hospital benefits. See Section 5( c) . Inpatient
hospital . Insertion of the device is paid as surgery. See Section 5( b)
.
Surgical procedures .
Not covered:
Orthopedic and corrective shoes
Arch supports
Foot
orthotics ( shoe inserts)
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings,
support hose, and other supportive
devices
Prosthetic replacement provided less than 3 years after the last one we
covered
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges
Durable medical equipment ( DME)
Durable medical equipment ( DME)
is equipment and supplies that:
1. Are prescribed by your attending
physician ( i. e. , the physician who
is treating your illness or injury) ;
2. Are medically necessary;
3. Are primarily and customarily used only
for a medical purpose;
4. Are generally useful only to a person with an
illness or injury;
5. Are designed for prolonged use; and
6. Serve a
specific therapeutic purpose in the treatment of an illness or
injury.
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Durable medical equipment ( DME) Continued on next page
Section 5( a)
19
19 Page 20
21
20 2002 NALC Health Benefit Plan
Note:
Call us at 1-800-433-NALC ( 6252) as soon as your physician
prescribes
equipment or supplies. We have arranged with a health care
provider to rent
or sell durable medical equipment at discounted rates and
will tell you more
about this service when you call.
We cover rental or purchase ( at our option) including repair and
adjust-
ment of durable medical equipment:
Oxygen and oxygen apparatus
Dialysis appliances
We also cover supplies, such as:
Hospital beds
Wheelchairs
Crutches, canes, and walkers
Insulin
and diabetic supplies
Needles and syringes for covered injectables
Ostomy and catheter supplies
Home IV and antibiotic therapy
Not covered:
DME replacements provided less than 3 years after
the last one we
covered
Sun or heat lamps, whirlpool baths, saunas and similar household
equipment
Safety, convenience and exercise equipment
Communication
equipment including computer story boards or
light talkers
Enhanced vision systems, computer switch boards or environmental
control units
Heating pads, air conditioners, purifiers and humidifiers
Stair
climbing equipment, stair glides, ramps, elevators
Modifications or
alterations to vehicles or households
Other items ( such as wigs)
that do not meet the criteria 1 thru 6 above
You pay Durable medical equipment ( DME) ( continued)
All
charges
Home health services
Up to 90 days per calendar year
( with a maximum Plan payment of $ 75
per day) when:
A registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) or
licensed
vocational nurse ( L. V. N. ) provides the services;
The attending physician orders the care;
The physician identifies the
specific professional skills required by the
patient and the medical
necessity for skilled services; and
The physician indicates the length of time the services are needed.
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
PPO: 20% of the Plan allowance
( No deductible) plus all charges
after we pay $ 75 per day
Non-PPO: 20% of the Plan allowance
( No deductible) plus all charges
after
we pay $ 75 per day
All charges
Section 5( a)
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount 20
20 Page 21 22
21 2002 NALC Health Benefit Plan
Alternative treatments
Acupuncture, limited to treatment by a
doctor of medicine or
osteopathy for pain relief
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and the difference, if any, between
our
allowance and the billed amount
All charges Not covered:
Naturopathic services
Note: In
medically underserved areas, we may cover services of
alternative treatment
providers. See Section 3. Covered providers.
Educational classes and programs
Coverage is limited to:
Smoking Cessation One smoking cessation program per
member per lifetime,
up to a maximum Plan payment of $ 100
including all related expenses such as drugs
Diabetes training for self-management when:
Prescribed by the attending
physician; and
Administered by a covered provider, such as a registered
nurse.
PPO: Nothing for the first $ 100
Non-PPO: Nothing for the first $ 100
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Section 5( a)
Chiropractic
Coverage limited to medically underserved areas. See
Section 3.
Covered providers.
You pay
PPO: 15% of the Plan allowance
Non-PPO: 30% of the
Plan allowance
and the difference, if any, between our
allowance and the
billed amount 21
21 Page
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22 2002 NALC Health Benefit Plan
I
M
P
O
R
T
A
N
T
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.
The PPO calendar year deductible is $ 250 per person ( $ 500 per family) . If
you use non-PPO providers, your calendar year deductible is $ 300 per person ( $
600 per family) . Whether you
use PPO or non-PPO providers, your deductible
will not exceed $ 300 per person ( $ 600 per
family) . The calendar year
deductible applies to almost all benefits in this Section. We
say ( No
deductible) to show when the calendar year deductible does not apply. .
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. When no PPO provider is available,
non-PPO benefits apply.
Please keep in mind that when you use a PPO hospital, the professionals who
provide services to you in the hospital, such as emergency room physicians,
radiologists,
anesthetists, and pathologists, may not all be
preferred providers. If they are not, they
will be paid by this Plan as
non-PPO providers.
Be sure to read Section 4. Your costs for covered services, for
valuable information about cost sharing, with special sections for members who
are age 65 or older. Also
read Section 9. Coordinating benefits with other coverage .
The
amounts listed below are for the charges billed by a physician or other health
care professional for your surgical procedure, including normal pre-and
post-operative care.
See Section 5( c) . Services provided by a hospital or other facility, and
ambulance
services, for charges associated with the facility ( i. e. ,
hospital, surgical center, etc. ) .
YOU MUST GET PRIOR AUTHORIZATION FOR ORGAN/ TISSUE TRANS-
PLANTS. See
Section 5( b) . Organ/ tissue transplants .
Benefit Description
You pay
After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this
Section. We say ( No deductible)
when it does not apply.
Section 5( b) . Surgical and anesthesia services provided by physicians
and other health care professionals
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care
Correction of amblyopia and
strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors
and cysts
Correction of congenital anomalies
Gastric bypass or stapling
for treatment of morbid obesity a condition in which an individual weighs 100
pounds or 100%
over his or her normal weight with complicating medical
conditions and
attempts to reduce weight using a doctor-
monitored diet and exercise program
were unsuccessful;
patients must be age 18 or older
Insertion of internal prosthetic devices. See Section 5( a) . Ortho-pedic
and prosthetic devices, for device coverage information.
Surgical procedures -Continued on next page
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Section 5( b) 22
22 Page 23 24
23 2002 NALC
Health Benefit Plan
Voluntary sterilization, surgically implanted
contraceptives and
intrauterine devices ( IUDs)
Debridement of burns
Note: When multiple or bilateral surgical procedures add complexity to an
operative session, the Plan allowance for the second or less expensive
procedure is one-half of what the Plan allowance would have been if that
procedure had been performed independently.
The Plan allowance for an assistant surgeon will not exceed 25% of our
allowance for the surgeon.
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (
such as the periodontal membrane, gingival and alveolar bone)
Cosmetic surgery, except for: repair of accidental injury if repair is
initiated within six months after an accident; correction of a congeni-
tal
anomaly; or breast reconstruction following a mastectomy
Radial
keratotomy and other refractive surgery
Procedures performed through
the same incision deemed incidental to the total surgery, such as appendectomy,
lysis of adhesion, puncture of
ovarian cyst
Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty or other
high risk procedures when we determine standby surgeons are medically
necessary
Cutting, trimming or removal of corns, calluses, or
the free edge of toenails, and similar routine treatment of conditions of the
foot, except
as listed under Section 5( a) . Foot care
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
payment and the billed amount
Surgical procedures ( continued) You pay
All charges
Reconstructive surgery
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 appear-
ance; and
The condition can reasonably be expected to be corrected by
such surgery
Surgery to correct a congenital anomaly ( 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
deformi-
ties; cleft lip; cleft palate; birth marks; and webbed fingers and
toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
Surgery to produce a symmetrical appearance on the other breast
Treatment
of any physical complications, such as lymphedemas
Note: Congenital anomaly does not include conditions related to teeth or
intra-oral structures supporting the teeth.
Note: We cover internal and external breast prostheses, surgical bras and
replacements. See Section 5( a) . Orthopedic and prosthetic devices,
and
Section 5( c) . Inpatient hospital .
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.
Reconstructive surgery Continued on next page
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Section 5( b) 23
23 Page 24 25
24 2002 NALC
Health Benefit Plan
You pay
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 if
repair is initiated within six months
Injections of silicone, collagens and similar substances
Surgeries related to sex transformation or sexual dysfunction
Organ/ tissue transplants Continued on next page
Reconstructive surgery ( continued)
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Treatment of fractures of the jaws or facial bones
Surgical
correction of cleft lip, cleft palate or severe functional malocclusion
Removal of stones from salivary ducts
Excision of leukoplakia or
malignancies
Excision of cysts and incision of abscesses when done as
independent procedures
Other surgical procedures that do not involve the teeth or their support-ing
structures
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (
such as the periodontal membrane, gingiva, and alveolar bone)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges
Organ/ tissue transplants
Limited to:
Bone
Cornea
Heart
Heart/ lung
Kidney
Kidney/ pancreas
Liver
Lung: Single only for the following end-stage pulmonary diseases:
pulmonary fibrosis, primary pulmonary hypertension, or emphysema;
Double only for patients with cystic fibrosis
Pancreas
Allogenic bone
marrow transplants, limited to patients with acute leukemia, advanced Hodgkin s
lymphoma, advanced non-Hodgkin s
lymphoma, advanced neuroblastoma, aplastic anemia, chronic myelog-
enous
leukemia, infantile malignant osteoporosis, severe combined
immunodeficiency, thalassemia major, or Wiskott-Aldrich syndrome
Autologous bone marrow transplants ( autologous stem cell support) and
autologous peripheral stem cell support for 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, mediasti-
nal
retroperitoneal, and ovarian germ cell tumors
Intestinal transplants ( small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
Nothing, for services obtained through
the National Transplant Program
( NTP) . ( No deductible)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Section 5( b) 24
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25 2002 NALC
Health Benefit Plan
National Transplant Program ( NTP) The Plan
participates in The First
Health , National Transplant Program.
Before your initial evaluation as a
potential candidate for a transplant
procedure, you or your physician must
contact First Health at
1-800-622-6252 and speak to a Transplant Case
Manager. You will be given
information about this program including a
list of participating providers.
Charges for services performed by a
National Transplant Program provider,
whether incurred by the recipient
or donor are paid at 100% . Participants
in the program must receive prior
approval from the Plan for travel and
lodging expenses.
Note: We cover related medical and hospital expenses of the donor only
when we cover the recipient.
Note: Limited Benefits If you do not obtain prior approval or do not use
a designated facility, we pay a maximum of $ 100,000 for each listed
transplant ( kidney limit, $ 50,000) , for these combined expenses:
pre-
transplant evaluation; organ procurement; and inpatient hospital,
surgical
and medical expenses. We pay benefits according to the appropriate
benefit section, such as Section 5( c) . Inpatient hospital, and
Surgical
procedures . The limitation applies to expenses incurred by
either the
recipient or donor.
