Panama Canal Area Benefit Plan
http:// www. healthnetworkamerica.
com
2002
A Managed Fee-for-Service plan
with a Point of Service Option
Sponsored and administered by: The Association of Retirees of the
Panama Canal Area (AJAC)
Who may enroll in this Plan: A member of the Association (Panama
Canal Area) who is
eligible for coverage under the Federal Employees Health
Benefits Program. Annuitants
(retirees and/ or survivors), residing in
Panama may enroll in the Panama Canal Area
Benefit Plan provided
they were previously enrolled in the Plan.
Enrollment codes for this Plan:
431 Self Only
432 Self and Family
For changes
in benefits
see page 8.
2002 Panama Canal Area Benefit Plan Table of Contents 2
Table
of Contents
Introduction………………………………………………………………….............................................................
4
Plain
Language………………………………………………………………............................................................
4
Inspector General
Advisory………………………………………………………………………………………….. 5
Section
1. Facts about this fee-for-service
plan........................................................................................................
6
Section 2. How we change for
2002………………………………………...............................................................
8
Section 3. How you get care …………...
..................................................................................................................
9
Identification cards
...................................................................................................................................
9
Where you get covered
care......................................................................................................................
9
Covered providers
............................................................................................................................
9
Covered
facilities............................................................................................................................
10
What you must do to get covered
care....................................................................................................
11
How to get approval for…
...................................................................................................................
11
Your hospital stay (precertification)
...............................................................................................
11
Other services
.................................................................................................................................
13
Section 4. Your costs for covered services
...............................................................................................................
14
Copayments
....................................................................................................................................
14
Deductible.......................................................................................................................................
14
Coinsurance
....................................................................................................................................
14
Differences between our allowance and the bill
.............................................................................
14
FFS out-of-pocket
maximum..................................................................................................................
15
When government facilities bill us…
..................................................................................................
16
If we overpay you
...................................................................................................................................
16
When you are age 65 or over and you do not have
Medicare ................................................................ 16
When you have Medicare
.......................................................................................................................
17
Section 5.
Benefits…………………………………………………………............................................................
18
Overview.................................................................................................................................................
18
(a) Medical services and supplies provided by
physicians and other health care professionals............ 19
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ........ 31
(c)
Services provided by a hospital or other facility, and ambulance
services...................................... 37
(d)
Emergency services/ accidents
.........................................................................................................
41
(e) Mental health and substance abuse benefits
....................................................................................
44
(f) Prescription drug benefits
................................................................................................................
48
(g) Special
features................................................................................................................................
50
Flexible benefits option
Centers
of excellence for transplants
(h) Dental
benefits.................................................................................................................................
51 2
2 Page 3 4
2002 Panama Canal Area Benefit Plan Table of Contents 3
Section 6. General exclusions --things we don't cover
...........................................................................................
53
Section 7. Filing a claim for covered services
.........................................................................................................
54
Section 8. The disputed claims process
...................................................................................................................
56
Section 9. Coordinating benefits with other
coverage
.............................................................................................
58
When you have other health
coverage............................................................................................
58
Original
Medicare...........................................................................................................................
58
Medicare Managed Care Plan
……………………………………………………………………. 60
TRICARE/ Workers
Compensation/
Medicaid.................................................................................
61
When other Government agencies are responsible for
your care ................................................... 62
When others are responsible for injuries
........................................................................................
62
Section 10. Definitions of terms we use in this
brochure
........................................................................................
63
Section 11. FEHB
facts............................................................................................................................................
66
Coverage information
...........................................................................................................................
66
No pre-existing condition
limitation...............................................................................................
66
Where you get information about enrolling in the
FEHB Program................................................ 66
Types of
coverage available for you and your family
.................................................................... 66
When benefits and premiums
start..................................................................................................
66
Your medical and claims records are
confidential..........................................................................
67
When you retire
..............................................................................................................................
67
When you lose
benefits...........................................................................................................................
67
When FEHB coverage
ends............................................................................................................
67
Spouse equity coverage
..................................................................................................................
67
Temporary Continuation of Coverage
(TCC).................................................................................
67
Converting to individual
coverage..................................................................................................
68
Getting a Certificate of Group Health Plan Coverage
.................................................................... 68
Long term care insurance is coming later in
2002…………………………………………………………………. 69
Index………
...........................................................................................................................................................
70
Summary of
benefits............................................................................................................................................
71-72
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2002 Panama Canal Area Benefit Plan 4 Introduction/ Plain Language/
Advisory
Introduction
Panama Canal Area Benefit Plan
Edificio Hatillo
Esquina Avenida Justo Arosemena y Calle 36
Panama,
Republica de Panama
This brochure describes the benefits of the Panama Canal Area Benefit
Plan (PCABP) under our contract (CS 1066)
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 8. 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 The Panama Canal Area
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, D. C. 20415-3650. 4
4 Page 5 6
2002 Panama Canal Area Benefit Plan 5
Introduction/ Plain Language/ Advisory
Inspector General Advisory
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 800-548-8969 in
the US or
227-7555 in Panama 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.
Stop health care fraud! 5
5 Page 6 7
2002 Panama Canal Area Benefit Plan Section 1 6
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, 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 a Point-of-Service (POS) option available to Plan members who
reside in the Republic of Panama:
Our fee-for-service plan offers POS
benefits. This means you can get better benefits at less cost by signing up with
us
for the POS program, selecting a contracted primary care physician (PCP),
and letting the PCP manage your care. We
offer the POS program in the
following area: Republic of Panama.
Contact us for the names of POS 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-POS benefits are standard for this plan. POS benefits apply only when
you use a POS provider. Provider
networks may be more extensive in some
areas than others. We cannot guarantee the availability of every specialty in
all areas. If you select the POS option but choose to use a non-POS
provider, the standard FFS benefits apply.
How we pay providers
Panama POS: We have contracted with
individual physicians, hospitals, and providers within the Republic of Panama to
provide you with all of your health care needs. These "in-network" providers
have agreed to accept our negotiated rates
as payment in full. If you reside
within the Republic of Panama and you select the POS option and comply with the
obligations required of you under this option, we will reimburse
point-of-service providers directly for the medical
services provided to
you. If you select the POS option and use the point-of-service providers, you
will usually only have
to pay your copayments described in this brochure and
your prescription drug and dental claims.
If you live in Panama and select the Fee-for-Service (FFS) option, or if you
live anywhere outside of Panama, you will
usually have to pay for the
medical services provided to you and then we will reimburse you according to the
benefits
described in this brochure.
For claims incurred in the United States or any country outside of Panama, we
will reimburse you at the coinsurance
stated in this brochure based on the
Health Insurance Association of America (HIAA) fee schedule at the 75 th
percentile.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about
us, our networks, providers, and facilities. OPM's FEHB website (www. opm.
gov/ insure) lists the specific types of
information that we must make available to you. Some of the required
information is listed below.
The Association of Retirees from the Panama Canal Area is a legal Panamanian
entity incorporated in June 1999.
Before this date the Association (Panama
Canal Area) was the Group Insurance Board which came into effect in 1960
as
an entity appointed by the Panama Canal Commission to administer Federal
Employees Health Benefits Contract CS
1066 (the Panama Canal Area Benefit
Plan). All members of the Association (Panama Canal Area) have the right to
review the by-laws of the Association.
If you want more information about us, call 800-548-8969 in the United States
(732-222-9696 if outside of the US or
Panama) or 227-7555 within the
Republic of Panama or write to: 6
6 Page 7 8
2002 Panama Canal Area Benefit Plan Section 1 7
Health Network
America, Inc. (in the US or any country other than Panama) HNA Panama, S. A.
Panama Canal Area 0832-1240 World Trade Center
P. O. Box 398 Panama,
Republica de Panama
W. Long Branch, NJ 07764
You may also contact us by fax
at 732-222- 4584 (in the United States)
or 227-8031 (in Panama) or visit our website at
http:// www. healthnetworkamerica.
com. or http:// www. hnapanama. com 7
7 Page 8 9
2002 Panama Canal Area Benefit Plan Section 2
8
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
We changed the address for sending disputed claims
to OPM. (Section 8)
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).
Changes to the Panama Canal Area Benefit Plan
We no longer limit
total blood cholesterol tests to certain age groups. (Section 5( a))
We now
cover certain intestinal transplants. (Section 5( b)) We changed speech therapy
benefits by removing the requirement that services must be required to restore
functional speech. (Section 5( a))
Your share of the non-Postal premium
will decrease by less than 1% for both Self only and Self and Family.
We clarified the brochure to better explain that the non-POS benefits are the
standard benefits of this Plan, that POS benefits apply only when you use a POS
provider, and that when no POS provider is available, non-POS benefits
apply.
We will waive the POS hospital admission copayment if you are
readmitted to a participating hospital with the same diagnosis within 30 days of
being discharged.
We changed the POS ambulance benefit to distinguish between intra and
inter-province ambulance use in order to province greater coverage for plan
members.
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 changed the physical therapy
benefit limitation to a dollar limit.
We reduced the copayments for
acupuncture and chiropractic visits from $10 per visit to $10 for the first
visit in an authorized series.
We included a speech therapy benefit
We added a benefit for diabetic toe
nail clipping as part of the two annual check-ups.
We clarified that the
routine gynecological exam is covered the same as the routine pap test.
We
clarified the prescription drug benefit to specifically exclude medications for
the treatment of cancers, aplastic anemia, sickle cell anemia, and
myelodysplasia syndrome from the deductible and coinsurance. We cover
medicines used to treat these specific illnesses at 100%.
We clarified
the chemotherapy and hemodialysis treatment benefit to specifically state that
the chemotherapy and hemodialysis medications administered during these
treatments are covered as part of the treatment. 8
8
Page 9 10
2002
Panama Canal Area Benefit Plan Section 3 9
Section 3. How you get
care
Identification cards We will send you an identification (ID) card
when you enroll. You should carry your ID card with you at all times. You must
show it whenever you
receive services from a Plan provider. Until you
receive your ID card, use
your copy of the Health Benefits Election Form,
SF-2809, your health
benefits enrollment confirmation (for annuitants), or
your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 800-548-8969
in the US or 227-7555 within the Republic of Panama.
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
point-of-service program, 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:
For purposes of this Plan, covered providers include: a licensed doctor of
medicine (M. D.) or a licensed doctor of osteopathy (D. O.); a licensed
specialist in his/ her specialty. Other covered providers include: a
licensed
doctor of podiatry (D. P. M.); a licensed dentist (D. D. S. or D.
