Serving: All of New York and Northern New Jersey
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 6 for
requirements.
This Plan has full accreditation from URAC See the 2002 Guide for more
information on accreditation.
Enrollment codes for this Plan:
801
Self Only 802 Self and Family
For changes in benefits,
see page 7.
RI73-007 1
1 Page
2 3
Table of Contents
Introduction
.....................................................................................................................................................................................
4
Plain
language...................................................................................................................................................................................
4
Inspector General
Advisory............................................................................................................................................................
4
Section 1. Facts about this Prepaid Plan
.....................................................................................................................................
6 We also have Point-of-Service (POS) benefits
.......................................................................................................
6
How we pay
providers.................................................................................................................................................
6
Your
rights.....................................................................................................................................................................
6
Service area
...................................................................................................................................................................
6
Section 2. How we change for
2002............................................................................................................................................
7
Program-wide
changes................................................................................................................................................
7
Changes to this
Plan.....................................................................................................................................................
7
Section 3. How you get
care..........................................................................................................................................................
8
Identification
cards.......................................................................................................................................................
8
Where you get covered care
.......................................................................................................................................
8
Plan providers
........................................................................................................................................................
8
Plan
facilities..........................................................................................................................................................
8
What you must do to get covered care
.....................................................................................................................
8
Primary care
...........................................................................................................................................................
8
Specialty care
.........................................................................................................................................................
8
Hospital care
..........................................................................................................................................................
9
Circumstances beyond our
control............................................................................................................................
9
Services requiring our prior
approval.......................................................................................................................
9
Section 4. Your costs for covered
services...............................................................................................................................
10
Copayments..........................................................................................................................................................
10
Deductible
............................................................................................................................................................
10
Coinsurance..........................................................................................................................................................
10
Your out-of-pocket
maximum.................................................................................................................................
10
Section 5. Benefits
........................................................................................................................................................................
11
Overview.....................................................................................................................................................................
11
(a) Medical services and supplies provided by physicians and other health
care professionals............. 12
(b) Surgical and anesthesia services
provided by physicians and other health care professionals......... 22
(c)
Services provided by a hospital or other facility, and ambulance services
.......................................... 27
(d) Emergency services/
accidents......................................................................................................................
30
(e) Mental health and substance abuse
benefits..............................................................................................
32
(f) Prescription drug benefits
.............................................................................................................................
34
(g) Special
features...............................................................................................................................................
37
Flexible benefit
options..............................................................................................................................
37
Large Case Management
...........................................................................................................................
37
Customer Service AnswerLine
.................................................................................................................
37
Services for deaf and hearing
impaired...................................................................................................
37
High risk
pregnancies.................................................................................................................................
37
Centers of excellence for transplants/ heart surgery/
etc........................................................................ 38
Travel benefit/ services
overseas...............................................................................................................
38
(h) Dental benefits
................................................................................................................................................
39 2
2 Page 3 4
(i) Point of service
product.................................................................................................................................
41
(j) Non-FEHB benefits available to Plan members
........................................................................................
43
Section 6. General exclusions --things we don't
cover...........................................................................................................
44
Section 7. Filing a claim for covered services
..........................................................................................................................
45
Section 8. The disputed claims
process.....................................................................................................................................
46
Section 9. Coordinating benefits with other
coverage.............................................................................................................
48
When you have…
Other health coverage
.......................................................................................................................................
48
Original Medicare
..............................................................................................................................................
48
Medicare managed care plan
...........................................................................................................................
50
TRICARE/ Workers' Compensation/ Medicaid
......................................................................................................
51
Other Government
agencies......................................................................................................................................
51
When others are responsible for injuries
................................................................................................................
51
Section 10. Definitions of terms we use in this brochure
.......................................................................................................
52
Section 11. FEHB
facts.................................................................................................................................................................
53
Coverage
information.................................................................................................................................................
53
No pre -existing condition limitation
..............................................................................................................
53
Where you get information about enrolling in the FEHB
Program.......................................................... 53
Types
of coverage available for you and your family
.................................................................................
53
When benefits and premiums
start..................................................................................................................
53
Your medical and claims records are
confidential.......................................................................................
54
When you
retire..................................................................................................................................................
54
When you lose
benefits..............................................................................................................................................
54
When FEHB coverage
ends.............................................................................................................................
54
Spouse equity
coverage....................................................................................................................................
54
Temporary Continuation of Coverage
(TCC)...............................................................................................
54
Converting to individual
coverage..................................................................................................................
55
Getting a Certificate of Group Health Plan
Coverage.................................................................................
55
Long term care insurance is coming later in 2002
....................................................................................................................
56
Index
....................................................................................................................................................................................
58
Summary of benefits
......................................................................................................................................................................