Treatment for breast cancer, multiple myeloma, and epithelial ovarian
cancer may be provided in a National Cancer Institute ( NCI) -or National
Institute of Health ( NIH) -approved clinical trial at a designated center
for
excellence when approved by our medical director in accordance with the
Plan s protocols.
Not covered:
Donor screening tests and donor search expenses,
except those
performed for the actual donor
Travel and lodging expenses, except when approved by the Plan
Implants of artificial organs
Transplants and related
services and supplies not listed as covered
Organ/ tissue transplants ( continued) You pay
Nothing, for services obtained through
the National Transplant
Program
( NTP) . ( No deductible)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges
Anesthesia
Professional services provided
in:
Hospital ( inpatient)
Professional services provided in:
Hospital outpatient department
Ambulatory surgical center
Office
Other outpatient facility
PPO: 15% of the Plan allowance ( No
deductible)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between
our
allowance and the billed amount ( No
deductible)
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Note: If your PPO provider uses a
non-PPO anesthesiologist, we will pay
non-PPO benefits for the anesthesia
charges.
Section 5( b) 25
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26 2002 NALC
Health Benefit Plan
Benefit Description You pay
NOTE: The
calendar year deductible applies ONLY when we say ( calendar year deductible
applies) .
Section 5( c) . Services provided by a hospital or other facility,
and
ambulance services
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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 medi-
cally necessary.
The PPO calendar year deductible is $ 250 per person ( $ 500 per family) . If
you use
non-PPO providers, your calendar year deductible is $ 300 per person
( $ 600 per
family) . Whether you use PPO or non-PPO providers, your deductible will not
exceed
$ 300 per person ( $ 600 per family) . Unlike Sections ( a) and ( b)
, in this Section, the
calendar year deductible applies to only a few
benefits. In that case, we say ( calendar
year deducible applies) .
Be sure to read Section 4. Your costs for covered services, for
valuable information
about cost sharing, with special sections for members
who are age 65 or older. Also
read Section 9. Coordinating benefits with other coverage .
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only
when you use a PPO provider. When no PPO provider is available,
non-PPO benefits
apply.
Please keep in mind that when you use a PPO hospital, the professionals who
provide
services to you in the hospital, such as emergency room physicians,
radiologists,
anesthetists, and pathologists, may not all be preferred providers. If
they are not, they
will be paid by this Plan as non-PPO providers.
The amounts listed below are for charges billed by the facility ( i. e. ,
hospital or surgical
center) or ambulance service for your surgery or care.
Look in Sections 5( a) or ( b) for
costs associated with the professional charge ( i. e. , physicians, etc. ) .
YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE
TO DO SO
WILL RESULT IN A $ 500 PENALTY. Please refer to the precertifica-
tion information shown in Section 3 to be sure which services require
precertification.
Inpatient hospital
Room and board, such as:
Ward, semiprivate,
or intensive care accommodations;
General nursing care; and
Meals and
special diets.
Note: We cover a private room only when you must be isolated to prevent
contagion. Otherwise, we pay the hospital s average charge for semiprivate
accommodations. If the hospital has private rooms only, we base our
payment on the average semiprivate rate of the most comparable hospital in
the area.
Note: When the non-PPO hospital bills a flat rate, we prorate the charge
as follows: 30% room and board and 70% other charges.
Inpatient hospital Continued on next page
PPO: 10% of the Plan allowance
Non-PPO: $ 100 copayment per
admission
and 30% of the Plan
allowance
Section 5( c) 26
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27 2002 NALC
Health Benefit Plan
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed
drugs and medicines
Diagnostic laboratory tests and X-rays
Preadmission
testing ( within 7 days of admission)
Blood or blood plasma, if not donated
or replaced
Dressings, splints, casts, and sterile tray services
Medical
supplies and equipment, including oxygen
Anesthetics, including nurse
anesthetist services
Internal prostheses
Professional ambulance service
to the nearest hospital equipped to handle your condition
Occupational, physical, and speech therapy
Note: We base payment on who
bills for the services or supplies. For
example, when the hospital bills for
its nurse anesthetist s services, we
pay hospital benefits ( Inpatient
hospital) and when the anesthesiologist
bills, we pay anesthesia
benefits. See Section 5( b) . Surgical procedures .
Note: We cover your admission for dental procedures only when you
have a
nondental physical impairment that makes admission necessary to
safeguard
your health. We do not cover the dental procedures.
Note: We cover your admission for inpatient foot treatment even if no
other benefits are payable.
Take-home items
Medical supplies, appliances, and equipment; and any
covered items
billed by a hospital for use at home
Inpatient hospital ( continued) You pay
PPO: 10% of
the Plan allowance
Non-PPO: $ 100 copayment per
admission and 30% of the
Plan
allowance
PPO: 15% of the Plan allowance
( calendar year deductible applies)
Non-PPO: 30% of the Plan allow-
ance ( calendar year deductible
applies)
All charges Not covered:
Any part of a hospital admission that
is not medically necessary ( See
Section 10. Definitions . . . Medical
Necessity ) , such as long term care or
when you do not need acute hospital inpatient ( overnight) care, but could
receive care in some other setting without adversely affecting your
condition or the quality of your medical care. In this event, we pay
benefits for services and supplies other than room and board and
in-
hospital physician care at the level they would have been covered if
provided in an alternative setting.
Custodial care; see Section 10. Definitions . . . Custodial
care
Non-covered facilities, such as nursing homes, extended care
facilities,
and schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
Section 5( c) 27
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28 2002 NALC
Health Benefit Plan
Outpatient hospital or ambulatory surgical center
Services and supplies, such as:
Operating, recovery, and other
treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory
tests, X-rays, and pathology services
Administration of blood, blood plasma,
and other biologicals
Blood and blood plasma, if not donated or replaced
Dressings, casts, splints, and sterile tray services
Medical supplies,
including oxygen
Anesthetics and anesthesia service
Note: We cover hospital services and supplies related to dental
proce-
dures when necessitated by a nondental physical impairment. We do not
cover the dental procedures.
Not covered: Personal comfort items
PPO: 15% of the Plan allowance
( calendar year deductible applies)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between
our
allowance and the billed amount
( calendar year deductible applies)
All charges
You pay
Skilled nursing care facility benefits
Limited to care in a
skilled nursing facility ( SNF) when your Medicare
Part A is primary. We
cover semiprivate room, board, services and
supplies in a SNF for up to 30
days per confinement when:
You are admitted directly from a hospital stay of at least 3 consecutive
days;
You are admitted for the same condition as the hospital stay;
Your
skilled nursing care is supervised by a physician and provided by
an R. N. ,
L. P. N. , or L. V. N. ; and
SNF care is medically necessary.
Not covered: Custodial care
PPO: Nothing
Non-PPO: The difference, if any,
between our allowance
and the
billed amount
All charges
Hospice care
Hospice is a coordinated
program of maintenance and supportive care for
the terminally ill provided
by a medically supervised team under the
direction of a Plan-approved
independent hospice administration.
Limited benefits: We pay up to $ 3000 per lifetime for a combination of
inpatient and outpatient services.
PPO: 15% of the Plan allowance,
and all charges after we pay $ 3000
(
calendar year deductible applies)
Non-PPO: 30% of the Plan allowance,
and all charges after we pay $ 3000
( calendar year deductible applies)
All charges Not covered:
Private nursing care
Homemaker services
Bereavement services
Ambulance
Local professional ambulance service when medically
necessary
Not covered: Transportation ( other than professional ambulance
services) , such as by ambulette or medicab
PPO: 15% of the Plan allowance
( calendar year deductible applies)
Non-PPO: 30% of the Plan allowance
and the difference, if any, between
our
allowance and the billed amount
( calendar year deductible applies)
All charges
Section 5( c) 28
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29 2002 NALC
Health Benefit Plan
Section 5( d) . Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are medi-
cally necessary.
The PPO calendar year deductible is $ 250 per person ( $ 500 per family) . If
you use
non-PPO providers, your calendar year deductible is $ 300 per person
( $ 600 per family) .
Whether you use PPO or non-PPO providers, your deductible will not exceed $
300 per
person ( $ 600 per family) . The calendar year deductible applies to
almost all benefits
in this Section. We say ( No deductible) to show when
the calendar year deductible
does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only
when you use a PPO provider. When no PPO provider is available,
non-PPO benefits
apply.
Please keep in mind that when you use a PPO hospital, the professionals who
provide
services to you in the hospital, such as emergency room physicians,
radiologists,
anesthetists and pathologists, may not all be preferred providers. If
they are not, they
will be paid by this Plan as non-PPO providers.
Be sure to read Section 4, Your costs for covered services, for
valuable information
about cost sharing, with special sections for members
who are age 65 or older. Also
read Section 9. Coordinating benefits with other coverage .
Benefit Description
You pay
After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this
Section. We say ( No deductible)
when it does not apply.
What is an accidental injury?
An accidental injury is a bodily
injury sustained solely through violent, external and accidental means. We do
not
cover dental care for accidental injury .
Accidental injury
If you receive the care within 72 hours after
your accidental injury,
we cover:
Nonsurgical services and supplies by a physician
Related nonsurgical
outpatient hospital services and supplies
Local professional ambulance
service when medically
necessary
Note: For surgery related to an accidental injury, see Section 5( b) .
Surgical procedures.
If you receive care for your accidental injury after 72 hours, we cover:
Outpatient hospital and physician services and supplies not
related to
surgical procedures
PPO: Nothing ( No deductible)
Non-PPO: The difference, if any,
between the Plan allowance and the
billed amount ( No deductible)
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between the
Plan allowance and the billed amount
Section 5( d) 29
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30 2002 NALC
Health Benefit Plan
Medical emergency
Outpatient medical
services and supplies. See Section 5( a) .
Medical services and supplies.
. .
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and the difference, if any, between
our
allowance and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
Surgical services. See Section 5( b) Surgical procedures.
Ambulance
Local professional ambulance service when medically
necessary,
not related to an accidental injury
Not covered: Transportation ( other than professional ambulance
services) , such as by ambulette or medicab
PPO: 15% of the Plan allowance
Non-PPO: 30% of the Plan allowance
and
the difference, if any, between our
allowance and the billed amount
All charges
Section 5( d)
You pay 30
30 Page
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31 2002 NALC Health Benefit Plan
Section 5( e) . Mental health and substance abuse benefits
In-Network Benefits
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Benefit Description
You pay
After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this
Section. We say ( No deductible)
when it does not apply.
You may choose to get care In-Network or Out-of-Network. When you receive
In-
Network care, you must get our approval for services and follow a
treatment plan we
approve. If you do, cost-sharing and limitations for
In-Network mental health and
substance abuse benefits will be no greater
than for similar benefits for other illnesses and
conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in
this brochure.
There is a separate calendar year deductible for In-Network
mental health and sub-
stance abuse of $ 250 per person ( $ 500 per family) .