M. D.);
licensed chiropractor (D. C.); licensed registered physical or
occupational
therapist (R. P. T., R. O. T.) practicing within the scope of
their license. Other
covered providers include a qualified clinical
psychologist, clinical social
worker, optometrist, nurse midwife, nurse
practitioner/ clinical specialist
and nursing school administered clinic.
For purposes of this FEHB
brochure, the term "doctor" includes all of these
providers when the
services are performed within the scope of their license
or certification.
Doctor— A licensed doctor of Medicine (M. D.) or osteopathy (D. O.); a
licensed specialist in his/ her specialty; or, for other certain specified
services covered by this Plan, a licensed dentist.
Independent Consulting Doctor— An independent consulting doctor is a
specialist who:
1. Is certified by the American Board of Medical Specialists
in a field
related to the proposed surgery;
2. Is independent of the
doctor who first advised the surgery;
3. Does not perform the surgery for
the insured person;
4. Makes a personal exam of the insured person; and
5. Sends the Plan a written report.
Primary Care physician— A licensed medical doctor whose practice is devoted
to internal medicine, family/ general practice or pediatrics.
Medically underserved areas Note: 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. 9
9 Page
10 11
2002 Panama Canal Area Benefit
Plan Section 3 10
Covered facilities Covered facilities include:
Clinic— A place, other than a hospital, licensed to provide treatment or
diagnosis and staffed by one or more doctors.
Hospice— A public or private agency or organization which: 1. administers and
provides hospice care; and
2. is either:
a) licensed or certified as
such by the state in which it is
located;
b) certified (or is qualified
and could be certified) to
participate as such under Medicare;
c)
accredited as such by the Joint Commission on the
Accreditation of Health
Care Organizations; or
d) meets the standards established by the National
Hospice
Organization.
Hospital 1. An institution which is accredited as a hospital under the
Hospital Accreditation Program of the Joint Commission on
Accreditation
of Healthcare Organizations or
2. Any other institution which is operated
persuant to law under
the supervision of a staff of doctors and with
24-hour-a-day
nursing service, and which is primarily engaged in providing:
1. General patient care and treatment of sick or injured
persons through
medical, diagnostic and major surgical
facilities, all of which must be
provided on its premises
or under its control; or
2. Specialized
inpatient medical care and treatment of sick
or injured persons through
medical and diagnostic
facilities (including X-ray and laboratory) on its
premises, under its control or through a written
agreement with a
Hospital (as defined above) or with a
specialized provider of those
facilities or
3. In Panama, authorized by the Ministry of Health to
operate as such.
In no event shall the term Hospital include a convalescent nursing
home,
or an institution or part thereof which:
1. Is used principally as a
convalescent facility, rest facility, or
facility for the aged;
2.
Furnishes primarily domiciliary or custodial care, including
training in the
routine of daily living; or
3. Is operated as a school.
Rehabilitation Facility— An institution that: (1) meets the "hospital"
definition as stated; or (2) provides a program for the treatment of alcohol
or drug abuse and meets one of the following requirements: (a) is affiliated
with a hospital under a contractual agreement with an established patient
referral system; (b) is licensed, certified or approved as an alcohol or
drug
abuse rehabilitation facility by the State; or (c) is accredited as
such a
facility by the Joint Commission on Accreditation of Healthcare
Organizations.
Skilled Nursing Facility— An institution that (1) is operated pursuant to law
and primarily engaged in providing the following services for patients
recovering from an illness or injury: room, board and 24-hour-a-day
nursing service by professional nurses; (2) is under the full-time
supervision of a doctor or registered nurse (R. N.); (3) maintains adequate
10
10 Page 11 12
2002 Panama Canal Area Benefit Plan Section 3
11
medical records; and (4) has the services of a doctor available under
an
established agreement for 24 hours a day, if not supervised by a doctor.
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 POS 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 POS
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 POS 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. However, if you are in the hospital when your enrollment in our
Plan
begins, call our customer service department immediately at
800-548-8969
in the US, 227-7555 in Panama or 732-222-9696 outside of the US
and
Panama.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
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 admission – 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.
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 will reduce our benefits for the inpatient hospital stay
by $500 if no 11
11 Page
12 13
2002 Panama Canal Area Benefit
Plan Section 3 12
one contacts us for precertification. In addition, if
the stay is not medically
necessary, we will only pay for any covered
medical supplies and services
that are otherwise payable on an outpatient
basis.
How to precertify an admission: We require both FFS and POS Plan
members to precertify all admissions
to evaluate the medical necessity of
your proposed admission and the
number of hospital days you will need.
You, your representative, your doctor, or your hospital must call us at
800-548-8969 in the US, 227-7555 in Panama or 732-222-9696 if you
reside
outside of the US and Panama, at least 24 hours prior to
admission.
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 doctor, 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 Plan
identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and
phone number of admitting doctor;
Name of hospital or facility; and
Number of planned days of hospital stay.
We will then tell the doctor
and/ or hospital the number of approved inpatient days and we will send written
confirmation of our decision to
you, your doctor, 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 for
precertification of
additional days for your baby.
If your hospital stay If your hospital stay --including for maternity
care --needs to be
needs to be extended: extended, you, your
representative, your doctor or the hospital must ask us
to approve the
additional days.
What happens when you When we precertified the admission but you
remained
do not follow the in the hospital beyond the number of days
we approved and
precertification rules did not get the additional
days precertified, then:
for the part of the admission that was medically necessary, we will pay
inpatient benefits, but
for the part of the admission that was not medically necessary, we will pay
only medical services and supplies otherwise payable on 12
12 Page 13 14
2002 Panama Canal Area Benefit Plan Section 3
13
an outpatient basis and will not pay inpatient benefits.
If no
one contacted us, we will decide whether the hospital stay was medically
necessary.
If we determine that the stay was medically necessary, we will pay the
inpatient benefits, less the $500 penalty.
If we determine that it was not
medically necessary for you to be an inpatient, we will not pay inpatient
hospital benefits. We will
only pay for any covered medical supplies and
services that are
otherwise payable on an outpatient basis.
If we denied the precertification request, we will not pay inpatient hospital
benefits. We will only pay for any covered medical supplies
and services
that are 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, Puerto Rico and Panama.
You have another group health insurance policy that is the primary payer for
the hospital stay.
Your Medicare Part A is the primary payer for the
hospital stay. Note: If you exhaust your Medicare hospital benefits and do not
want to use
your Medicare lifetime reserve days, then we will become the
primary
payer and you do need precertification.
Other services Some services require a referral, precertification, or
prior authorization. These services are as follows:
All surgeries, both
inpatient and outpatient must be precertified. For all elective (non-emergency)
surgical procedures, we require a
second surgical opinion. If you fail to
comply with this requirement,
we will limit our payment to 50% of our Plan
allowance for these
surgery charges.
For all in hospital surgical procedures not related to the original diagnosis
for which you obtained precertification, we require you to
get a second surgical opinion. If you fail to comply with this
requirement, we will limit our payment to 50% of our Plan allowance
for
these surgery charges if medical necessity can be determined.
Growth hormone therapy (GHT)
If designated outpatient surgical procedures (see page 33 for a complete
listing) are performed on an inpatient basis, we will limit our
payment to 50% of our Plan allowance. However, if it is medically
necessary that you be hospitalized for the surgical procedure, we will
pay our regular benefits if you have precertified your admission
We require you to obtain precertification on both an inpatient and outpatient
basis for specifically designated, non-routine diagnostic
procedures that are high cost, involve high technology or that may be
over-utilized. These tests include Cat scans, MRIs, Nuclear Medicine
Studies (e. g. Thallium Cardiac Studies), certain Arteriographies,
Genetic Studies and other similar procedures. If you fail to comply
with
this requirement, we will limit our payment for outpatient
services to 50%
of our Plan allowance and impose a $500 penalty for
inpatient charges. 13
13 Page 14 15
2002 Panama Canal Area Benefit Plan Section 4
14
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.
Example: When you see a participating physician you pay a copayment of
$10 per visit and when you go to a participating hospital you pay $75 per
admission if you belong to the POS plan. If you are a FFS member, or are a
POS member and choose to go to a non-participating hospital, you pay
$125 per admission.
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
them. Copayments do not count toward any deductible.
The calendar year deductible for prescription drugs is $400 per enrollee (see
page 48). This Plan has no other calendar year
deductibles.
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: FFS members pay a 50% coinsurance for all medical
services.
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 US law. In this case, when we
calculate our share,
we will reduce the provider's fee by the amount waived.
For example, in the US, if your physician ordinarily charges $100 for a
service but routinely waives your 50% coinsurance, the actual charge is
$50. We will pay $25 (50% of the actual charge of $50).
Fee-for-Service Outpatient Most Fee-for-Service outpatient benefits
are subject to the outpatient Maximum benefit maximums of $650 for Self
Only enrollment and $1,500 for Self
and Family enrollment per calendar year,
regardless of where the services
are provided. If an enrollee has Self and
Family enrollment, the $1,500
outpatient maximum can be reached by one or
more family members.
Differences between Our "Plan allowance" is the amount we use to
calculate our payment our allowance and for covered services.
Fee-for-service plans arrive at their allowances in
the bill
different ways, so their allowances vary. For more information about how
we determine our Plan allowance, see the definition of Plan allowance in
Section 10. 14
14 Page
15 16
2002 Panama Canal Area Benefit
Plan Section 4 15
Often, the provider's bill is more than the plan's
allowance. Whether or not
you have to pay the difference between our
allowance and the bill will
depend on the provider you use.
POS providers agree to limit what they will bill you. Because of that,
when you use a POS provider, your share of covered charges consists
only
of your copayment. Here is an example about copayment: You see
a POS
physician who charges $50, but our allowance is $30. You are
only
responsible for your copayment amount. That is, you pay just --
$10 of our
$30 allowance. Because of the agreement, your POS
physician should not bill
you for the $20 difference between our
allowance and his bill.
FFS providers, on the other hand, have no agreement to limit what
they will bill you. When you use the FFS option, you will pay your
coinsurance --plus any difference between our allowance and charges
on the bill. Here is an example: You see a FFS physician who charges
$50
and our allowance is again $30. You are responsible for your
coinsurance, so
you pay 50% of our $30 allowance ($ 15.00). Plus,
because there is no
agreement between the FFS physician and us, he
can bill you for the $20
difference between our allowance and his bill.