59
Rates
....................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 GHI Health Plan 4
Introduction/ Plain Language
Introduction
Group Health
Incorporated
441 Ninth Avenue New York, NY 10001
This brochure describes the benefits of Group Health Incorporated under our
contract (CS 1056) 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 beginning on page 6. 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 GHI Health Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the
Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you compare
plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www. opm.
gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write
to OPM at the Office of Personnel Management, Office of Insurance Planning and
Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650
Inspector General Advisory
Stop health care fraud! Fraud increases
the cost of health care for everyone. If you suspect that a physician, pharmacy,
or hospital has charged you for services you did not receive, billed you
twice for the same service, or misrepresented any information, do the
following:
Call the provider and ask for an explanation. There may be an
error.
If the provider does not resolve the matter, call us at (888) 456-3728 and
explain the situation.
If we do not resolve the issue, call 4
4
Page 5 6
2002 GHI
Health Plan 5 Introduction/ Plain Language
THE HEALTH CARE
FRAUD HOTLINE—( 202) 418-3300 or write to: 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. 5
5 Page 6 7
2002 GHI Health
Plan 6 Section 1
Section 1. Facts about this Prepaid Plan with
a Point-of-Service product
This Plan is a prepaid medical plan that
offers a point of service, or POS, product. Within the Plan's network you are
encouraged to select a personal doctor who will provide or arrange your care and
you will pay minimal amounts for
comprehensive benefits.
Because the
Plan emphasizes care through participating providers and pays the cost, it seeks
efficient and effective
delivery of health services. By controlling
unnecessary or inappropriate care, it can afford to offer a more comprehensive
range of benefits than many insurance plans. In addition to providing
comprehensive health services
and benefits for accidents, illness and injury, the Plan emphasizes
preventive benefits such as office visits, physicals,
immunizations and
well-baby care. You are encouraged to get medical attention at the first sign of
illness. Whenever you need services, you may choose to obtain them from your
personal doctor within the Plan's provider network or go
outside the network for treatment. When you choose a non-Plan doctor or other
non-Plan provider, you will pay a
substantial portion of the charges, and
the benefits available may be less comprehensive.
You should join a prepaid plan because you prefer the plan's benefits, not
because a particular provider is
available. You cannot change plans because
a provider leaves our Plan. We cannot guarantee that any one
physician,
hospital, or other provider will be available and/ or remain under contract with
us.
We also have Point-of-Service (POS) benefits:
Our prepaid Plan
offers Point-of-Service (POS) benefits. This means you can receive covered
services from a
non-participating provider. These out-of-network benefits
have higher out-of-pocket costs than our in-network benefits.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB Plans provide certain information to their
FEHB members. You may get information about us, our networks, providers, and
facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required
information is listed below.
GHI is URAC-accredited and is licensed under
Article 43 of the New York State Insurance Law as a health services corporation.
GHI has been in continuous existence for over sixty (60) years GHI is a
not-for-profit New York corporation
If you want more information about us, call 212/ 501-4GHI (4444), or write to
GHI, PO Box 1701, New York, NY 10023-9476. You may also visit our website at
www. ghi. com.
Service area
To enroll with us, you must live or
work in our service area. This is where our providers practice. Our service area
is:
all of New York and the New Jersey counties of Bergen, Essex, Hudson,
Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex and Union.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the area (for example, if
your child goes to college in another state), you should consider
enrolling
in a fee-for-service plan or an HMO that has agreements with affiliates in other
areas. If you or a family
member move, you do not have to wait until Open
Season to change plans. Contact your employing or retirement office. 6
6 Page 7 8
2002 GHI Health Plan 7 Section 2
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)
Changes to this
Plan
We no longer limit total blood cholesterol tests to certain age
groups. (Section 5( a))
We now cover routine screening for chlamydial
infection. (Section 5( a))
We increased speech therapy benefits by
removing the requirement that services must be required to restore functional
speech. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We
clarified the brochure to show why we think you should use generic drugs
whenever possible. We moved other language around within the Prescription drugs
section but didn't change its meaning. (Section 5( f))
Your share of the non-Postal premium will increase by 51.2% for Self Only
or 40.9% for Self and Family.
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.
We clarified the Family planning and Infertility benefits by providing more
examples of covered and not covered benefits. (Section 5( a))
We clarified
Surgical procedures to show that we cover a comprehensive range of services,
such as operative procedures. (Section 5( b))
We clarified the Medicare
Primary Payer Chart to explain how we coordinate benefits for former spouses.
(Section 9)
We clarified other language about coordinating benefits with
Medicare. (Section 9)
Under the Prescription Drug benefits section, the
following changes were made:
The Retail Drug copays have been increased
from $5 to $10 for generic drugs, $15 to $20 for a name brand drug which is
listed on the preferred prescription drug formulary, and $30 to $50 for a brand
name drug which is not
listed on the preferred prescription drug formulary.