This calendar year deductible
applies to almost all benefits in this Section. We say ( No deductible) to
show when
the calendar year deductible does not apply.
When no In-Network provider is available, Out-of-Network benefits will be
paid.
Be sure to read Section 4. Your costs for covered services, for
valuable information
about cost sharing, with special sections for members
who are age 65 or older. Also
read Section 9. Coordinating benefits with other coverage .
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits descriptions below.
In-Network mental health and substance abuse benefits are below, then
Out-of-
Network benefits begin on page 33.
In-Network benefits
All diagnostic and treatment services
contained in a treatment plan
that we approve. The treatment plan may
include services, drugs,
and supplies described elsewhere in this brochure.
Note: In-Network benefits are payable only when we determine
the care is
clinically appropriate to treat your condition and only
when you receive the
care as part of a treatment plan that we
approve.
Outpatient professional services, including individual or group
therapy
by providers such as psychiatrists, psychologists, or
clinical social workers
Outpatient medication management
Outpatient diagnostic tests
Your cost-sharing responsibilities are no
greater than for other illness
or condi-
tions, such as $ 20 copayment per office
visit, or 15% of the
Plan allowance for
other outpatient services after the
calendar year
deductible is met.
$ 20 copayment per visit ( No deductible)
15% of the Plan allowance
In-Network benefits Continued on next page.
.
Section 5( e) 31
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32 2002 NALC
Health Benefit Plan
In-Network benefits ( continued)
Inpatient professional services, including individual or group therapy
by providers such as psychiatrists, psychologists, or clinical social
workers
Inpatient services provided by a hospital or other facility
Services in
approved alternative care settings such as partial hospital-
ization,
half-way house, residential treatment, full-day hospitalization,
facility based intensive outpatient treatment
Not covered:
Services we have not approved
Treatment
for learning disabilities and mental retardation
Treatment for
marital discord
Note: Exclusions that apply to other benefits apply to these mental health
and substance abuse benefits, unless the services are included in a
treatment plan that we approve.
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.
You pay
15% of the Plan allowance
Nothing ( No deductible)
All charges
Preauthorization To be eligible to receive these enhanced mental
health and substance abuse
benefits you must obtain a treatment plan and
follow all of the following
network authorization processes:
United Behavioral Health provides our mental health and substance abuse
benefits. Call 1-877-468-1016 to locate network clinicians who can best meet
your needs, and to receive authorization to see a provider. You and your
provider will receive written confirmation of the authorization from United
Behavioral Health for the initial and any ongoing authorizations.
Exceptions When Medicare is the primary payer, call the Plan at
1-888-636-NALC
( 6252) to preauthorize treatment if:
Medicare does not cover your services; or
Medicare hospital benefits are
exhausted and you do not want to use your
Medicare lifetime reserve days.
Note: You do not need to preauthorize treatment when Medicare covers your
services.
Where to file claims If you are using In-Network benefits for mental
health and substance abuse
treatment, you will not have to submit a claim.
United Behavioral Health s
network providers are responsible for filing.
Claims should be submitted to:
United Behavioral Health
P. O. Box 23250
Oakland, CA 94623-0250
Questions? 1-877-468-1016
Section 5( e) 32
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Out-of-Network Benefits
Here are some important things to keep in mind
about these benefits:
Please remember that all benefits are subject to
the definitions, limitations, and exclusions in this brochure and are payable
only when we determine they are medically necessary.
The calendar year deductible for inpatient and outpatient professional
services is $ 300 per person ( $ 600 per family) . The calendar year deductible
applies to almost all
benefits in this Section. We say ( No deductible) to
show when the calendar year
deductible does not apply.
The calendar year deductible in a treatment facility is $ 300 per person.
Be sure to read Section 4. Your costs for covered services, for
valuable information about cost sharing, with special sections for members who
are age 65 or older. Also
read Section 9. Coordinating benefits with other coverage .
YOU
MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A
$ 500 PENALTY. Please refer to the precertifica-
tion information shown in Section 3 to be sure which services require
precertification.
Benefit Description You pay
After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this
Section. We say ( No deductible)
when it does not apply.
Out-of-Network benefits
Inpatient and outpatient professional
services of providers, such as
psychiatrists, psychologists, clinical social
workers, or community
mental health organizations:
Up to 30 visits per calendar year for diagnostic tests; office,
outpatient, and hospital visits
Up to 50 days per calendar year for inpatient hospital charges:
Ward or
semiprivate accommodations
Other charges
Up to a 30 day lifetime maximum for inpatient care in a treatment
facility for rehabilitative substance abuse:
Ward or semiprivate accommodations
Other charges
Not covered:
Services by pastoral, marital, drug/ alcohol, and
other counselors
Treatment for learning disabilities and mental retardation
Treatment for marital discord
Services rendered or billed by schools,
residential treatment centers or halfway houses or members of their staffs
Note: In medically underserved areas, we may cover services of
pastoral
counselors. See Section 3. Covered providers.
$ 300 mental conditions/ substance abuse
calendar year deductible, then
50% of the
Plan allowance and the difference, if any,
between our
allowance and the billed
amount; all charges after 30 visits
$ 500 copayment per admission plus 50%
of the Plan allowance ( No
deductible) ;
all charges after 50 days
$ 300 treatment facility calendar year
deductible, then 50% of the Plan
allow-
ance; all charges after 30 days
All charges
Lifetime maximum Out-of-Network inpatient care for the treatment of
substance abuse in a treatment facility is
limited to a 30-day lifetime
benefit.
Precertification The medical necessity of your admission to a hospital
or other covered facility must be
precertified for you to receive these
Out-of-Network benefits. Emergency admissions must be
reported within two
business days following the day of admission even if you have been
dis-
charged. Otherwise, the benefits payable will be reduced by $ 500. See
Section 3 for details.
Where to file claims United Behavioral Health
P. O. Box 23250
Oakland, CA 94623-0250
Questions? 1-877-468-1016
Section 5( e) 33
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Here are some important things to keep in mind about these benefits:
We cover prescribed medications and supplies 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 drug deductible of $ 25 per person or $ 50 per
family applies only to non-network benefits. We say ( No deductible) to show
when the calendar year drug
deductible does not apply.
Some drugs
require prior authorization. Call the Plan at 1-800-433-NALC ( 6252) for
information.
Maximum dosage dispensed may be limited by protocols established by the Plan.
When we say Medicare in this Section we mean you have Medicare Part B and it
is primary. .
Be sure to read Section 4. Your costs for covered services,
for valuable information about cost sharing, with special sections for
members who are age 65 or older. Also
read Section 9. Coordinating benefits with other coverage .
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 a network pharmacy, a non-network phar-macy, or by mail. We pay
a higher level of benefits when you use a network pharmacy.
Network pharmacy Present your Plan identification card at an NALC
CareSelect Network pharmacy to purchase prescription drugs. Call 1-800-933-NALC
( 6252) to locate the nearest network pharmacy.
Non
-network pharmacy You may purchase prescriptions at
pharmacies that are not part of our network. You pay full cost and must file a
claim for reimbursement. See When you have to file a claim in this
Section .
Mail order Complete the patient profile/ order form
with your order. Send this form, along with your prescription( s) and payment,
in the preaddressed envelope to:
NALC Prescription Drug Program
P. O.
Box 7615
Mount Prospect, IL 60056-7615
We use an open formulary. If your physician believes a name brand
product is necessary, or there is no generic available, your physician may
prescribe a name brand drug from our formulary list. These preferred name brand
drugs are selected to meet patient needs at lower cost. To order the
Formulary pamphlet, call 1-800-933-NALC
( 6252) .
These are the dispensing limitations.
Network retail pharmacy You
may obtain up to a 30-day supply plus one refill for each prescription. No
deductible applies. After one refill, you must obtain a new prescription and
submit it to the mail order
program. Failure to do so results in benefits
payable at the non-network retail pharmacy benefit level
( which includes a
deductible) , and you will need to file a claim for reimbursement.
Non-network retail pharmacy You may obtain up to a 30-day supply and
unlimited refills for each
prescription. You will need to file a claim for
reimbursement.
Mail order You may order up to a 60-day or 90-day ( 21-day minimum) supply of
medication for each
prescription or refill. No deductible applies. You
cannot obtain a refill until 75% of the drug has been
used. Medications
dispensed through the mail order program are subject to the following standards:
the
professional judgment of the pharmacist, limitations imposed on
controlled substances, manufacturer s
recommendations, and applicable state
law.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally-approved generic drug is available, and
your physician has not specified Dispense as Written for the name brand drug,
you have to pay the
difference in cost between the name brand drug and the
generic.
Why use generic drugs? Generic drugs offer a safe and economic way to meet
your prescription drug needs. The generic name of a drug is its chemical name;
the name brand is the name under which the
manufacturer advertises and sells a drug. Under federal law, generic and name
brand drugs must meet
the same standards for safety, purity, strength, and
effectiveness. A generic prescription costs you and
us less than a name
brand prescription.
Benefit Description begins on next page.
Section 5( f) . Prescription drug benefits
Section 5( f) 34
34 Page 35 36
35 2002 NALC
Health Benefit Plan
Benefit Description
You pay
After the calendar year deductible
NOTE: The calendar year drug deductible applies to almost all benefits in
this Section. We say ( No deductible)
when it does not apply.
Covered medications and supplies
Each new enrollee receives a
description of our prescription drug
program, a combined prescription drug/
Plan identification card, a mail
order form/ patient profile and a
preaddressed reply envelope. You
may purchase the following medications and
supplies from a
pharmacy or by mail:
Drugs and medicines ( including those administered during a
non-covered
admission or in a non-covered facility) that by
Federal law of the United States require a physician s prescrip-
tion for
their purchase, except as shown in Not covered
Insulin
Needles and syringes for the administration of covered
medica-
tions
Contraceptive drugs and devices
Drugs for sexual dysfunction ( only when
the dysfunction is
caused by medically documented organic disease and prior
authorization has been given)
Retail:
Network retail: 25% of cost ( No deductible)
Network retail Medicare: 15% of cost ( No deductible)
Non-network retail:
40% of the Plan allowance, and the difference,
if any, between our allowance
and
the billed amount
Non-network retail Medicare: 40% of the Plan allowance, and the
difference, if any, between our
allowance and the billed amount
( No
deductible)
Mail order:
60-day supply: $ 8 generic/ $ 17 name brand ( No deductible)
90-day supply: $ 12 generic/ $ 25 name brand ( No deductible)
Mail order Medicare:
60-day supply: $ 5 generic/ $ 13 name brand ( No
deductible)
90-day supply: $ 7.50 generic/ $ 19.50 name brand ( No deductible)
Note: If there is no generic equivalent
available, you will have to pay
the name
brand copay.