The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a POS physician vs. a FFS physician. The
table uses our example of a service for which the physician charges $50
and our allowance is $30. The table shows the amount you pay.
EXAMPLE POS physician FFS physician
Physician's charge $50 $50
Our allowance We set it at: 30 We set it at: 30
We pay Allowance less
copay: 20 50% of our allowance: 15
You owe:
Coinsurance/ Copay $10
copayment: 10 50% of our allowance: 15
+Difference up to
charge? No: 0
Yes: 20
TOTAL YOU PAY $10 $35
Your FFS Catastrophic Protection
out-of-pocket maximum
for
hospital coinsurance After your FFS out-of-pocket expenses for the 50%
coinsurance for inpatient hospital room and board and other charges reach $2,500
in a
calendar year, we will then pay the remaining hospital inpatient room and
board and other charges at 100% of Plan allowance.
Out-of-pocket expenses applicable to this benefit are limited to the 50%
coinsurance you pay for hospital room and board and other inpatient
charges.
The following are not counted toward out-of-pocket expenses:
Expenses in
excess of our Plan allowances and maximum benefit limitations;
Expenses for mental conditions, substance abuse, dental care or prescription
drugs;
Any amounts you pay because benefits have been reduced for
non-compliance with this plans cost containment requirements (see pages
11-13); and 15
15 Page
16 17
2002 Panama Canal Area Benefit
Plan Section 4 16
The $125 copayment per person per admission for
hospital room and board.
When government facilities Facilities of the
Department of Veterans Affairs, the Department of
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 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.
When you are age 65 or over 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 over, 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,
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 applicable deductibles, coinsurance, or
copayments you owe under this Plan;
you are not responsible for any charges
greater than the equivalent Medicare amount; we will show that amount on the
explanation of benefits (EOB) form 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.
If your physician… Then you are responsible for…
Participates with Medicare your coinsurance or copayments, and any
balance up to the Medicare approved amount;
Does not participate with Medicare, your coinsurance or copayments, and any
balance up to 115% of the Medicare approved
amount 16
16 Page 17 18
2002 Panama Canal Area Benefit Plan Section 4
17
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 (EOB) form will tell you how much the physician
or hospital may collect from you. If
your physician 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.
When you have the Original
Medicare Plan
(Part A, Part B, or both)
We limit our payment to an amount that supplements the benefits that
Medicare would pay under Medicare Part A (Hospital insurance) and
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.
If you are covered by Medicare Part B and it is primary, your out-of-pocket
costs for services that both Medicare Part B and we cover depend on
whether your physician accepts Medicare assignment for the claim.
If your physician accepts Medicare assignment, then you pay nothing for
covered charges.
If your physician does not accept Medicare assignment, then you pay the
difference between our payment combined with Medicare's payment and
the
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 their 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
Private Contract with a
Physician A
physician may ask you to sign a private contract agreeing that you can be billed
directly for services Medicare ordinarily covers. 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 Medicare's payment.
Please see Section 9, Coordinating benefits with other coverage, for more
information about how we coordinate benefits with Medicare. 17
17 Page 18 19
2002 Panama Canal Area Benefit Plan Section 5 18
Section 5.
Benefits – OVERVIEW
(See page 8 for how our benefits changed this
year and pages 71-72 for a benefits summary.)
NOTE: This benefits section is broken 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 800-548-8969 in the
United States or 227-7555 in the Republic of Panama or at our
website
http:// www.
healthnetworkamerica. com.
(a) Medical services and supplies provided by
physicians and other health care professionals ..................... 19-30
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment
therapies
Physical and Occupational 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 and Acupuncture
Alternative
treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals.................... 31-36
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services.................................................. 37-40
Inpatient
hospital
Outpatient hospital or ambulatory surgical
center
Extended
care benefits/ Skilled nursing care
facility benefits
Hospice care
Ambulance
(d) Emergency services/ Accidents
....................................................................................................................
41-43
Medical emergency
Accidental injury
Ambulance
(e) Mental health and substance abuse benefits
................................................................................................
44-47
(f) Prescription drug
benefits............................................................................................................................
48-49
(g) Special
features.................................................................................................................................................
50
Flexible Benefit Option Centers of excellence for transplants/ heart
surgery/ etc
(h) Dental benefits………………………………………………………………………………………………… 51-52
SUMMARY
OF BENEFITS…………………………………………………………………………………………………… 71-72 18
18 Page 19 20
2002 Panama Canal Area Benefit Plan 19
Section 5( a)
Section 5 (a). Medical services and supplies
provided by physicians and other
health care professionals
I M
P O
R T
A N
T
Here are some important things 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.
Except for the prescription drug benefit there is no
calendar year deductible. However, if you are a FFS member, almost all
outpatient benefits are applied to an
outpatient maximum of $650 under the self only option and $1500 under the
self
and family option. We added "No outpatient maximum" to show when the
calendar
year outpatient maximum does not apply.
The FFS benefits are the standard benefits of this Plan. POS benefits apply
only when you use a POS provider. When no POS provider is available, FFS
benefits
apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special sections
for members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
NOTE: The outpatient maximum applies
to almost all FFS benefits. We say "( No Outpatient maximum)" when it
does
not apply.
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office
medical consultations
Physician home visits
In a skilled nursing
facility
POS: $10 copayment
FFS Panama: 50% of the Panama
POS Fee schedule
amount and any
difference between the POS Fee
schedule and the billed
amount.
FFS US: 50% of the US FFS Plan
allowance (see page 64 describing how we
derive our US FFS allowance) and any
difference between our allowance
and the
billed amount.
Professional services of physicians
In an urgent care center
Initial
examination of a newborn child covered under a family enrollment
Second surgical opinion
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS Fee
schedule and the billed amount.
FFS US: 50% of the US FFS Plan
allowance and any difference between our
allowance and the billed amount 19
19 Page 20 21
2002 Panama
Canal Area Benefit Plan 20 Section 5( a)
Inpatient Physician
Hospital Visit
Note: Under the FFS option this benefit is limited to $35 per
day
per doctor.
POS: Nothing
FFS Panama: Nothing up to $35 per
doctor per day and all
charges
thereafter.
FFS US: Nothing up to $35 per doctor
per day and all charges thereafter.
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount
Note: If your POS provider uses a
FFS lab or radiologist, we will pay
FFS benefits for any lab and X-ray
charges.
Preventive care, adult You pay
Routine Medical Check-up every 6
months
NOTE: These routine check-ups include toe nail clipping for
diabetics.
POS: Nothing
FFS Panama: All Charges
FFS US: All Charges
Routine screenings, limited to:
Total Blood Cholesterol – once every
three years
Chlamydial infection
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening – every five years starting at age 50
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
(No
outpatient maximum).
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount
(No outpatient maximum). 20
20 Page 21 22
2002 Panama Canal Area Benefit Plan 21
Section 5( a)
Preventive care, adult--continued
You pay
Prostate Specific Antigen (PSA test) – one annually
for men
age 40 and older
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount (No
outpatient maximum).
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount
(No outpatient maximum).
Routine annual gynecological examination, including pap test
.
POS:
Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount (No
outpatient maximum).
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount
(No outpatient maximum).
Routine mammogram – covered for women age 35 and older,
as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
(No
outpatient maximum).
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount
(No outpatient maximum).
Preventive care, adult You pay
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over
(except as provided for under Childhood
immunizations)
Influenza, annually, age 60 and over
Pneumococcal vaccines, every 5 years age 60 and over
POS: Nothing
FFS Panama: Not a covered benefit.
You pay all billed
charges
FFS US: Not a covered benefit. You
pay all billed charges. 21
21 Page 22 23
2002 Panama Canal Area Benefit Plan 22
Section 5( a)
Preventive care, children You pay
Childhood
immunizations for dependent children under the age of 22 as follows: DPT
(diphtheria, tetanus, pertussis
vaccine); OPV (oral polio vaccine);
Hepatitis B Vaccine;
Haemophilus influenza type b vaccine (flu shot); MMR
(measles, mumps, rubella vaccine); and Td (tetanus diphtheria
toxoid
booster).
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
(No
outpatient maximum).
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount (No outpatient maximum).
For well-child care charges for routine examinations, the following schedule
applies: 6 annual visits up to age 1; 2
annual visits between the ages of 1 and 2; 1 annual visit ages
3 to 22.
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
(No
outpatient maximum).
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount (No outpatient maximum).
Examinations, limited to:
Examinations for amblyopia and strabismus –
limited to one screening examination (ages 2 through 6)
Examinations done on the day of immunizations (ages 3 through 22) See above
schedule.
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount. 22
22
Page 23 24
2002
Panama Canal Area Benefit Plan 23 Section 5( a)
Maternity care
You pay
Complete maternity (obstetrical) care, such as:
Prenatal
care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify
your normal delivery; however, you must obtain precertification 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 doctor, or your hospital must precertify.
POS: $10 copayment for all office
visits.
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount.
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 Hospital benefits (Section
5c) and Surgery benefits (Section 5b).
(see above)
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Injectable contraceptive drugs
(such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note:
We cover oral contraceptives under the prescription drug
benefit.
Note: We cover contraceptive drugs in Section 5( f).
POS: Nothing.
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount.
Not covered: reversal of voluntary surgical sterilization,
genetic
counseling,
All charges. 23
23 Page 24 25
2002 Panama
Canal Area Benefit Plan 24 Section 5( a)
Infertility services
You pay
Diagnosis and treatment of infertility including fertility
drugs,
except shown in Not covered.
POS: $10 copayment per
consultation
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount.
Not covered:
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination
in vitro fertilization
embryo transfer and GIFT
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination
(IUI)
Services and supplies related to ART procedures.
Cost of donor sperm
Cost of donor egg
All charges.
Allergy care You pay
Testing and treatment, including materials
(such as allergy
serum) and allergy injections.
POS: $10 copayment for
the
consultation; nothing for the
authorized injections.
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount. 24
24
Page 25 26
2002
Panama Canal Area Benefit Plan 25 Section 5( a)
Allergy
injections (without office consultation) POS: Nothing
FFS Panama: 50% of the
Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount.