All Charges
Section 5( f)
When you have to file a claim. If you purchase prescriptions at a
non-network pharmacy, or are unable to use your card
at an NALC CareSelect
Network pharmacy, complete the short-term prescription claim form. Mail it with
your prescrip-
tion receipts to the NALC Prescription Drug Program. Receipts
must include the prescription number, name of drug,
prescribing doctor s
name, date, charge, and name of drugstore.
When you have other prescription drug coverage, and the other carrier is
primary, use that carrier s drug benefit first.
After the primary carrier
has processed the claim, complete the short-term claim form, attach the drug
receipts and other
carrier s payment explanation and mail to the NALC
Prescription Drug Program.
NALC Prescription Drug Program
P. O. Box 686005
San Antonio, TX
78268-6005
Note: If you have questions about the Program, wish to locate an NALC
CareSelect Network retail pharmacy, or need
additional claim forms, call
1-800-933-NALC ( 6252) ( 7: 00 a. m. 9: : 00 p. m. , Monday through Friday; 8:
00 a. m. -12: 00
noon, Saturday, Central time) .
Not covered:
Drugs and supplies when prescribed for cosmetic
purposes
Vitamins, nutrients and food supplements, even when a
physi-
cian prescribes or administers them
Over-the-counter medicines and supplies 35
35 Page 36 37
36 2002 NALC Health Benefit Plan
Section
5( g) . Special features
Flexible benefits option Under the flexible
benefits option, we determine the most effective
way to provide services.
We may identify medically appropriate alternatives to traditional
care
and coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will
get it in the future.
The decision to offer an alternative benefit is solely ours, and we
may
withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject
to
OPM review under the disputed claims process.
24-hour nurse line You may call a registered nurse at 1-800-622-NALC (
6252) 24 hours a
day, 7 days a week, to discuss your health concerns and
treatment options.
24-hour help line for You may call 1-877-468-1016, 24 hours a day, 7
days a week, to access
mental health and in-person support for a wide
range of concerns, including depression,
substance abuse eating
disorders, coping with grief and loss, alcohol or drug depen-
dency, physical
abuse and managing stress.
Services for deaf and TDD lines are available for the following:
hearing impaired CAREMARK : 1-800-238-1217
( prescription benefit information)
First Health : 1-800-259-8179
( PPO locator, 24-hour nurse line, medical inpatient hospital
precer-
tification, National Transplant Program)
United Behavioral Health : 1-800-842-2479
( mental health and
substance abuse information)
Centers of excellence for The Plan participates in the First Health
National Transplant
transplants/ heart surgery Program that
includes more than 25 centers of excellence.
Call 1-800-622-6252 for
information.
Disease management These programs offer a considerable amount of
personalized attention
programs from clinicians and program
educators. Nurse educators are available
to discuss lifestyle changes,
therapeutic outcomes, and other health
related matters to assist patients in
dealing with their experiences.
Support is available for patients with
multiple sclerosis, growth
hormone deficiency, hemophilia, hepatitis,
diabetes, and other diseases.
You may be contacted about one of these
programs.
Discounts for durable We have arranged with a health care provider to
rent or sell durable
medical equipment ( DME) medical equipment at
discounted rates. Call us at 1-800-433-NALC
( 6252) .
Worldwide coverage We cover the medical care you receive outside the
United States,
subject to the terms and conditions of this brochure. See
Section 7.
Overseas claims .
Special features Description
Section 5( g) 36
36 Page 37 38
37 2002 NALC
Health Benefit Plan
Section 5( h) . Dental benefits
We have
no dental benefit.
Section 5( h) 37
37 Page 38 39
38 2002 NALC
Health Benefit Plan
Section 5( i) . Non-FEHB benefits available to
Plan members
The benefits described on this page are not part of the FEHB
contract or premium, and you
cannot file a FEHB disputed claim about them.
Fees you pay for these services do not count toward
FEHB plan
deductibles or out-of-pocket maximums.
The following non-FEHB Program benefit is available only to letter
carriers who are members in
good standing with the National Association of
Letter Carriers, their spouses, children and
retired NALC members.
Hospital Plus ( hospital indemnity)
Hospital Plus is a hospital
indemnity policy available for purchase from the United States Letter
Carriers Mutual Benefit Association.
Hospital Plus means money in your pocket when you are hospitalized, from the
first day of your
stay up to one full year. These benefits are not subject
to federal income tax.
Hospital Plus allows you to choose the amount of coverage you need. You may
elect to receive a
$ 75 a day, $ 50 a day or $ 30 a day plan. Members can
insure their spouses and eligible children
also. The spousal coverage is the
same as the member s. Children s coverages are limited to
either $ 45 a day,
$ 30 a day or $ 18 a day plans. Benefits will be based on the number of days in
the hospital, up to 365 days or as much as $ 27,375 ( if a $ 75 a day
benefit is chosen) .
Use your benefits to pay for travel to and from the hospital, childcare,
medical costs not covered
by health insurance, legal fees, or other costs.
This plan is available to all qualified members regardless of their age.
Hospital Plus is renewable
for life and you may keep your policy for as long
as you like, regardless of benefits you have
received or future health
conditions.
For more information, please call the United States Letter Carriers Mutual
Benefit Association at
202/ 638-4318 Monday through Friday or 1-800-424-5184
Tuesdays and Thursdays, 8: 00 a. m. -
3: 30 p. m. Eastern time.
Benefits on this page are not part of the FEHB contract.
Section 5( i) 38
38 Page 39 40
39 2002 NALC
Health Benefit Plan
Section 6. General exclusions things we don t
cover
The exclusions in this section apply to all benefits. Although
we may list a specific service as a benefit, we will not
cover it unless we
determine it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury,
or condition.
We do not cover the following:
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice
in the United States;
Experimental or investigational procedures, treatments, drugs, or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus
were carried to term, or when
the pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations, sexual
inadequacy, or sexual dysfunction ( except with
prior authorization) ;
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program;
Charges that would not be made if a covered
individual had no health insurance;
Services furnished without charge (
except as described in Section 9. Coordinating benefits with other coverage
) ,
while on active military service; or required for illness or injury
sustained on or after the effective date of enroll-
ment ( 1) as a result of an act of war within the United States, its
territories, or possessions or ( 2) during combat;
Services furnished by a household member or immediate relative such as
spouse, parent, child, brother or sister by
blood, marriage, or adoption;
Charges billed by a noncovered facility or provider, except medically
necessary prescription drugs;
Charges for which you or the Plan have no
legal obligation to pay, such as state premium taxes or surcharges;
Charges
for interest, completion of claim forms, missed or canceled appointments, and/
or administrative fees;
Nonmedical social services or recreational therapy;
Testing for mental aptitude or scholastic ability;
Therapy, other than
speech therapy, for developmental delays and learning disabilities;
Transportation ( other than professional ambulance services or travel under
the National Transplant Program) ;
Dental services and supplies ( except
those oral surgical procedures listed in Section 5 ( b) . Oral and
maxillofacial
surgery ) ;
Services for and/ or related to procedures not listed as covered;
Charges
in excess of the Plan allowance; or
Treatment for cosmetic purposes and/ or
related expenses.
40 2002 NALC Health Benefit Plan
Section 7. Filing a claim for
covered services
How to claim benefits To obtain claim forms, claims
filing advice, or answers about our benefits,
contact us at 703/ 729-4677 or
1-888-636-NALC ( 6252) or at our website at
www. nalc. org/ depart/ hbp.
In most cases, providers and facilities file claims for you. Your physician
must file
on the form HCFA-1500, Health Insurance Claim Form. Your facility
will file on
the UB-92 form. For claims questions and assistance, call us at
703/ 729-4677 or
1-888-636-NALC ( 6252) .
When you must file a claim such as for overseas claims, when another group
health plan is primary, or you are seeing an Out-of-Network provider submit
it on
the HCFA-1500 or a claim form that includes the information shown
below. Bills
and receipts must be itemized and show:
Patient s name and relationship to enrollee; Member # as shown on your
identification card;
Name, address and tax identification number of person or facility providing
the service or supply;
Signature of physician or supplier including degrees
or credentials of individual providing the service;
Dates that services or
supplies were furnished; Diagnosis ( ICD-9 Code) ;
Type of each service or
supply ( CPT/ HCPCS Code) ; and Charge for each service or supply.
Note: Canceled checks, cash register receipts, or balance due statements are
not
acceptable substitutes for itemized bills.
In addition:
You must send a copy of the explanation of benefits from any primary payer (
such as the Medicare Summary Notice ( MSN) ) with your claim.
Bills for home health services must show that the nurse is a registered nurse
( R. N. ) , licensed practical nurse ( L. P. N. ) , or licensed vocational nurse
( L. V. N. ) .
Claims for rental or purchase of durable medical equipment;
private nursing care; and physical, occupational, and speech therapy require a
written statement from
the physician specifying the medical necessity for
the service or supply and the
length of time needed.
Claims for prescription drugs and supplies purchased without your card or
those that are not purchased through a CareSelect Network pharmacy or the Mail
Service Prescription Drug Program must include receipts that show the
prescrip-
tion number, name of drug or supply, prescribing physician s name,
date, charge,
and name of drugstore.
Records Keep a separate record of the medical expenses of each covered
family member as
deductibles and maximum allowances apply separately to each
person. Save copies
of all medical bills, including those you accumulate to
satisfy a deductible. In most
instances they will serve as evidence of your
claim. We will not provide duplicate
or year-end statements.
Deadline for filing Send us all of the documents for your claim as
soon as possible. You must submit
your claim the claim within two
years from the date the expense was incurred, unless timely filing was prevented
by administrative operations of Government or legal incapac-
ity, provided the claim was submitted as soon as reasonably possible. Once we
pay
benefits, there is a three-year limitation on the reissuance of uncashed
checks.
Overseas claims Claims for overseas ( foreign) services must include
an English translation. Charges
must be converted to U. S. dollars using the
exchange rate applicable at the time the
expense was incurred.
When we need more Please reply promptly when we ask for additional
information. We may
information delay processing or deny your claim
if you do not respond.
The Plan, its medical staff and/ or an independent medical review determines
whether services, supplies and charges meet the coverage requirements of the
Plan
( subject to the disputed claims procedure described in Section 8.
The disputed
claims process ) . We are entitled to obtain medical or
other information including
an independent medical examination that we feel
is necessary to determine
whether a service or supply is covered.
Section 7 40
40 Page
41 42
41 2002 NALC Health Benefit Plan
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on
your claim or request for services, drugs, or supplies
including a request for preauthorization/ prior approval:
Step Description
Ask us in writing to reconsider our initial decision. You must:
Write to
us within 6 months from the date of our decision;
Send your request to us
at: NALC Health Benefit Plan, 20547 Waverly Court, Ashburn, VA 20149-0001;
Include a statement about why you believe our initial decision was wrong,
based on specific benefit provi-
sions in this brochure; and
Include copies of documents that support your claim, such as physicians
letters, , operative reports, bills,
medical records, and explanation of
benefits forms.
We have 30 days from the date we receive your request to:
Pay the claim (
or, if applicable, arrange for the health care provider to give you the care) ;
Write to you and maintain our denial go to step 4; or
Ask you or your
provider for more information. If we ask your provider, we will send you a copy
of our
request go to step 3.
You or your provider must send the information so that we receive it within
60 days of our request. We will
then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the information
was due. We will base our decision on the
information we already have.
We will write to you with our decision.
If you do not agree with our decision, you may ask OPM to review it.
You
must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us if we did not answer that request in
some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 2, 1900
E Street, NW, Washington, DC
20415-3620.
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific
benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians letters, ,
operative reports, bills, medical
records, and explanation of benefits
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which
claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the review
request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
Section 8
continues on next page
2
1
3
4 41
41 Page
42 43
42 2002 NALC Health Benefit Plan
OPM will review your disputed claim request and will use the information
it collects from you and us to decide
whether our decision is correct. OPM
will send you a final decision within 60 days. There are no other
administrative appeals.
If you do not agree with OPM s decision, your only recourse is to sue. If you
decide to sue, you must file the
suit against OPM in Federal court by
December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were
denied precertification or prior
approval. This is the only deadline that
may not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to uphold or overturn our decision. You may recover
only the amount of benefits in
dispute.
NOTE: If you have a serious or life threatening condition ( one that
may cause permanent loss of bodily functions
or death if not treated as soon
as possible) , and
a) We haven t responded to your initial request for care or preauthorization/
prior approval, then call us at
703/ 729-4677 or 1-888-636-NALC ( 6252) and
we will expedite our review; or
b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they too can expedite your
request, or
You can call OPM s Health Benefits Contracts Division 2 at 202/ 606-3818
between 8 a. m. and 5 p. m.
Eastern time.
Section 8
5
6 42
42 Page
43 44
43 2002 NALC Health Benefit Plan
Section 9. Coordinating benefits with other coverage
When you
have You must tell us if you are covered or a family member is covered under
another group
other health health plan or have automobile insurance
that pays health care expenses without regard to
coverage fault. This
is called double coverage.
When you have double coverage, one plan normally
pays its benefits in full as the primary
payer and the other plan pays a
reduced benefit as the secondary payer. Like other insurers, we
determine
which coverage is primary according to the National Association of Insurance
Commissioners guidelines. .
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we usually pay what is left after
the primary plan pays,
up to our regular benefit. We will not pay more than
our allowance.
What is Medicare is a health insurance program for:
Medicare?
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with end-stage renal disease ( permanent kidney
failure requiring dialysis or a transplant) .
Medicare has two parts:
Part A ( Hospital Insurance) . Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able
to qualify for premium-free Part A insurance. Otherwise, if you are age 65 or
older, you
may be able to buy it. Contact 1-800-MEDICARE ( 1-800-633-4227)
for more information.
Part B ( Medical Insurance) . Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care.
Medicare+ Choice is the term used to describe the various
health plan choices available to
Medicare beneficiaries. The information in
the next few pages shows how we coordinate
benefits with Medicare, depending
on the type of Medicare+ Choice plan you have.
The Original The Original Medicare Plan ( Original Medicare) is
available everywhere in the United States. Medicare Plan It is the way
everyone used to get Medicare benefits and is the way most people get their
( Part A or Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital that
Part B) accepts Medicare. The
Original Medicare Plan pays its share and you pay your share. Some
things
are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow
the rules in this brochure for us to cover your care.
Claims process: If Medicare is primary, you probably will never have
to file a claim form
when you have both our Plan and the Original Medicare
Plan.
When we are the primary payer, we process the claim first. When Original
Medicare is the primary payer, Medicare processes your claim first. In
most cases, your claims will be coordinated automatically and we will pay the
balance of
covered charges. You will not need to do anything. To find out if
you need to do
something about filing your claims, call us at 703/ 729-4677
or 1-888-636-NALC ( 6252) .
We waive some costs when you have the Original Medicare Plan: When
Original Medicare
is the primary payer, we waive most copayments,
coinsurance, and deductibles as follows:
If you have Medicare Part A as primary payer, we waive: The copayment for a
hospital admission
The coinsurance for a hospital admission
The deductible for inpatient
care in a treatment facility
If you have Medicare Part B as primary payer, we waive: The PPO copayments
for office or outpatient visits
The PPO copayments for preventive care
The PPO copayments for allergy
care
The coinsurance for services billed by physicians, other health care
professionals, and
facilities
All calendar year deductibles
Note: If you have Medicare Part B as primary payer, we will not waive the
copayments for mail
order drugs, or the coinsurance for retail prescription
drugs.
Section 9 43
43 Page
44 45
44 2002 NALC Health Benefit Plan
The following chart illustrates whether Original Medicare or this Plan
should be the primary payer for you according to
your employment status and
other factors determined by Medicare. It is critical that you tell us if you or
a covered family
member has Medicare coverage so we can administer these
requirements correctly.
Primary Payer Chart
A. When either you or your covered spouse are age 65 or older and
Then
the primary payer is
Original
Medicare
This Plan
( for Part B
services)
( for other
services)
( except for claims
related to Workers
Compensation. )
1) Are an active employee with the Federal government ( including when you or
a family member are eligible for Medicare solely because of a disability) ,
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
b) The
position is not excluded from FEHB
( Ask your employing office which of
these applies to you. )
4) Are a Federal judge who retired under Title 28, U. S. C. , or a Tax Court
judge who retired under Section 7447 of Title 26, U. S. C. ( or if your
covered spouse is this type of judge) ,
5) Are enrolled in Part B only, regardless of your employment status,
6) Are a former Federal employee receiving Workers Compensation and the
Office of Workers Compensation Programs has determined that you are
unable to return to duty,
B. When you or a covered family member have Medicare based on
end
stage renal disease ( ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
C. When you or a covered family member have FEHB and
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant
b) Are an active employee
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
45 2002 NALC Health Benefit Plan
Medicare managed care plan
If you are eligible for Medicare, you may choose to enroll in and get your
Medicare benefits from another type of Medicare+ Choice plan a Medicare
managed care plan. These are health care choices ( like HMOs) in some
areas of the country. In most Medicare managed care plans, you can only
go to doctors, specialists, or hospitals that are part of the plan. Medicare
managed care plans provide all the benefits that Original Medicare covers.
Some cover extras, like prescription drugs. To learn more about enrolling
in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE
(
1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan s Medicare managed care plan: You may enroll
in another plan s Medicare managed care plan and also remain enrolled in
our FEHB plan. We will still provide benefits when your Medicare
man-
aged care plan is primary, even out of the managed care plan s network
and/
or service area. We waive coinsurance, deductibles, and most copayments
when you use a participating provider with your Medicare managed care
plan. If you receive services from providers that do not participate in your
Medicare managed care plan, we do not waive any coinsurance,
copayments,
or deductibles. If you enroll in a Medicare managed care plan,
tell us. We
will need to know whether you are in the Original Medicare
Plan or in a
Medicare managed care plan so we can correctly coordinate
benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you
are an annuitant or former spouse, you can suspend your FEHB
coverage to
enroll in a Medicare managed care plan, eliminating your
FEHB premium. ( OPM
does not contribute to your Medicare managed care
plan premium. ) For
information on suspending your FEHB enrollment,
contact your retirement
office. If you later want to re-enroll in the FEHB
Program, generally you
may do so only at the next Open Season unless you
involuntarily lose
coverage or move out of the Medicare managed care
plan s service area.
Private contract A physician may ask you to sign a private contract
agreeing that you can be with your physician billed directly for service
ordinarily covered by Original Medicare. Should
you sign an agreement, Medicare will not pay any portion of the charges, and
we will not increase our payment. We will still limit our payment to the
amount we would have paid after Original Medicare s payment.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered Medicare Part A or under the FEHB
Program. We will not require you to enroll in Medicare
Part B Part B and, if you can t get premium-free Part A, we will not
ask you to
enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military
persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage.
Workers Compensation We do not cover services that:
You need because of a workplace-related illness or injury that the Office of
Workers Compensation Programs ( ( OWCP) or a similar Federal or
State agency determines they must provide; or
OWCP or a similar agency
pays for through a third party injury settle-ment or other similar proceeding
that is based on a claim you filed under
OWCP or similar laws.
If OWCP or a similar agency disallows benefits for
your treatment, we will
pay the benefits described in this brochure.
Section 9 45
45 Page
46 47
46 2002 NALC Health Benefit Plan
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible Subrogation/ Reimbursement guidelines: The
Plan has a right
for injuries to recover payments made to you by a
third party or third party s insurer
when the third party caused your
illness or injury. Third party means
another person or organization. Our
right to reimbursement is limited to the
amount we have paid or will pay
because of the illness or injury.
You must notify us promptly if you are seeking a recovery from a third party
because of the act or omission of another person. Further, you must notify
us of any recovery you receive, whether in or out of court, and you must
reimburse us to the extent the Plan paid benefits.
We will pay benefits for your illness or injury provided you do not interfere
with our attempts to recover the amounts we have paid in benefits, and that
you assist us in obtaining a recovery. If we have paid benefits and you
recover money from the third party, you must reimburse us for the benefits
we paid. If you do not seek damages from the third party, you must agree to
let us seek damages. We may require you to assign the proceeds of your
claim or the right to take action against the third party, and we may
withhold
payment until the assignment is provided.
All payments from the third party must be used to reimburse the Plan for
benefits paid. Our share of the recovery is not reduced because you do not
receive the full amount of damages claimed, unless we agree in writing to a
reduction. Any reduction of our claim for payment of attorney s fees or
costs related to the claim is subject to prior approval by the Plan.
Section 9 46
46 Page
47 48
47 2002 NALC Health Benefit Plan
Section 10. Definitions of terms we use in this brochure
Admission The period from entry ( admission) into a hospital or other
covered facility until dis-
charge. In counting days of inpatient care, the
date of entry and the date of discharge are
counted as a single day.
Assignment Your authorization for us to issue payment of benefits
directly to the provider. We
reserve the right to pay you directly for all
covered services.
Calendar year January 1 through December 31 of the same year. For new
enrollees, the calendar year
begins on the effective date of their
enrollment and ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See
Section 4. Your costs for covered services.
Congenital anomaly A condition that existed at or from birth and is a
significant deviation from the common
form or norm. For purposes of this
Plan, congenital anomalies include protruding ear
deformities, cleft lips,
cleft palates, birthmarks, webbed fingers or toes, and other
conditions that
the Plan may determine to be congenital anomalies. In no event will the
term
congenital anomaly include conditions relating to teeth or intra-oral structure
supporting the teeth.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services.
See Section 4. Your costs for covered services.
Cosmetic surgery Any operative procedure or any portion of a procedure
performed primarily to improve
physical appearance and/ or treat a mental
condition through change in bodily form.