Not covered: provocative food testing and sublingual allergy
desensitization
All charges
Treatment therapies You pay
Chemotherapy and radiation therapy
including medications used directly with the chemotherapy and radiation
treatment.
Note: High dose chemotherapy in association with autologous
bone marrow
transplants is limited to those transplants listed on
page 35.
Dialysis – Hemodialysis and peritoneal dialysis including medications used
directly with the dialysis treatment.
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug
benefit.
Note: – We only cover GHT when we preauthorize the treatment.
Call
800-548-8969 in the US or 227-7555 in Panama for
preauthorization. We will
ask you to submit information that
establishes that the GHT is medically
necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we
will
only cover GHT services from the date you submit the
information.
If you do not ask or if we determine GHT is not
medically necessary, we will
not cover the GHT or related
services and supplies. See Services
requiring our prior approval
in Section 3.
Respiratory and inhalation therapies
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount.
"No
outpatient maximum".
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount. "No outpatient Maximum". 25
25 Page 26 27
2002 Panama Canal Area Benefit Plan 26
Section 5( a)
Physical and Occupational Therapies You pay
Short-term rehabilitative physical therapy (POS) or physical
and
occupational therapy (FFS) is provided on an inpatient or
outpatient basis
for up to $300 per condition (POS) and $250 per
condition FFS, if
significant improvement can be expected
within two months. Physical therapy
is limited to services that
assist the member to achieve and maintain
self-care and
improved functioning in other activities of daily living.
NOTE: The annual benefit limit for the FFS option is $250.
POS: $10 copayment for first visit in
an authorized series and all
charges
over the $300 annual benefit
maximum
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount and
all charges over the $250 annual
benefit maximum.
FFS: 50% of the US FFS Plan
allowance and any difference
between our
allowance and the billed
amount and all charges over the
$250 annual
benefit maximum.
Note: A physician must:
1) Order the care;
2) identify the specific
professional skills the patient requires and the
medical necessity for
skilled services; and
3) indicate the length of time the services are needed.
Not covered:
long-term rehabilitative therapy exercise programs
Occupational therapy (POS)
All charges.
Speech Therapy You pay
Speech Therapy is covered up to $250
annually in all
situations where it is medically necessary
POS: $10
copayment for first visit in
an authorized series and all charges
over
the $250 annual benefit
maximum
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount and
all charges over the $250 annual
benefit maximum.
FFS: 50% of the US FFS Plan
allowance and any difference
between our
allowance and the billed
amount and all charges over the
$250 annual
benefit maximum. 26
26 Page
27 28
2002 Panama Canal Area Benefit
Plan 27 Section 5( a)
Hearing services (testing, treatment,
and supplies)
Hearing Exam— annual audiologist visit. POS: $10 copayment
FFS Panama: Not covered. You must pay
all billed charges.
FFS US: Not covered. You must pay all
billed charges.
Not covered:
hearing testing, except as mentioned above
hearing aids
All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or
intraocular surgery (such as for cataracts)
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount.
Not covered:
Eyeglasses or contact lenses and examinations for
them
Eye exercises and orthoptics
Radial keratotomy and
other refractive surgery
All charges.
Foot care You pay
Specific foot care when you are under active
treatment for a
metabolic or peripheral vascular disease, such as diabetes.
Note: See orthopedic and prosthetic devices for information on
podiatric
shoe inserts
POS: $10 copayment
FFS Panama: 50% of the Panama
POS Fee schedule
amount and any
difference between the POS fee
schedule and the billed
amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount. 27
27
Page 28 29
2002
Panama Canal Area Benefit Plan 28 Section 5( a)
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of
toenails, and similar routine treatment of
conditions of the foot, except as stated above
Treatment of
weak, strained or flat feet or bunions or spurs; and of any instability,
imbalance or subluxation of
the foot (unless the treatment is by open cutting surgery)
All charges
Orthopedic and prosthetic devices
Externally worn breast
prostheses and surgical bras, including necessary replacements following a
mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted
breast implant following mastectomy.
Note: See 5( b) for
coverage of the surgery to insert the device.
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount.
Not covered: Prosthetic
appliances such as:
Artificial limbs and eyes; stump hose
Orthopedic and corrective
shoes
Arch supports
Foot orthotics
Heel pads
and heel cups
Lumbosacral supports
Corsets, trusses,
elastic stockings, support hose, and other supportive devices
All charges.
Durable medical equipment (DME) You pay
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.
POS: All charges
FFS Panama: All charges
FFS US: All charges 28
28 Page 29 30
2002 Panama Canal Area Benefit Plan 29
Section 5( a)
Not covered: All DME such as:
Hospital beds;
Wheelchairs
Crutches Walkers.
All charges
Home health services
40 visits per calendar year up to the Plan
allowable amount 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.
Note:
Up to 4 hours of skilled services equal one visit.
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount.
Not covered:
Nursing care requested by, or for the convenience of, the patient or the
patient's family;
Home care primarily for personal assistance that
does not include a medical component and is not diagnostic,
therapeutic, or
rehabilitative.
All charges.
Chiropractic You pay
Chiropractic Services— By a physician or
licensed doctor of
chiropractic medicine for pain management, asthma and
arthritis
up to benefit maximum of $250 per calendar year.
Manipulation of the spine and extremities
Adjunctive procedures such as
ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack
application
POS: $10 Copayment for the first visit in an authorized
series and all
charges over the $250 annual maximum
FFS Panama: 50% of the Panama POS Fee schedule
amount and any difference
between the POS fee
schedule and the billed amount and all charges over
the $250 annual benefit maximum.
FFS US: 50% of the US FFS Plan allowance and
any difference between our
allowance and the billed
amount and all charges over the $250 annual benefit
maximum. 29
29 Page
30 31
2002 Panama Canal Area Benefit
Plan 30 Section 5( a)
Alternative treatments You pay
Acupuncture – by a doctor of medicine or osteopathy for:
anesthesia
or pain relief up benefit maximum of $250 per
calendar year.
POS: $10 Copayment for the first visit in
an authorized series and all
charges over
the $250 annual benefit maximum
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount and
all charges over the $250 annual
benefit maximum.
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount and all charges over the
$250 annual
benefit maximum.
Not covered:
naturopathic services
(Note: benefits of certain alternative treatment providers may be
covered
in medically underserved areas; see page 9).
.
All charges
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related
expenses such as drugs.
POS: Nothing up to $100. All
charges greater than $100.
FFS Panama: Nothing up to $100.
All charges greater than $100
FFS US: Nothing up to $100. All
charges greater than $100. 30
30 Page 31 32
2002 Panama Canal Area Benefit Plan 31
Section 5( b)
Section 5 (b). Surgical and anesthesia services
provided by physicians and
other health care professionals
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.
This Plan has no calendar year deductible. However,
in most cases, both POS and non-POS members will be asked to share the costs of
the procedures in the form of
a copayment or coinsurance. In some cases, FFS benefits may be applied to a
FFS
outpatient maximum of $650 for self-only and $1500 for self and family.
When
the benefits apply to the FFS outpatient maximum, we say "( Outpatient
maximum
applies)"
The FFS benefits are the standard benefits of this Plan. POS benefits apply
only when you use a POS provider. When no POS provider is available, FFS
benefits
apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special sections
for members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the
facility (i. e. hospital, surgical center, etc.).
YOU MUST GET PRECERTIFICATION OF ALL SURGICAL PROCEDURES. Please refer
to the precertification information shown in Section 3 to be sure which services
require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
After the calendar year deductible…
Surgical procedures You Pay
A comprehensive range of services such as:
Operative procedures Treatment of fractures, including casting
Normal
pre-and post-operative care by the surgeon Correction of amblyopia and
strabismus
Endoscopy procedures Biopsy procedures
Electroconvulsive
therapy
POS: Nothing.
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
Note: For plan allowances please see
page 64. 31
31 Page 32 33
2002 Panama Canal Area Benefit Plan 32
Section 5( b)
Surgical procedures-continued
You pay
Removal of tumors and cysts (non-cosmetic) Correction
of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual
weighs 100 pounds or 100% over his or her normal
weight according to current
underwriting standards; eligible
members must be age 18 or over
Insertion of internal prostethic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information
Voluntary sterilization, Norplant (a surgically implanted contraceptive), and
intrauterine devices (IUDs)
Eye Surgery Treatment of burns
Note: You must precertify all surgical procedures. In additional, we
may
require you to obtain a second surgical opinion for certain
procedures. If
you are planning to have a surgery, please call our
nursing department at
800-548-8969 in the US or 227-7555 in Panama
to precertify and determine
whether or not we require a second opinion
for your specific procedure.
If you do not precertify or obtain a required second opinion for your
procedure, you will be responsible for 50%. You pay nothing for the
second surgical opinion if we require you to obtain it.
POS: Nothing.
FFS Panama: 50% of the Panama POS Fee
schedule amount
for the primary procedure
and 50% of one-half of the Plan allowance
for
the secondary procedure( s); and any
difference between our payment and the
billed amount
FFS US: 50% of the US FFS Plan
allowance for the primary procedure and
50% of one-half of the Plan allowance for
the secondary procedure( s);
and any
difference between our payment and the
billed amount
When multiple or bilateral surgical procedures performed
during the same
operative session add time or complexity to
patient care, our benefits are:
For the primary procedure:
POS: 100% of the POS fee schedule amount or
FFS: 50% of the Plan allowance
For the secondary procedure( s):
POS: 100% of one-half of the POS fee
schedule amount or FFS: 50% of one-half of the Plan allowance
Note: Multiple procedures performed through the same incision may be
"incidental" to the primary surgery. That is, the procedure would not add
time or complexity to patient care. We do not pay extra for incidental
procedures.
POS: Nothing.
FFS Panama: 50% of the Panama POS Fee
schedule amount
for the primary procedure
and 50% of one-half of the Plan allowance
for
the secondary procedure( s); and any
difference between our payment and the
billed amount
FFS US: 50% of the US FFS Plan
allowance for the primary procedure and
50% of one-half of the Plan allowance for
the secondary procedure( s);
and any
difference between our payment and the
billed amount 32
32 Page 33 34
2002 Panama Canal Area Benefit Plan 33
Section 5( b)
Surgical procedures-continued
You pay
Not covered:
Reversal of voluntary
sterilization Services of an assistant surgeon except when required by
law.