Covered services Services we provide benefits for, as described in
this brochure.
Custodial care Treatment or services that help the
patient with daily living activities, or can safely and
reasonably be
provided by a person that is not medically skilled, regardless of who
recommends them or where they are provided. Custodial care includes such
services as:
Caring for personal needs, such as helping the patient bathe, dress, or eat;
Homemaking, such as preparing meals or planning special diets;
Moving the patient, or helping the patient walk, get in and out of bed, or
exercise; Acting as a companion or sitter;
Supervising self-administered
medication; or Performing services that require minimal instruction, such as
recording temperature,
pulse, and respirations; or administration and
monitoring of feeding systems.
The Plan determines whether services are
custodial care.
Deductible A deductible is a fixed amount of covered
expenses you must incur for certain covered
services and supplies before we
start paying benefits for those services. See Section
4. Your costs for
covered services.
Effective date The effective date of benefits described in this
brochure is:
January 1 for continuing enrollments and for all annuitant enrollments; The
first day of the first full pay period of the new year for enrollees who change
plans or options or elect FEHB coverage during the Open Season; or
Determined by the employing office or retirement system for enrollments and
changes that are not Open Season actions.
Experimental or A drug, device, or biological product that cannot
lawfully be marketed without approval
investigational services of the
U. S. Food and Drug Administration ( FDA) and that approval has not been given
at
the time the drug, device, or biological product is furnished. Approval
means all
forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological product is
considered
experimental or investigational if reliable evidence shows that:
It is the subject of ongoing phase I, II, or III clinical trials or under
study to determine its maximum tolerated dose, its toxicity, safety,
effectiveness, or
effectiveness as compared with the standard means of treatment or diagnosis;
or
The consensus of opinion among experts is that further studies or
clinical trials are necessary to determine its toxicity, safety, effectiveness,
or effectiveness as
compared with the standard means of treatment or diagnosis.
Our Medical
Director reviews current medical resources to determine whether a service or
supply is experimental or investigational. We will seek an independent
expert opinion if
necessary.
Section 10 47
47 Page
48 49
48 2002 NALC Health Benefit Plan
Group health coverage Coverage through employment ( including
benefits through COBRA) or membership in
an organization that provides
payment for hospital, medical, or other health care services
or supplies, or
that pays more than $ 200 per day for each day of hospitalization.
Medical necessity Services, drugs, supplies, or equipment provided by
a hospital or covered provider of the
health care services that we
determine:
Are appropriate to diagnose or treat your condition, illness, or injury;
Are consistent with standards of good medical practice in the United States;
Are not primarily for the personal comfort or convenience of you, your
family, or your provider;
Are not related to your scholastic education or vocational training; and
In the case of inpatient care, cannot be provided safely on an outpatient
basis.
The fact that a covered provider has prescribed, recommended, or approved a
service,
supply, drug, or equipment does not, in itself, make it medically
necessary.
Mental health and Conditions and diseases listed in the most recent
edition of the International Classification
substance abuse of
Diseases ( ICD) as psychoses, neurotic disorders, or personality disorders;
other
nonpsychotic mental disorders listed in the ICD, to be determined by
the Plan; or
disorders listed in the ICD requiring treatment for abuse of or
dependence upon sub-
stances such as alcohol, narcotics, or hallucinogens.
Plan allowance Our Plan allowance is the amount we use to determine
our payment and your coinsurance
for covered services. Fee-for-service plans
determine their allowances in different ways.
PPO benefits:
For services rendered by a covered provider who
participates in the Plan s PPO
network, our allowance is based on a
negotiated rate agreed to under the providers
network agreement. These
providers accept the Plan allowance as their charge.
In-Network mental health and substance abuse benefits:
For services
rendered by a covered provider who participates in the Plan s mental health
and substance abuse network, our allowance is based on a negotiated rate
agreed to
under the providers network agreement. These providers accept the
Plan allowance as
their charge.
Non-PPO benefits:
When you do not use a PPO provider, we may use one of
the following methods:
In geographic areas where you have adequate access to a PPO provider, but do
not use one, our allowance is based on the average PPO negotiated rate for that
region;
If you do not have adequate access to a PPO provider, our allowance
is based on the 80 th percentile of data gathered by Ingenix, Inc. , including
both the Prevailing
Healthcare Charges System for surgeries and Medical Data
Research for physician
and other professional services; or
For medication charges, our allowance is based on the average wholesale price
from data prepared by Drug Topics: Red Book.
Out-of-Network mental health and substance abuse benefits:
Our allowance
is based on the 80 th percentile of data gathered by Ingenix, Inc. , for
physician and other professional services when you:
Do not preauthorize your treatment;
Do not follow the authorized
treatment plan; or
Do not use an In-Network provider.
Note: For other categories of benefits and for certain specific services
within each of the
above categories, exceptions to the usual method of
determining the Plan allowance may
exist. At times, we may seek an
independent expert opinion to determine our Plan allowance.
For more information, see Section 4. Differences between our allowance and
the bill .
Preadmission testing Routine tests ordered by a
physician and usually required prior to surgery or hospital
inpatient
admission that are not diagnostic in nature.
Us/ We Us and we refer to the NALC Health Benefit Plan.
You
You refers to the enrollee and each covered family member.
49 2002 NALC Health Benefit Plan
Section 11. FEHB facts
Coverage information
No pre-existing We will not refuse to
cover the treatment of a condition that you had before you
condition
limitation enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get See www. opm.
gov/ insure. Also, your employing or retirement office can
information about answer your questions and give you a Guide to
Federal Employees Health
enrolling in the Benefit Plans, brochures for other plans, and
other materials you need to
FEHB Program make an informed decision
about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave
without pay, enter military service, or retire;
When your enrollment ends; and
When the next Open Season for enrollment
begins.
We don t determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.
Types of coverage Self Only coverage is for you alone. Self and Family
coverage is for you,
available for you and your spouse, and your
unmarried dependent children under age 22, including
your family any foster children or stepchildren for whom coverage is
authorized. Under
certain circumstances, you may continue coverage for a
disabled/ incapable
of self-support child age 22 or older.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. When
you change to Self and Family because of the addition of a child, the Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to
Self and Family because you marry, the change is effective on the first day
of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell
us immediately when you add or remove family members from your coverage
for any reason, including divorce, or when your child under age 22 marries.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.
When benefits and The benefits in this brochure are effective on
January 1. If you joined this premiums start Plan during Open Season,
your coverage begins on the first day of your first pay
period that starts on or after January 1. Annuitants coverage and premiums
begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage.
Your medical and We keep your medical and claims information
confidential. Only claims records are the following will have access to
it:
confidential
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as other insurance plans
and
the Office of Workers Compensation Programs ( ( OWCP) , when coordi-
nating benefit payments and subrogating claims;
50 2002 NALC Health Benefit Plan
Law enforcement officials
when investigating and/ or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education when
your identity is not disclosed;
OPM, when reviewing a disputed claim or defending litigation about a
claim; or
Treating physicians or dispensing pharmacies, as part of
the Plan s administration of the prescription drug program.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for
other forms of coverage, such as Temporary Continuation
of Coverage ( TCC) .
When you lose benefits
When FEHB coverage ends You receive an additional 31 days of coverage,
for no additional premium, when:
Your enrollment ends, unless you
cancel your enrollment, or
You are a family member no longer eligible
for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not continue coverage to get benefits under your
former spouse s enrollment. But, you may be
eligible for your own FEHB coverage under the spouse equity law. If you
are recently divorced or are anticipating a divorce, contact your ex-spouse
s
employing or retirement office to get RI 70-5, the Guide to Federal
Employ-
ees Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees , or other information about your coverage
choices.
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no longer of Coverage ( TCC) qualify as a family
member, you may be eligible for Temporary Continuation
of Coverage ( TCC) . For example, you can receive TCC if you are not able
to continue your FEHB enrollment after you retire, if you lose your Federal
job, if you are a covered dependent child that turns 22 or marries, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5,
the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees , from your
employ-
ing or retirement office or from www. opm. gov/ insure.
If you leave Federal service your employing office will notify you of your
right to enroll under TCC. You must enroll within 60 days of leaving, or
receiving this notice, whichever is later.
Children: You must notify your employing or retirement office within 60
days after your child is no longer an eligible family member. That office
will send you information about enrolling in TCC. You must enroll your
child within 60 days after he or she becomes eligible for TCC, or receives
this notice, whichever is later.
Former spouses: You or your former spouse must notify your employing or
retirement office within 60 days of one of these qualifying events:
Divorce
Loss of spouse equity coverage within 36 months
after the divorce
Your employing or retirement office will then send your former spouse
information about enrolling in TCC. Your former spouse must enroll within
60 days after the event, that qualifies them for coverage, or receiving the
information, whichever is later.
Section 11
continues on next page 50
50
Page 51 52
51 2002 NALC Health Benefit Plan
Note: Your child or former spouse
loses TCC eligibility unless you or your
former spouse notifies your
employing or retirement office within the 60-day
deadline.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under Temporary Continuation of
Coverage ( TCC) or the
spouse equity law ends ( If you canceled your coverage or did not pay
your premium, you cannot convert) ;
You decided not to receive coverage under TCC or the spouse equity
law; or
You are not eligible for coverage under TCC or the spouse
equity law.
If you leave Federal service, your employing office will notify you of your
right
to convert. You must apply in writing to us within 31 days after you
receive
this notice. However, if you are a family member who is losing
coverage,
the employing or retirement office will not notify you. You
must apply in
writing to us within 31 days after you are no longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 ( HIPAA)
Group Health Plan Coverage is a
Federal law that offers limited Federal protection for health coverage
availability and continuity to people who lose employer group coverage. If
you leave the FEHB Program, we will give you a Certificate of Group
Health Plan Coverage that indicates how long you have been enrolled with
us. You can use this certificate when getting health insurance or other
health
care coverage. Your new plan must reduce or eliminate waiting
periods,
limitations, or exclusions for health-related conditions based on
the infor-
mation in the certificate, as long as you enroll within 63 days of
losing
coverage under this Plan. If you have been enrolled with us for less
than 12
months, but were previously enrolled in other FEHB plans, you may
also
request a certificate from those plans.
Get OPM pamphlet RI 79-27, Temporary Continuation of Coverage ( TCC)
under the FEHB Program. See also the FEHB web site ( www.
opm. gov/
insure/ health) : refer to the TCC and
HIPAA frequently asked questions. .
These highlight HIPAA rules, such as the
requirement that Federal employ-
ees must exhaust any TCC eligibility as one
condition for guaranteed access
to individual health coverage under HIPAA,
and have information about
Federal and State agencies you can contact for
more information.
52 2002 NALC Health Benefit Plan Long Term Care Insurance
Long
Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think
that their health plan and/ or Medicare will cover their long-term care needs.
Unfortunately, they are WRONG !