Services of a standby surgeon, except during angioplasty or other high
risk procedures when we determine standbys are medically necessary
Routine treatment of conditions of the foot; see Foot care
All charges.
Note: We have designated the following as outpatient surgical
procedures.
If you undergo one of the following procedures inpatient
without explicit
approval from us, we will apply a $500 penalty:
Arthroscopy (internal exam of a joint) Breast Biopsy
Bronchoscopy (internal exam of lung), adult, with or without biopsy
Cataract removal Cystourethroscopy
Digestive tract endoscopy (internal
exam of esophagus, stomach, colon or rectum)
Dilation and curettage of
uterus (D& C) Excision of pilonidal cyst, simple
Laparoscopy (internal
exam of abdomen) with or without tubal ligation (female sterilization)
Laryngoscopy and tracheoscopy (internal exam of larynx and windpipe)
Myringotomy (incision of the membrane in ear) Prostate biopsy
Reduction
of nasal fracture, open or closed Vasectomy (male sterilization). 33
33 Page 34 35
2002 Panama Canal Area Benefit Plan 34
Section 5( b)
Reconstructive surgery You pay
Surgery to
correct a functional defect
Surgery to correct a condition caused by injury
or illness if:
the condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by such surgery.
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples
of congenital
anomalies are: protruding ear deformaties; 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;
breast
prostheses; and surgical bras and replacements (see Prosthetic devices for
coverage)
POS: Nothing.
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
Note: We pay for Internal breast prostheses as hospital benefits.
Note:
If you need a mastectomy, you may choose to have this
procedure performed on
an inpatient basis and remain in the
hospital up to 48 hours after the
procedure.
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical
appearance through change in bodily form, except repair of
accidental
injury.
Surgeries related to sex transformation or sexual dysfunction
All charges 34
34 Page
35 36
2002 Panama Canal Area Benefit
Plan 35 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures limited to:
Reduction of fractures of the jaws or facial bones Surgical correction of
cleft lip, cleft palate or severe functional
malocclusion
Removal of
stones from salivary ducts Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent
procedures
Other surgical procedures that do not involve the teeth or their
supporting structures.
POS: Nothing.
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva,
and alveolar
bone)
All charges
Organ/ tissue transplants
Limited to:
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 Allogeneic bone marrow transplants – only for patients
with acute lymphocytic or non-lymphocytc leukemia:
advanced Hodgkins
lymphoma; advanced non-Hodgkins
lymphoma; advanced neuroblastoma; and
testicular,
mediastinal, retroperitoneal and ovarian germ cell tumors.
Autologous bone marrow transplants (autologous stem cell support) and
autologous peripheral stem cell support for
acute lymphocytic or non-lymphocytic leukemia; advanced
Hodgkins
lymphoma; advanced non-Hodgkins
lymphoma; advanced neuroblastoma; breast
cancer;
multiple myloma and epithelial ovarian cancer; and
testicular,
mediastinal, retroperitoneal and ovarian germ
cell tumors.
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple
organs such as the liver, stomach, and pancreas
Note: We cover related
medical and hospital expenses of the donor
when we cover the recipient.
POS: Nothing
FFS Panama: 50% of the Panama POS
Fee schedule amount
and any difference
between the POS fee schedule and the
billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between our
allowance and the billed amount. 35
35 Page 36 37
2002 Panama
Canal Area Benefit Plan 36 Section 5( b)
Not covered:
Donor screening tests and donor search expenses, except those
performed for the actual donor
Implants of artificial organs Transplants not listed as covered
All charges
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
Professional services provided in –
Hospital outpatient department Skilled nursing facility
Ambulatory
surgical center Office
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
Note: If your POS provider uses a non-participating
anesthesiologist, we
will pay
FFS benefits for any anesthesia charges. 36
36 Page 37 38
2002 Panama Canal Area Benefit Plan 37
Section 5( c)
Section 5 (c). Services provided by a hospital or
other facility, and ambulance
services
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.
In this section a $75 per admission copayment for POS members
and a $125 per admission copayment for Non-POS members applies to only a few
benefits.
The FFS benefits are the standard benefits of this Plan. POS benefits apply
only when you use a POS provider. When no POS provider is available, non-POS
benefits apply.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works, with
special sections for members who are age 65 or
over. Also read Section 9
about coordinating benefits with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by the facility (i. e.
hospital or surgical center) or ambulance service for your surgery or care. Any
costs associated
with the professional charge (i. e. physicians, etc.) are in Sections 5( a)
or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO
WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the
precertification information shown in Section 3 to be sure which services
require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general nursing
care; and
meals and special diets.
NOTE: We only cover a private room when you must
be isolated to
prevent contagion. Otherwise, we will pay the hospital's
average
charge for semiprivate accommodations. If the hospital only has
private rooms, we base our payment on the average semiprivate rate
of
the most comparable hospital in the area.
NOTE: When the non-POS hospital bills a flat rate, we prorate
the charges
to determine how to pay them, as follows: 30%
room and board and 70% other
charges.
POS: Nothing after the $75 per admission
copayment
FFS Panama: $125 per admission, then
50% of the Panama POS Fee schedule
amount and any difference between the
POS fee schedule and the billed
amount
FFS US: $125 per admission and 50% of
the covered charges.
NOTE: When you select the POS
option and are readmitted to a
participating hospital with the same
diagnosis within 30 days of being
discharged, we will waive the $75
copayment for the readmission.
Inpatient hospital -Continued on next page. 37
37 Page 38 39
2002 Panama Canal Area Benefit Plan 38
Section 5( c)
Inpatient hospital -Continued You pay
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Blood or blood plasma, if not donated
or replaced
Dressings, splints, casts, and sterile tray services Medical
supplies and equipment, including oxygen
Anesthetics, including nurse
anesthetist services Take-home items— Except medicines
Medical supplies,
appliances, medical equipment, and any covered items billed by a hospital for
use at home.
NOTE: We base payment on whether the facility or a health
care professional bills for the services or supplies. For
example, when
the hospital bills for its nurse anesthetists'
services, we pay Hospital
benefits and when the
anesthesiologist bills, we pay Surgery benefits.
(see above)
Not covered:
Any part of a hospital admission that is not
medically necessary (see definition), such as 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.
Note: 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 definition. Non-covered facilities, such as
nursing homes or schools.
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Injectable drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced
Pre-surgical testing
Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services
and supplies related to dental
procedures when necessitated by a non-dental
physical
impairment. We do not cover the dental procedures.
POS: $75 Copayment to facility for
surgeries and nothing for other
services.
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount. 38
38
Page 39 40
2002
Panama Canal Area Benefit Plan 39 Section 5( c)
Extended care
benefits/ Skilled nursing care
facility benefits
You pay
Skilled nursing facility (SNF): We cover semiprivate room,
board,
services and supplies in a SNF for up to 60 days per
confinement when:
1) You are admitted directly from a precertified hospital stay
of at
least 3 consecutive days; and
2) You are admitted for the same condition as
the hospital
stay; and
3) Your skilled nursing care is supervised by a
physician and
provided by an R. N., L. P. N., or L. V. N.; and
4) SNF
care is medically appropriate.
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount.
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the billed
amount
Extended care benefit: Sub-Acute Care: We cover room, board
and general
nursing services, in a hospital or sub-acute care
facility, when we
determine that you are eligible for this less
acute hospital care.
POS: Nothing
FFS: Not an eligible benefit outside
of the POS network.
Not covered: Custodial care 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.
We pay $5000 per lifetime.
POS: Nothing until benefits stop at
$5000.
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount. You
pay all charges after the $5000
lifetime benefit maximum.
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount
You pay all charges after the $5000
lifetime benefit maximum.
Not covered: Independent nursing, homemaker All charges. 39
39 Page 40 41
2002 Panama Canal Area Benefit Plan 40
Section 5( c)
Ambulance (non-emergency) You pay
Professional ambulance service when medically appropriate.
Under the
POS option, we pay a maximum of $100 per incident for intra-province ambulance
service that results in
transfer between medical facilities or medical facility and
patient's
home.
Under the POS option, we pay a maximum of $200 per incident for
inter-province ambulance service that results in
transfer between medical facilities or medical facility and
patient's
home.
Under the FFS option, we pay a maximum of $100 per incident that results in
transfer between medical facilities or
medical facility and patient's home.
We require you to pre-authorize the
use of an ambulance if it is not an emergency situation.
NOTE: Under FFS benefits, we make no distinction between intra
and
inter-province ambulance use. The FFS benefit maximum is
$100.
POS: Nothing. All charges after $100
maximum for intra-province
ambulance use and $200 for inter-province
ambulance use.
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount. All
charges after $100 maximum
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
All charges after $100 maximum 40
40 Page 41 42
2002 Panama Canal Area Benefit Plan 41
Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
If you are a FFS member, almost all outpatient benefits are applied to an
outpatient maximum of $650 under the self only option and $1500 under the self
and family
option.
The FFS benefits are the standard benefits of this
Plan. POS benefits apply only when you use a POS provider. When no POS provider
is available, FFS benefits
apply.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special sections
for members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
I M
P O
R T
A N
T
What is an accidental injury?
An accidental injury is a bodily
injury sustained solely through violent, external, and accidental means, such as
broken bones, animal bites, and poisonings. We cover dental care for
accidental injury up to a maximum of $250.
Benefit Description You pay
Accidental injury
If you receive
care for your accidental injury within 72 hours, we cover:
Physician
services and supplies
Related outpatient hospital services
Note: We pay Hospital benefits if you are admitted.
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
Accidental injury --Continued on next page 41
41 Page 42 43
2002 Panama Canal Area Benefit Plan 42
Section 5( d)
Accidental injury-continued You
pay
If you receive care for your accidental injury after 72 hours, we
cover:
Physician services and supplies
Surgical care
Note: We pay Hospital benefits if you are admitted.
POS: $10 copayment for office visit
or emergency room visit.
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
Medical emergency
Outpatient medical or surgical services and
supplies
Note: We define medical emergency as the sudden and
unexpected onset of a
condition requiring immediate medical
care, that the covered person secures
within 72 hours after the
onset. The severity of the condition as revealed
by the doctors
diagnosis, must be such as would normally require emergency
care. Medical emergencies include heart attacks,
cardiovascular
accidents, poisonings, loss of consciousness or
respiration, convulsions,
and such other acute conditions as
may be determined by the Plan to be
medical emergencies
POS: $10 facility copayment for
emergency room visit or office visit.
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount. 42
42
Page 43 44
2002
Panama Canal Area Benefit Plan 43 Section 5( d)
Ambulance
We pay reasonable and customary charges up to $100 per
incident for
intra-province ambulance use and $200 for inter-province
ambulance use that
results in admission to a hospital
or transfer between medical facilities,
when pre-authorization
is obtained and services are provided by a Plan
participating
ambulance service provider.
Professional medical treatment and supplies (not first aid)
furnished
during the transportation of the patient when an
ambulance service charge is
authorized, will be reimbursed by
the Plan at reasonable and customary
charges.
NOTE: Under FFS benefits, we make no distinction between
intra and
inter-province ambulance use. The FFS benefit
maximum is $100.
Note: See5 (c) for non-emergent service
Air Ambulance
In certain extreme emergency situations we may pay for air
ambulance services to transfer a Panama member either from
outlying
areas in the Republic of Panama to Panama City, or
from Panama to the United
States if you require care that we
determine cannot be adequately provided
in the Republic of
Panama.
POS: Nothing. All charges after $100
maximum for intra-province
ambulance use and $200 for inter-province
ambulance use
FFS Panama: 50% of the Panama
POS Fee schedule amount and any
difference between the POS fee
schedule and the billed amount. All
charges after $100 maximum
FFS US: 50% of the US FFS Plan
allowance and any difference between
our allowance and the billed amount.
All charges after $100 maximum
POS: Nothing
FFS Panama: 50% of the Panama
POS Fee schedule amount
and any
difference between the POS fee
schedule and the billed amount
FFS US: Not an eligible benefit 43
43 Page 44 45
2002 Panama
Canal Area Benefit Plan 44 Section 5( e)
Section 5 (e). Mental
health and substance abuse benefits
I M
P O
R T
A N
T
You may choose to get care as Point-of-Service or Fee-for-Service (same as
before).
When you receive Point-of-Service (POS) care, you must get our
approval for services
and follow a treatment plan we approve. If you do,
cost-sharing and limitations for POS
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.
The outpatient and inpatient copayments apply to almost all benefits in this
section. We added "( No copayment)" to show when a copayment does not apply.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. See the
instructions after the benefits descriptions below.
POS mental health and substance abuse benefits are below, then
Fee-for-Service (FFS) benefits begin on page 46.
I M
P O
R T
A N
T
Point-of-Service Benefit
Description You Pay
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: POS 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.
Your cost sharing responsibilities are no
greater than for other
illnesses or
conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$10 copayment per visit
Diagnostic tests Nothing
Services provided by a hospital or other
facility Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
$75 per admission copayment or $10
copayment per office visit
Not covered: Services we have not approved
Note: OPM will base its
review of disputes about treatment plans on
the treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one
clinically appropriate treatment plan
in favor of another
All charges
Network mental health and substance abuse benefits --Continued on next
page. 44
44 Page
45 46
2002 Panama Canal Area Benefit
Plan 45 Section 5( e)
Point-of-Service Benefit –
CONTINUED
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
network authorization
processes. These include:
After your initial visit to your PCP (with a
mental health illness)
or a POS mental health provider, you or your provider
must
contact our nursing department. Our case management nurses
and
medical director will work with you and your mental health
provider to
develop a treatment plan for you.
If you are initially diagnosed with a
mental health illness while
in the hospital or emergency room, you, your
representative,
your doctor or the hospital must contact us within 48 hours
so
that we may coordinate a treatment Plan with you and your
mental
health provider.
If you fail to follow these obligations or do not follow
your
prescribed treatment Plan we will reimburse you at the Panama
FFS
benefit level.
Network limitation If you do not obtain an approved treatment plan, we
will provide only FFS benefits. 45
45 Page 46 47
2002 Panama
Canal Area Benefit Plan 46 Section 5( e)
Fee-for-Service
Benefit
Description You Pay
Fee-for-Service mental health and
substance abuse benefits
Outpatient Care
Mental Health: We pay for a maximum of 30 visits per
calendar
year. This benefit is subject to the outpatient
maximum limits of $650 (self
only) and $1500 (self and
family).
Substance Abuse: We pay a maximum of $30 per session
with a
licensed psychologist or clinical social worker. This
benefit has a $600
calendar year maximum and is subject
to the outpatient maximum.
Inpatient hospital
Mental Health: We pay for up to 90 days
per calendar
year
Substance Abuse: We pay for up to 30 days per
calendar year up to
a Plan limit of $700.
Inpatient professional charges: We pay our
allowance for a maximum
of one visit per day per
doctor.
FFS Panama: 50% of the Panama POS Fee
schedule amount and any difference
between
the POS fee schedule and the billed amount
FFS US: 50% of the US FFS Plan allowance
and any difference between our
allowance
and the billed amount
FFS Panama: 50% of the Panama POS Fee
schedule amount and any difference
between
the POS fee schedule and the billed amount
FFS US: 50% of the US FFS Plan allowance and
any difference between our
allowance and the
billed amount.
FFS Panama: 50% of Panama POS Fee
schedule amount and any difference
between the POS fee schedule and the
billed amount. $125 per admission
deductible applies.
FFS US: 50% of US FFS Plan allowance
and any difference between our
allowance
and the billed amount. $125 per admission
deductible applies.
FFS Panama: You pay all charges in excess
of $35 per doctor per day.
FFS US: You pay all charges in excess of
$35 per doctor per day. 46
46 Page 47 48
2002 Panama Canal Area Benefit Plan 47
Section 5( e)
FFS Benefit-continued You pay
Not covered FFS:
Marital, family, or other counseling or
training services.
Specialized treatment for mental retardation and/
or learning disabilities.
All charges for chemical aversion therapy,
condition reflex treatments, narcotherapy or any similar aversion
treatments
and all related charges (including room and
board).
All charges.
Precertification The medical necessity of your admission to a hospital
or other covered facility must be precertified for you to receive these FFS
benefits. Emergency admissions must be reported within two
business days following the day of admission even if you have been
discharged. Otherwise, the benefits payable will be reduced by
$500. See
section 3 for details.
See section 7, Filing a claim for covered services, for information
about submitting FFS claims. 47
47 Page 48 49
2002 Panama
Canal Area Benefit Plan 48 Section 5( f)
Section 5 (f).
Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
below.
All benefits are subject to the definitions, limitations and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
This Plans prescription drug deductible is $400 per member per calendar
year.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage,
including
with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or licensed
dentist must write the prescription.
Where you can obtain them. You may fill the prescription at any
pharmacy or, in the US, by mail.
How to submit your claims for
prescription drugs: Claims for prescription drugs and medicines must include
receipts that include the prescription number, name of drug, prescribing
doctor's name,
date and charge.
Benefit Description You Pay After the prescription drug deductible…
NOTE: The prescription drug deductible applies to all benefits in this
Section.
Covered medications and supplies You Pay
After a $400
deductible per member per calendar year has been met, we
Pay 50% of covered
expenses.
You may purchase the following medications and supplies
prescribed by a
physician from either 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
prescription for their purchase, except those
listed as Not
covered
Insulin Needles and syringes for the administration of covered
medications
FDA approved prescription drugs and devices for birth
control.
NOTE: We cover approved medications for treatment of cancers,
aplastic
anemia, sickle-cell anemia, and myelodysplasia syndrome
at 100% with no
deductible. Pre-authorization is required.
POS: 50% of charges plus any non-covered
expenses.
FFS Panama: 50% of charges plus any
non-covered expenses
FFS US: 50% of charges plus any non-covered
expenses. 48
48 Page 49 50
2002 Panama Canal Area Benefit Plan 49
Section 5( f)
Not covered:
Drugs and supplies for cosmetic
purposes Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Nonprescription medicines
Medical supplies such as dressings and antiseptics
All Charges 49
49 Page 50 51
2002 Panama
Canal Area Benefit Plan 50 Section 5( g)
Section 5 (g).
Special features
Special features Description
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.
Centers of excellence for
transplants/ heart
surgery/ etc
In the United States we have designated certain specialty
hospitals we
strongly encourage Plan members to use for
highly specialized procedures. If
you are planning to undergo
a highly specialized surgical procedure such as
open heart
surgery, or would like additional information on these
facilities, please call our case management department in the
United
States at 1-800-548-8969 or in Panama at 227-7555. 50
50 Page 51 52
2002 Panama Canal Area Benefit Plan 51
Section 5( h)
Section 5 (h). Dental benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine
they are medically necessary.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works,
with special sections for
members who are age 65 or over. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.
Note: We cover hospitalization for dental procedures only when a non-dental
physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient. We do not cover the dental procedure.
I
M
P
O
R
T
A
N
T
Accidental injury benefit
We cover restorative services and supplies
necessary to promptly repair (but not replace) sound natural teeth. The
need
for these services must result from an accidental injury. We pay 80% of our Plan
allowance up to a maximum
of $250 (per incident) for covered dental work
required as a result of accidental injury, that you incur within 52
weeks
after the accident. You pay all charges over $250. 51
51 Page 52 53
2002 Panama Canal Area Benefit Plan 52
Section 5( h)
Dental benefits
Service We pay (scheduled
allowance) You pay
Office visits for
preventive care. Oral
prophylaxis or
periodontal
maintenance limited to
two visits per
calendar
year.
Dental Surgery
Extraction of impacted
teeth, including X-rays
Apicoectomy
Lancing of erupting
tooth
Periodontics*
Periodontal scaling
and root planing
Endodontics*
Root Canal treatment,
including:
intra-oral drainage of
abscess
devitalization removal of pulp
root canal filling (limited to 4
canals), and
X-rays
$20 per visit
$100
$85
$70
$60 per quadrant
$120 for one canal
$150 for two canals
$180 for three canals
$210
for four canals
All charges in excess
of the scheduled
amounts listed to the
left
All charges in excess
of the scheduled
amounts listed to the
left
All charges in excess
of the scheduled
amounts listed to the
left
*Note: Prior to treatment, you must submit a completed dental Pre-Treatment
Estimate form to obtain approval of
benefits for the work to be performed.
If approval is not obtained, we will limit benefits to 50% of the fee schedule.
52
52 Page 53 54
2002 Panama Canal Area Benefit Plan 53
Section 6
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;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term, or when the
pregnancy is the result of an act of rape or incest.