How are YOU planning to pay for the future custodial or chronic care you may
need?
You should consider buying long-term care insurance.
The Office of Personnel Management ( OPM) will sponsor a high-quality long
term care insurance program
effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is long term care It s insurance to help pay for long term care
services you may need if you
( LTC) insurance? can t take care of
yourself because of an extended illness or injury, or an age-
related disease
such as Alzheimer s.
LTC insurance can provide broad, flexible benefits for nursing home care,
care in an assisted living facility, care in your home, adult day care,
hospice
care, and more. Long term care insurance can supplement care provided by
family members, reducing the burden you place on them.
I m healthy. I won t need Welcome to the club!
long term care.
Or, will I? 76% of Americans believe they will never need long term care,
but the facts
are that about half of them will. And it s not just the
elderly. About 40% of
people needing long term care are under age 65. They
may need chronic care
due to a serious accident, a stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be
vital
to their financial and retirement planning.
Is long term care expensive? Yes, it can be very expensive. A year in
a nursing home can exceed $ 50,000.
Home care for only three 8-hour shifts a
week can exceed $ 20,000 a year.
And that s before inflation!
Long term care can easily exhaust your savings. Long term care insurance
can protect your savings.
But won t my FEHB plan, Not FEHB. Look at the Not covered
blocks in sections 5( ( a) and 5( c) of
Medicare or Medicaid cover
your FEHB brochure. Health plans don t cover custodial care or a stay in an
my long term care? assisted living facility or a continuing need for
a home health aide to help you
get in and out of bed and with other
activities of daily living. Limited stays
in skilled nursing facilities can
be covered in some circumstances.
Medicare only covers skilled nursing home care ( the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or
fully
disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state s poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and
preserve
your independence.
When will I get more information Employees will get more information
from their agencies during the LTC
on how to apply for this new open
enrollment period in the late summer/ early fall of 2002.
insurance
coverage? Retirees will receive information at home.
How can I find out more about Our toll-free teleservice center will
begin in mid-2002. In the meantime, you can
the program NOW? learn
more about the program on our web site at www. opm. gov/ insure/ ltc. 52
52 Page 53 54
53 2002 NALC Health Benefit Plan
Department of Defense/
FEHB Demonstration Project
What is it? The Department of Defense ( DoD)
/ FEHB Demonstration Project allows some active and
retired uniformed
service members and their dependents to enroll in the FEHB Program.
The
demonstration will last for three years and began with the 1999 Open Season for
the
year 2000. Open Season enrollments will be effective January 1. DoD and
OPM have set
up some special procedures to implement the Demonstration
Project, noted below. Other-
wise, the provisions described in this brochure
apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible
for Medicare;
You are a dependent of an active or retired uniformed
service member and are eligible for Medicare;
You are a qualified former spouse of an active or retired uniformed
service member and you have not remarried; or
You are a survivor
dependent of a deceased active or retired uniformed service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits
Program, you are not eligible to enroll under the DoD/ FEHB
Demonstration Project.
The demonstration Dover AFB, DE Commonwealth of Puerto Rico
areas Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt County, CA area
New Orleans, LA
Naval Hospital, Camp Pendleton, CA
Adair County, IA area
Coffee County, GA area
When you can join You may enroll under the DoD/ FEHB Demonstration
Project during the 2001 Open Season,
November 12, 2001, through December 10,
2001. Your coverage will begin January 1,
2002. DoD has set-up an
Information Processing Center ( IPC) in Iowa to provide you with
information
about how to enroll. IPC staff will verify your eligibility and provide you with
FEHB Program information, plan brochures, enrollment instructions, and
forms. The toll-
free phone number for the IPC is 1-877-DOD-FEHB (
1-877-363-3342) .
You may select coverage for yourself ( Self Only) or for you and your family
( Self and
Family) during open season. Your coverage will begin January 1,
2002. If you become
eligible for the DoD/ FEHB Demonstration Project outside
of open season, contact the IPC
to find out how to enroll and when your
coverage will begin.
DoD has a web site devoted to the Demonstration Project. You can view
information such
as their Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration
area locations and zip code lists at www. tricare. osd. mil/ fehbp. You can also view
informa-
tion about the demonstration project, including The 2002 Guide
to Federal Employees
Health Benefits Plans Participating in the DoD/
FEHB Demonstration Project, on the OPM
web site at www. opm. gov.
Temporary See Section 11. FEHB Facts ; it explains Temporary
Continuation of Coverage ( TCC) .
Continuation of Under this DoD/
FEHB Demonstration Project the only individual eligible for TCC is one
Coverage who ceases to be eligible as a member of family under your
Self and Family enrollment. .
( TCC) eligibility This occurs when a
child turns 22, for example, or if you divorce and your spouse does not qualify
to enroll as an unremarried former spouse under Title 10, United States Code.
For
these individuals, TCC begins the day after their enrollment in the DoD/ FEHB
Demonstration
Project ends. TCC enrollment terminates after 36 months or the
end of the Demonstration
Project, whichever occurs first. You, your child,
or another person must notify the Information
Processing Center when a
family member loses eligibility for coverage under the DoD/
FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project
area, you
cancel your coverage, or your coverage is terminated for any
reason. TCC is not available
when the demonstration project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB
Demonstration Project.
DoD/ FEHB Demonstration Project 53
53
Page 54 55
54
2002 NALC Health Benefit Plan
Index
Do not rely on this
page; it is for your convenience and may not show all pages where the term
appears.
A bortion 39
Accidental injury 29
Acupuncture 21
Allergy care 17
Allogenic ( donor) bone marrow
transplant 24
Alternative treatments 21
Ambulance 28, 30
Ambulatory surgical center
28
Anesthesia 25
Auto insurance 43, 46
B iopsies 22
Blood
and blood plasma 27, 28
C arryover 9
Catastrophic protection 10
Certificate of Coverage 51
Changes for 2002 5
Chemotherapy 17
Chiropractic 21
Chlamydial testing 15
Cholesterol tests 15
Claim
filing 40
Coinsurance 9, 47
Colorectal cancer screening 15
Congenital anomalies 23, 47
Contraceptive devices
and drugs 17, 35
Coordinating benefits with other
coverage 43 -46
Copayment 9, 47
Covered facilities 6, 7
Covered providers 6
Custodial care 47
D eductible 9, 47
Definitions 47, 48
Dental care 37
Department of Defense 53
Diabetic supplies 20
Diagnostic testing 15
Dialysis 17
Disease management 36
Disputed
claims process 41, 42
Donor expenses ( transplants) 25
Durable medical
equipment 8, 19, 20, 36
E ducational classes and programs 21
Effective date of enrollment
47, 49
Emergency 30
Experimental or investigational 39, 47
F
amily planning 17
Fecal occult blood test 15
Flexible benefits
option 36
Foot care 19
Fraud 4
Freestanding ambulatory
facilities 6, 7
G eneral exclusions 39
Genetic counseling 17
Government
facilities 10
Group health coverage 43, 48
Growth hormone 8, 17
H
earing services 18
Home health services 20
Hospice care 28
Hospital 6, 7, 26 -29
I dentification cards 6
Immunizations
15, 16
Infertility 17
Influenza vaccine 15
Inhospital physician care
14, 32, 33
Inpatient hospital 26, 27, 32, 33
Insulin 20, 35
L
aboratory and pathological
services 15, 27, 28
M ail order prescription drugs 34, 35
Mammograms 15
Mastectomy
23
Maternity benefits 16
Medicaid 46
Medical necessity 48
Medically underserved areas ( MUA) 6
Medicare 32, 34, 35, 43 -45
Medicare, 65 or older
without Medicare 11
Meningococcal vaccine 16
Mental health/ substance abuse
benefits 31
-33
MRIs ( Magnetic Resonance
Imagings) 15
N ewborn care 14, 16
Non-FEHB benefits 38
Nurse
Licensed practical nurse 20
Licensed vocational nurse 20
Nurse anesthetist 6, 27
Nurse midwife 6
Nurse
practitioner 6
Registered nurse 20 Nursery charges 16
Nursing school administered clinic 6
O besity 14, 22
Occupational therapy 18
Ocular injury 18
Office visits 14, 31, 33
Oral and maxillofacial surgery 24
Orthopedic devices 19
Ostomy and
catheter supplies 20
Out-of-pocket expenses 10
Outpatient facility care 28, 29
Overpayments 10
Overseas claims 40
Oxygen 20, 27, 28
P ap
test 15
Physical therapy 18
Plan allowance 9, 10, 48
Pneumococcal
vaccine 15
Preadmission testing 27, 48
Preauthorization 8, 31, 32
Precertification 7, 8, 26, 33
Preferred Provider Organization
( PPO)
4, 9, 10, 48
Prescription drugs 34, 35
Preventive care, adult 15
Preventive care,
children 16
Prostate cancer screening 15
Prosthetic devices 19
Psychiatrist 31, 33
Psychologist 6, 31, 33
R adiation therapy
17
Renal dialysis 17
S econd surgical opinion 14
Sigmoidoscopy, screening 15
Skilled nursing care facility 7, 28
Smoking cessation 21
Social worker 6, 31, 33
Speech therapy 18
Spouse equity 50
Sterilization procedures 17, 23
Subrogation 46
Substance abuse 31 -33
Surgery 22 -25
Assistant surgeon 23
Cosmetic 23, 24, 39, 47
Multiple procedures 23
Oral 23, 24
Reconstructive 23, 24
Syringes 20, 35
T emporary Continuation of Coverage
( TCC) 50, 51, 53
Transitional care 7
Transplants 8, 24, 25, 36
TRICARE 45
Treatment therapies 17
V ision services 18, 23
W
heelchairs 20
Workers compensation 45
X -rays 15, 27, 28
Index 54
54 Page
55 56
55 2002 NALC Health Benefit Plan
Summary of benefits for the NALC Health Benefit Plan 2002
Do not
rely on this chart alone. All benefits are subject to the definitions,
limitations, and exclusions in this bro-
chure. On this page we summarize
specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure
to put the correct enrollment code from the cover
on your enrollment form.
Below, an asterisk ( * ) means the item is subject to the $ 250 PPO or
$ 300 Non-PPO calendar year deductible. And,
after we pay, you generally pay
any difference between our allowance and the billed amount if you use a Non-PPO
physician or other health care professional.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office . . . . . .
. . . . . . . . . . . . . . . . . . .