Services, drugs, or supplies related to sex transformations;
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program;
Any portion of a provider's fee or charge that is ordinarily due
from the enrollee but has been waived. If a provider routinely waives (does not
require the enrollee to pay) a deductible or coinsurance, the Plan will
calculate the actual provider fee or charge by reducing the fee or charge of
the waived amount.
Charges the enrollee or Plan has no legal obligation to
pay, such as: excess charges for an annuitant age 65 or older who is not covered
by Medicare parts A and/ or B (see page 16), doctor's charges exceeding the
amount
specified by the Department of Health and Human Services when benefits are
payable under Medicare
(limiting charge) (see page 17), or State premium
taxes however applied;
Private duty nursing care services, in or out of hospital;
Expenses to
the extent they exceed the Plan allowance for the service or supply;
Weight
control or any treatment of obesity, except surgery for morbid obesity;
Any
facility not included in the definition of hospital or clinic;
Services of
any practitioner not included in the definition of covered provider, with the
exception of a physical, speech or occupational therapist; or
Eye refractions, eyeglasses and contact lenses.
Benefits will not be
paid for services and supplies when:
No charge would be made if the covered individual had no health insurance
coverage;
Furnished without charge while in active military service; or
required for illness or injury sustained on or after the effective date of
enrollment (1) as a result of an act of war within the United States, its
territories or
possessions, or within the Republic of Panama or (2) during combat;
Furnished by immediate relatives or household members, such as spouse,
parent, child, brother or sister by blood, marriage or adoption;
Furnished or billed by a non-covered facility, except that medically
necessary prescription drugs are covered;
For or related to sex
transformation, sexual dysfunction or sexual inadequacy;
Not specifically
listed as covered;
Investigational or experimental: or
Not provided in
accordance with accepted professional medical standards in the United States
and/ or Panama. 53
53 Page
54 55
2002 Panama Canal Area Benefit Plan 54 Section 7
Section
7. Filing a claim for covered services
How to claim benefits To obtain
claim forms or other claims filing advice or answers about our benefits, contact
us at 800-548-8969 in the US, 227-7555 in Panama or
732-222-9696 if you
reside elsewhere, or at our website at
http:// www. healthnetworkamerica.
com.
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 800-548-8969 in the US, 227-7555 in Panama
or
732-222-9696 if you reside elsewhere.
When you must file a claim --such as for overseas claims or when
another
group health plan is primary --submit it on the HCFA-1500 or a
claim form
that includes the information shown below. Bills and receipts
should be
itemized and show:
Name of patient and relationship to enrollee;
Plan identification number
of the enrollee;
Name and address of person or firm providing the service or
supply
Dates that services or supplies were furnished;
Diagnosis;
Type of
each service or supply; and
The 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 (EOB) from any primary
payer (such as the Medicare Summary Notice (MSN)) with
your claim.
Bills for home nursing care must show that the nurse is a registered or
licensed practical nurse.
Claims for speech, physical and occupational 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 must include receipts that include
the prescription number, name of drug or supply, prescribing
physician's
name, date, and charge.
You must provide translation and currency conversion services for claims for
overseas (foreign) services. 54
54 Page 55 56
2002 Panama
Canal Area Benefit Plan 55 Section 7
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 your claim Send us all documents for your claim as
soon as possible. You must file all claims within 90 days after the expense for
which you are making the
claim was incurred. We are not required to honor a
claim submitted after
the 90-day period unless you were prevented from
filing promptly due to
administrative operations of Government or legal
incapacity, provided you
submitted the claim as soon as reasonably possible.
Once we pay benefits,
there is a three year limitation on the reissuance of
uncashed checks.
Overseas claims For covered services you receive in hospitals outside
the United States, Panama and Puerto Rico and performed by physicians outside
the United
States, send a completed claim form and the itemized bills to:
Health
Network America, Inc. Panama Canal Area. P. O. Box 398. West Long
Branch, NJ 07764. You may also obtain claim forms from the same
address.
Send any written inquiries concerning the processing of
overseas claims to
this address.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 55
55 Page
56 57
2002 Panama Canal Area Benefit
Plan 56 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on
your claim or request for
services, drugs, or supplies – including a request for preauthorization/ prior
approval:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Health Network America, Inc. Panama Canal Area. P. O. Box 398.
West Long Branch, NJ 07764 (US and outside of Panama). If you reside in the
Republic of Panama,
please submit your disputed claim to HNA Panama, S. A.
Edificio Hatillo Local A. Esquina Avenida
Justo Arosemena y Calle 36 in
Panama City; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of
our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to 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 II,
1900 E Street, NW, Washington, D. C.
20415-3620. 56
56 Page
57 58
2002 Panama Canal Area Benefit
Plan 57 Section 8
The disputed claims
process-continued
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific
benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
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.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
800-548-8969 (in the US),
227-7555 (within the Republic of Panama) or 732-222-9696 (outside of the US
and Panama) and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division II at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 57
57
Page 58 59
2002
Panama Canal Area Benefit Plan 58 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older
Some people with disabilities, under 65
years of age.
People with End Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal employee on
January 1, 1983
or since automatically qualifies.) Otherwise, if you
are age 65 or older,
you may be able to buy it. Contact 1-800-
MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social
Security check or your retirement check.
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 Medicare Plan
(Part A or Part B) The Original
Medicare Plan (Original Medicare) is available everywhere
in the United
States. It is the way everyone used to get benefits and is the
way most
people get their Medicare Part A and Part B benefits now. You 58
58 Page 59 60
2002 Panama Canal Area Benefit Plan 59 Section 9
may go to
any doctor, specialist, or hospital that accepts Medicare. The
Original
Medicare Plan pays its share and you pay your share. Some
things are not
covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this plan, you
still need to follow the rules in this brochure for us to cover your care.
You are still required to fulfill all precertification requirements listed
on
pages 10-13.
Claims process when you have the Original Medicare Plan --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 800-548-8969
in the US or 227-
7555 in Panama or visit our website at
http:// www. healthnetworkamerica.
com.
We waive some costs when you have the Original Medicare Plan
--
When Original Medicare is the primary payer, we will waive some
out-of-
pocket costs, as follows:
Medical services and supplies provided by physicians and other
health
care professionals. If you are enrolled in Medicare Part B, we
will waive
your copayments and coinsurance amounts.
Hospital inpatient room and board
and other charges. If you are
enrolled in Medicare Part A, we waive your
copayment and
coinsurance amounts. 59
59
Page 60 61
2002
Panama Canal Area Benefit Plan 60 Section 9
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
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
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………………………………….………… !
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, ! (for
Part B
services)
!
(for other
services)
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,
!
(except for claims
related to Workers'
Compensation.)
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 !
d) Are a former spouse of an
active employee !
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 60
60 Page
61 62
2002 Panama Canal Area Benefit Plan 61 Section 9
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 managed
care plan is primary, even out of the managed
care plan's network and/ or
service area, but we will not waive any of our
copayments, coinsurance, 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 with your Physician A physician may ask you to sign
a private contract agreeing that you can
be billed directly for services
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 have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE 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 settlement or
other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
If you do not enroll in Medicare Part A or Part B 61
61 Page 62 63
2002 Panama Canal Area Benefit Plan 62
Section 9
Once OWCP or similar agency pays its maximum benefits for
your
treatment, we will cover your care.
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
for injuries When you receive money to
compensate you for medical or hospital care for injuries or illness caused by
another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement. If you do not
seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our subrogation procedures. 62
62 Page 63 64
2002 Panama Canal Area Benefit Plan 63
Section 10
Section 10. Definitions of terms we use in this
brochure
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. You may also be responsible for additional amounts. See page
14.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 14.
Covered services Services we provide benefits for, as described in
this brochure.
Custodial care Treatment or services, regardless of
who recommends them or where they are provided, that could be rendered safely
and reasonably by a
person not medically skilled, or that are designed
mainly to help the
patient with daily living activities. These activities
include but are not
limited to:
1. Personal care such as help in:
walking; getting in and out of bed;
bathing; eating by spoon, tube or
gastrostomy; exercising; dressing;
2. Homemaking, such as preparing meals or
special diets;
3. Moving the patient;
4. Acting as a companion or
sitter;
5. Supervising medication that can usually be self administered; or
6. Treatment or services that any person may be able to perform with
minimal instruction, including but not limited to recording
temperature,
pulse, and respirations, or administration and
monitoring of feeding tubes.
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 page 14.
Emergency See page 42 for definition of medical emergency.
Experimental or
investigational services A drug, device or
biological product is experimental or investigational if the drug, device or
biological product cannot be lawfully marketed
without approval of the U. S. Food and Drug Administration (FDA) and
approval for marketing has not been given at the time it is furnished.
Approval means all forms of acceptance by the FDA.
A medical treatment or procedure, or a drug, device, or biological
product is experimental or investigational if 1) reliable evidence shows
that it is subject to ongoing phase I, II, or III clinical trials or under
study
to determine its maximum tolerated dose, its toxicity, its safety, its
efficacy, or its efficacy compared with the standard means of treatment
or diagnosis; or 2) reliable evidence shows that the consensus of opinion
among experts regarding the drug, device or biological product or
medical treatment or procedure is that further studies or clinical trials
are
necessary to determine its maximum tolerated dose, its toxicity, its
safety, its efficacy, or its efficacy as compared with the standard means
of treatment or diagnosis. 63
63 Page 64 65
2002 Panama
Canal Area Benefit Plan 64 Section 10
Reliable evidence shall
mean only published reports and articles in the
authoritative medical and
scientific literature; the written protocol or
protocols used by the
treating facility or the protocol( s) of another facility
studying
substantially the same drug, device or medical treatment or
procedure; or
the written informed consent used by the treating facility or
by another
facility studying substantially the same drug, device or
medical treatment
or procedure. If you desire additional information
concerning the
experimental/ investigational determination process,
please contact the
Plan.
Group health coverage Health care coverage that a member is eligible
for because of employment, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies, or that pays a specific amount for
each day or period of hospitalization if the specified amount exceeds
$200 per day, including extension of any of these benefits through
COBRA.
Medical necessity Services, drugs, supplies or equipment provided by a
hospital or covered provider that we determine:
1. Are appropriate to
diagnose or treat your medical condition, illness
or injury;
2. Are
consistent with standards of good medical practice in the United
States;
3. Are not primarily for your personal comfort or convenience
4. Are not
part of or associated with your scholastic education or
vocational training;
and
5. In the case of inpatient care, cannot be provided on an
outpatient
basis.
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. We determine our allowance as
follows:
Panama Point-of-Service (In-network)
In the Republic of Panama, we
determine our Fee schedule amount by
applying the health care charges made
by local providers for health care
services or supplies in the absence of
insurance. From this determination
we have negotiated rates with all
point-of-service providers. These
negotiated rates are what we refer to in
the benefit section as the Panama
POS fee schedule.
Panama Fee-for-Service
If you reside in the Republic of Panama and
select the Fee-for-Service
option, or reside outside of Panama (including
the US) but receive
medical services within the Republic of Panama, we base
all claims
reimbursement payments on the Panama POS fee schedule (or
in-network)
amounts described above. However, your cost sharing
responsibility is much greater. Please refer to the section section 5
"Benefits" for additional detail regarding your responsibility. 64
64 Page 65 66
2002 Panama Canal Area Benefit Plan 65
Section 10
US Fee-for-Service
We use HIAA data for claims
incurred in the United States, updated
twice a year, at the 75 th percentile
to determine our Plan allowance. Some
inpatient doctor services are paid on
a fee schedule.
Us/ We Us and we refer to the Panama Canal Area Benefit Plan.
You You refers to the enrollee and each covered family member. 65
65 Page 66 67
2002 Panama Canal Area Benefit Plan 66 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had
limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing
or retirement office
about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to 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 available Self Only coverage is for you alone. Self
and Family coverage is for
for you and your family you, your spouse,
and your unmarried dependent children under age 22, including any
foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.
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.
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 or turns 22.
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
Premiums Start The benefits in this brochure are
effective on January 1. If you joined
this plan during Open Season, your
coverage begins on the first day of
your first pay period that starts on or
after January 1. Annuitants' 66
66 Page 67 68
2002 Panama
Canal Area Benefit Plan 67 Section 11
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 claims We will keep your medical and claims
information confidential. Only
records are confidential the following
will have access to it:
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
coordinating benefit payments and subrogating claims;
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 that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
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 will
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 coverage continue 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 Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
Temporary Continuance of Coverage (TCC) If you leave Federal service,
or if you lose coverage because you no
longer 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 and you
turn 22 or marry, 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 67
67 Page 68 69
2002 Panama Canal Area Benefit Plan 68 Section 11
Temporary
Continuation of Coverage and Former Spouse Enrollees,
from your
employing or retirement office or from www.
opm. gov/ insure.
It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under 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
Group Health Plan Coverage The Health
Insurance Insurance Portability and Accountability Act of 1996 (HIPAA) is a
Federal law that offers limited Federal protections 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 information 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.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB Program. See also the
FEHB website (www. opm. gov/ insure/ health);
refer to the "TCC and
HIPAA" frequently asked questions. These highlight
HIPAA rules, such
as the requirement that Federal employees 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. 68
68 Page 69 70
2002 Panama Canal Area Benefit Plan 69 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
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 (LTC) insurance?
It's insurance to help pay
for long term care services you may need if you 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 care in a nursing
home, in an assisted living facility, 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 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 old folks. 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 you should
have a plan just in case. LTC insurance may be vital to your financial and
retirement planning.
Is long term care expensive?
Yes. A year in a nursing home can
exceed $50,000 and only three 8-hour shifts a week can exceed $20,000 a year,
that's before inflation!
LTC can easily exhaust your savings but LTC insurance can protect it.
But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look under "Not covered" in sections 5( a) and 5( c) of
your FEHB brochure. Custodial care, assisted living, or continuing home health
care for activities of daily living are not covered. Limited stays in skilled
nursing facilities can be covered in some circumstances.
Medicare only
covers skilled nursing home care after a hospitalization with a 100 day limit.
Medicaid covers LTC for those who meet their state's guidelines, but restricts
covered services and where they
can be received. LTC 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 late summer/ early fall of
2002. Retirees will receive information at home.
How can I find out more about the program NOW?
A toll-free
telephone number will begin in mid-2002. You can learn more about the program
now at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think their health plan and/ or Medicare covers long-term
care. Unfortunately, they are WRONG! How are YOU planning to pay for the
future custodial or chronic care you may need? Consider buying long term care
insurance. 69
69 Page
70 71
2002 Panama Canal Area Benefit
Plan 70 Index
Index
Do not rely on this page; it is
for your convenience and may not show all pages where the terms appear.
Accidental injury 41 Allergy tests 24
Allogenetic (donor) bone
marrow
transplant 35
Alternative treatment 32
Ambulance 40,43
Anesthesia 36
Autologous bone marrow
transplant 35
Biopsies
31 Blood and blood plasma 38
Breast cancer screening 21
Casts 38
Catastrophic protection 15-16
Changes for 2002 8
Chemotherapy 25
Childbirth 23
Chiropractic 29
Cholesterol tests 20
Claims 54
Coinsurance 63
Colorectal cancer
screening 20
Congenital anomalies 32
Contraceptive devices and drugs 23
Coordination of benefits 58
Covered charges 64
Covered providers 9
Crutches 29
Deductible 14, 63
Definitions 63
Dental care
51-52
Diagnostic services 19
Disputed claims review 56-57
Donor
expenses (transplants) 35
Dressings 38
Durable medical equipment 28
Educational classes and programs 30 Effective date of enrollment 66
Emergency 42
Experimental or investigational 63
Eyeglasses 27
Family planning 23
Fecal occult blood test 20
Flexible
benefits option 50
Foot care 27
Freestanding ambulatory
facilities
38
General Exclusions 53
Hearing services 27 Home health services 29
Hospice care 39
Home nursing care 29
Hospital 10
Immunizations 21
Infertility 24
Inhospital physician care 20
Inpatient Hospital
Benefits 37
Insulin 48
Laboratory and pathological
services
20
Machine diagnostic tests 20 Magnetic Resonance Imagings
(MRIs) 20
Mammograms 21
Maternity Benefits 23
Medicaid 62
Medically necessary 64
Medically underserved areas 9
Medicare 17
Members Front Cover
Mental Conditions/ Substance
Abuse Benefits 44
Neurological testing 20 Newborn care 23
Nurse
Licensed Practical Nurse 29
Nurse Anesthetist 38
Nurse
Midwife 9
Nurse Practitioner 9
Psychiatric Nurse 9
Registered Nurse
10
Nursery charges 23
Nursing School Administered
Clinic 9
Obstetrical care 23 Occupational therapy 26
Ocular injury 27
Office visits 19
Oral and maxillofacial surgery 35
Orthopedic devices 28
Ostomy and catheter supplies
36
Out-of-pocket expenses 14
Outpatient facility care 38
Overseas
claims 54
Oxygen 38
Pap test 21 Physical examination 20
Physical therapy 26
Physician 9
Point-of-Service 6
Pre-admission testing 38
Precertification 47
Prescription drugs 48
Preventive care, adult 20
Preventive care, children 22
Prior approval 11
Prostate cancer
screening 21
Prosthetic devices 28
Psychologist 44
Psychotherapy 44
Radiation therapy 25 Renal dialysis 25
Room and board 37
Second surgical opinion 32 Skilled nursing
facility care 39
Smoking cessation 30
Social Worker 9, 44
Speech therapy 26
Splints 38
Sterilization procedures 32
Subrogation 62
Substance
abuse 44
Surgery 31
Anesthesia 36 Assistant surgeon 33
Multiple procedures 32 Oral 35
Outpatient 38 Reconstructive 34
Syringes 48
Temporary continuation of
coverage 67
Transplants 35
Treatment Therapies 25
Vision services 27
Well child care 22
Wheelchairs 29
Workers' compensation 61
X-rays 20 70
70 Page 71 72
2002 Panama canal Area Benefit Plan Summary 71
Summary of benefits for the Panama Canal Area Benefit Plan -2002
Do not rely on this chart alone. All benefits are subject to the
definitions, limitations, and exclusions in this brochure. 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.
Under
the FFS Option after we pay, you generally pay any difference between our
allowance and the billed amount.
If you are a POS member and receive your
medical care through your primary care physician and other POS providers you can
limit your out-of-pocket expenses. Please refer to Section 5 (benefits) for a
complete list of
POS benefits and your payment obligations under this
option.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
POS: $10 copayment
FFS Panama: 50% of the
Panama POS Fee schedule
amount and any difference
between the POS fee schedule
and the
billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the
billed amount.
19
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
POS: Nothing after the $75 per
admission copayment
FFS Panama: $125 per admission,
then 50% of the Panama POS Fee
schedule amount and any
difference between the POS fee
schedule and
the billed amount
FFS US: $125 per admission and
50% of all covered charges.
POS: $75 Copayment to
facility for surgeries and
nothing for other
services.
FFS Panama: 50% of the
Panama POS Fee schedule
amount and any
difference
between the POS fee schedule
and the billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the
billed amount.
37
38 71
71 Page
72 73
2002 Panama canal Area Benefit
Plan Summary 72
Emergency benefits:
Accidental injury (after 72
hours) ..................................................
Medical
emergency.........................................................................
POS: $10 copayment
FFS Panama: 50% of the
Panama POS Fee schedule
amount and any difference
between the POS fee schedule
and the
billed amount
FFS US: 50% of the US FFS Plan
allowance and any difference
between
our allowance and the
billed amount.
41
42
Mental health and substance abuse
treatment..................................... POS: Regular cost sharing
FFS: Benefits are limited
44
46
Prescription drugs
................................................................................
50% of eligible charges after the
$400 per member calendar year
deductible has been met.
48
Dental Care
.......................................................................................
scheduled allowances 51-
52
Protection against catastrophic costs
(your out-of-pocket
maximum).........................................................
Note: Applies only to FFS benefits only
After the 50% for hospital
inpatient room and board and other
expenses reaches $2,500 per
member per year, we will pay the
remaining hospital room and board
and other charges at 100%.
Some costs do not count toward
this protection
15-
16 72
72 Page
73 74
73
Notes 73
73 Page 74 75
74 74
74 Page 75
75
2002 Rate Information for
Panama Canal Area 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.
Non-Postal Premium
Biweekly Monthly
Type of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
Self Only 431 97.86 37.61 212.03 81.49
Self and Family 432 220.34
73.44 477.39 159.13 75