PPO: $ 20 copayment per office visit;
$ 5 copayment per allergy
injection; $ 5 -$ 25 copayment per routine
screening service; other
nonsurgical services, 15% * of our allowance
Non-PPO: 30% * of our allowance
PPO: 10% of our allowance
Non-PPO: $
100 copayment per admission, 30% of our allowance
PPO: 15% * of our allowance
Non-PPO: 30% * of our allowance
Within 72 hours: Nothing for nonsurgical outpatient care
After 72 hours:
PPO: 15% * of our allowance
Non-PPO: 30% * of our allowance
Regular benefits
In-Network: Regular cost sharing
Out-of-Network:
Benefits are limited
Network retail: 25% of cost
Network retail Medicare: 15% of cost
Non-network retail: $ 25 deductible, 40% of our allowance
Non-network
retail Medicare: 40% of our allowance
Mail order: 60-day supply, $ 8
generic/ $ 17 name brand
Mail order: 90-day supply, $ 12 generic/ $ 25 name
brand
Mail order Medicare: 60-day supply, $ 5 generic/ $ 13 name brand
Mail order Medicare: 90-day supply, $ 7.50 generic/ $ 19.50 name brand
No benefits
Services provided by a hospital:
Inpatient . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .
Emergency benefits:
Accidental injury . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . .
Medical emergency . . . . . . . .
. . . . . . . . . . . . . . . . . . . .
Mental health and substance abuse treatment
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . .
Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
Services with coinsurance ( excluding mental
health and substance
abuse care) , nothing after your coinsurance expenses
total:
$ 3000 for PPO providers/ facilities
$ 3500 for Non-PPO
providers/ facilities. When you use a combination of PPO and Non-PPO providers
your out-of-
pocket expense will not exceed $ 3500.
Mental health and substance abuse
benefits, nothing after your
coinsurance expenses total:
$ 3000 for In-Network mental health and substance abuse providers/
facilities
$ 8000 for Out-of-Network mental health and substance abuse inpatient
hospital treatment ( after 50 days you pay all charges)
Some costs do not count toward this protection.
Protection against catastrophic costs
( your out-of-pocket maximum) . . .
. . . . . . . . . . . . . .
Special features:
Flexible benefits option
24-hour
nurse line
24-hour help line for mental health and substance abuse
Services for deaf and hearing impaired
Centers of excellence for transplants/ heart surgery
Disease management programs
Discounts for durable medical
equipment ( DME)
Worldwide coverage
14
26
28
29
30
31
35
37
36
10
Summary of benefits
33 55
55 Page
56 57
2002 Rate Information for
NALC Health Benefit Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment
category, refer to the FEHB Guide for that category or
contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the
FEHB Guide for United States Postal Service Employees,
RI 70-2. Different postal rates
apply and special FEHB guides are published
for Postal Service Nurses, RI 70-2B; and for
Postal Service Inspectors and
Office of Inspector General ( OIG) employees ( see RI 70-2IN) .
Postal rates do not apply to non-career postal employees, postal retirees, or
associate
members of any postal employee organization who are not career
postal employees. Refer to
the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Gov t Your Gov t Your USPS Your
Enrollment Code Share Share Share Share
Share Share
High Option
Self Only 321 $ 97.86 $ 45.87 $ 212.03 $ 99.39 $ 115.52 $
28.21
High Option
Self and Family 322 $ 223.41 $ 83.72 $ 484.06 $ 181.39 $
263.75 $ 43.38 56
56 Page
57 58
Search:
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FEHB
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Mental Health
&
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Parity
Nearly 65?
IMPORTANT
REMINDER
Whether you are retired or
still employed, if
you are
not
already receiving
Social Security benefits
you must begin
the
process of
signing up for
Medicare Part A three
months before
your 65th
birthday (you can delay
You are here: OPM Home >
Insurance > FEHB Home
New Federal
Employee?
Click Here
The next Open Season will be
held November 12 through
December 10,
2001.
The Library
FEHB Law
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for
Retirees and
Survivor
Annuitants (RI
79-2, 5/
00)
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Coverage
for Former
Spouses
Spacer FEHB and
Continuation of
Coverage (RI
79-27, 12/ 00)
U. S. Office of Personnel Management
Federal Employees Health Benefits
Program
Providing health insurance benefits to 9 million Federal enrollees and
dependents.
Program
Overview | Frequently
Asked Questions | Glossary
FEHB Plan Changes and
Premium Rates for 2002 Announced
News
Release l
Plan Changes l
Plan Rates
l
TRICARE &
Medicare/
Medicaid
Conversions
Regulations were
issued
September
26 for conversions
between FEHB and DoD's
TRICARE program
or
Medicare/
Medicaid and certain
other government sponsored
health plans.
RIGHTS OF RESERVISTS CALLED TO ACTIVE DUTY
Guidance has been
issued on the
rights and benefits of Federal
employee reservists who are
called to active duty — see
Compensation Memo
2001-09 of
September 14,
2001. FEHB
coverage is discussed in item 7
of Attachment 1 to that
letter.
Federal Employees Health Benefits Program Home Page
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Go 57
57 Page
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the start of
Part B).
Send questions on the FEHB
program to fehb@ opm. gov.
Send comments on these
pages to
insure-webmaster@ opm. gov.
Information
for Agency
Human
Resources
Personnel
Open Season Plan Information Pages
In November of each year we
post
the guides, plan brochures, and
other files used to choose a FEHB
plan for the following year. These
files are available for 1997 through
this year.
To plan information for:
2001 |
2000 |
1999 |
1998 |
1997
Choosing a Plan
Considerations in
Selecting a
Plan
l
Considering Dental
Benefits
FAQ
l
Enrolling in a Plan
When Can I Enroll,
Change
Plans,
or Drop My
Enrollment?
l
How to Enroll l
Election Form (SF
2809) l
FEHB and Medicare
FEHB and Medicare Booklet l
Medicare Web Site l
Quality Care is Vital to Your Health
Satisfaction Surveys
and
Accreditation
l
Your Guide
to Choosing
Quality Health
Care
l
PlanSmartChoice
can help
you to identify the health
plan that is right for you.
l
Health Plan Report Card
An
interactive tool that gives
quality information on
FEHB
managed care plans.
l
Getting the Most from Your Plan
Getting the Most
Benefits l
Prescription Drugs FAQ l
Continuation of Coverage
Temporary Continuation of
Coverage
l
TCC and HIPAA l
Former
Spouses l
Retirees and
Survivor
Annuitants
l
Is there a local HMO that you would like to join but can't because they don't
participate in the FEHB program? Ask them to consider
joining the program,
and tell them to take a look at http:// www. opm. gov/
insure/ carriers/ index. htm.
Federal Employees Health Benefits Program Home Page
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58 Page 59 60
Insurance Programs
Home | Life
Insurance | Long Term Care
Insurance | Retirement |
OPM
Web Privacy Policy | OPM Web Site
Index | OPM Home Page
Page updated 26 September 2001
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59 Page 60 61
1 October 2001 --The Office of Personnel Management has issued an interim
rule to allow TRICARE-eligible FEHB Program annuitants and former spouses to
suspend their FEHB enrollments, and then return to the FEHB
Program during an Open
Season, or return to FEHB coverage immediately if they involuntarily lose
TRICARE coverage. The Interim Final Rule was published in the Federal
Register on September 27, 2001.
DoD/ FEHBP Demonstration Project Call Center Selected Sites
Dover Air
Force Base, Delaware ZIP
Codes Map
Commonwealth of Puerto Rico ZIP Codes Map
Fort Knox,
Kentucky ZIP Codes Map
Greensboro/ Winston-Salem/ High Point, North Carolina
ZIP Codes Map
Dallas, Texas
ZIP Codes Map
Humboldt County, California area
ZIP Codes Map
Naval
Hospital, Camp Pendleton, California ZIP Codes Map
New Orleans, Louisiana ZIP Codes Map
Coffee,
Georgia (includes parts of Florida, Georgia, and South Carolina)
ZIP Codes Map
Adair, Iowa
[includes all of Iowa (except for zip codes in Offutt AFB's catchment area) and
parts of
Minnesota, South Dakota, Nebraska, Kansas, and Missouri]
1-877-DOD-FEHB (1-877-363-3342) Hours of Operation: 7: 00 AM -7: 00 PM
Central
Standard Time (CST), Monday -Friday
Related Links The Uniform
Services Federal Employees Health
Benefits Program Demonstration Project
l
Federal Employees
Health Benefits Test Program for Military Retirees, Families Begins l
DoD/ FEHBP Demonstration Program May Be for You! l
Uniformed Services
Retirees' Federal Employees Health Benefits Program Test Sites Selected l
OPM Federal Employees Health Benefits
l
Frequently Asked
Questions l
Fact Sheet (PDF)
l
FEHBP
Tri-fold l
Bulletin Invitation Postcard
l Bulletin
l Adair
County
l Camp
Pendleton
l Coffee
County
l Dallas
l Dover
l Fort
Knox
l Humboldt
l New
Orleans
l Puerto
Rico
l Winston
Salem
Spanish Version
l Adair
County
l Camp
Pendleton
l Coffee
County
l Dallas
l Dover
l Fort
Knox
l Humboldt
l New
Orleans
l Puerto
Rico
l Winston
Salem
l Postcard
1
l Postcard
2
Spanish Version l
Spanish
Military Retirees' Federal Employees Health Benefits Program Test Sites
http:// www. tricare. osd. mil/ fehbp/ (1 of 2) [10/ 3/ 2001 9: 05: 06 AM] 60
60 Page 61
l Bulletin
Spanish Version
Programa de
Beneficios de Salud para Empleados Federales l
Preguntas Mas Frecuentes
l
Proyecto de
Demostracin del Programa de Beneficios de Salud para Empleados Federales l
FEHBP
Spanish handbook l
THE DOD/ FEHBP DEMONSTRATION PROJECT
MAY BE FOR YOU!
With the conclusion of the education sessions for Open Season 2001, 17,519
people attended one of the 90 education sessions that were held throughout the
ten demonstration sites. Open Season is currently under way
with only a few days left to enroll. If you have any questions, please call
the DoD Customer Care Center at 1-877-DOD-FEHB (1-877-363-3342).
TRICARE's Iron Man, FEHBP Program Manager Duaine Goodno, recently wrapped up
a demanding travel schedule in which he visited places far and wide to educate
eligible TRICARE beneficiaries about the ongoing and
expanded FEHBP demo.
His education series drew large crowds even in out-of-the-way places. In just
over 2 months, Duaine traveled to 54 sites, conducted 88 meetings and spoke to
over 17,500 people. Sometimes he
spoke to 5 crowds in a day! Now that Duaine
is back from the FEHBP education series, he says he'll take up something easy
--like triathlons! Duaine's hard work is appreciated by beneficiaries and
TRICARE leadership
alike. Thanks Duaine!"
Frequently Asked Questions
about the DoD/ FEHB Demonstration Project and Medicare l
The Military Health System Web Site
is the Official Web Presence of the Office of the Assistant Secretary of
Defense( Health Affairs) and the TRICARE Management Activity.
Skyline 5, Suite 810; 5111 Leesburg Pike; Falls Church, VA 22041-3206
The content of this page was updated on 1 October 2001.
TRICARE Help | Website Help
Military Retirees' Federal Employees Health Benefits Program Test Sites
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