The Maintenance
Drug copay has been increased from $10 to $20 for a generic drug, $30 to $40 for
a name brand drug which is listed on the preferred prescription drug formulary,
and $60 for a brand name drug which
is not listed on the preferred prescription drug formulary.
The office
copay has been increased from $10 to $15 per office visit.
There will be a
$10 copay for diagnostic x-rays and laboratory tests. A maximum of two
diagnostic copays will apply per date of service.
The emergency room copay has been increased from $25 to $50 7
7 Page 8 9
2002 GHI Health Plan 8 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it
whenever you receive services from a
Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your
ID card, use your copy of the
Health Benefits Election Form, SF-2809, your
health benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation
letter.
If you do not receive your ID card within
30 days after the effective date of your enrollment, or if you need replacement
cards, call us at 212/ 501-4GHI
(4444).
Where you get covered care
You get care from "Plan providers" and "Plan facilities." You will only pay
copayments, deductibles, and/ or coinsurance, and you will not have
to file
claims. If you use our point-of-service program, you can also get
care from
non-Plan providers, or from participating providers without a required referral,
but it will cost you more.
Plan providers A "provider" is any duly-licensed doctor,
dentist, podiatrist, qualified clinical psychologist, optometrist, chiropractor,
nurse, certified midwife,
nurse practitioner/ clinical specialist, or
qualified clinical social worker
and any other duly-licensed, registered or
certified practitioner or privately-operated facility permitted to perform or
render care or service
described in this brochure.
We list Plan providers in the provider
directory, which we update periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically. The list is also on our website.
What you must do to get covered care Within the Plan's network, you
are encouraged to select a personal
doctor who will provide or arrange your
care, in which case you will pay
minimal amounts for comprehensive benefits.
When you choose a non-Plan doctor or other non-Plan provider, you will pay a
substantial portion
of the charges, and the benefits available may be less comprehensive.
Primary care You may seek care from covered, doctor, dentist,
podiatrist, qualified clinical psychologist, optometrist, chiropractor, nurse,
certified midwife,
nurse practitioner/ clinical specialist, or qualified
clinical social worker and any other duly-licensed, registered or certified
practitioner or
privately-operated facility permitted to perform or render
care or service described in this brochure.
Specialty care You may see the specialist of your choice, whenever
you and your family feel you need care. Here are other things you should know
about
specialty care:
If you have a chronic or disabling condition and
lose access to your specialist because we: 8
8
Page 9 10
2002
GHI Health Plan 9 Section 3
– terminate our contract with your
specialist for other than cause; or
– drop out of the Federal Employees
Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
– reduce our service area and you enroll in another FEHB Plan
You may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the
Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and
you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise your care. This includes
admission
to a skilled nursing or other type of facility.
If you are in
the hospital when your enrollment in our Plan begins, call
our customer
service department immediately at 212/ 501-4GHI (4444). If you are new to the
FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 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.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to assist you with the necessary care.
Services requiring our prior approval For certain services, your
physician must obtain approval from us.
Before giving approval, we consider
if the service is covered, is medically necessary, and follows
generally-accepted medical practice.
We call this review and approval process precertification. Your physician
must obtain precertification for the following services:
High-tech nursing
Infusion therapy
Mental Health and Substance Abuse
Non-emergency
hospital admissions All inpatient hospital admissions for maternity care and
skilled
nursing facilities 9
9 Page
10 11
2002 GHI Health Plan 10
Section 4
Section 4. Your costs for covered services
You
must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc. when you receive services.
Example: When you see a participating provider you pay a copayment of $15 per
office visit and when you go in the hospital, you pay nothing.
Deductible A deductible is a fixed expense you must pay for certain
covered services and supplies before we start paying benefits for them.
Copayments do not count towards
any deductible.
The calendar year
deductible for certain services is:
For nursing service, you pay an annual deductible of $150 per individual or
family.
For appliances, oxygen or equipment, you pay an annual deductible of $100
per individual or family.
For referred ambulatory, laboratory tests and
diagnostic x-rays, you pay a $25 deductible per referral.
Catastrophic
services, you pay a $5000 annual deductible.
Note: If you change plans
during open season, you do not have to start a new deductible under your old
plan between January 1 and the effective date of your
new plan. If you change plans at another time during the year, you must begin
a
new deductible under your new plan.
And, if you change options in this Plan during the year, we will credit the
amount of
covered expenses already applied toward the deductible of your old
option to the deductible of your new option.
Coinsurance Any amount in excess of 50% of the Plan's fee schedule
for POS services provided by non-participating providers.
Your
out-of-pocket
maximum for deductibles,
coinsurance,
and copayments
After your out-of-pocket expenses total $5000 per person in any calendar year
for
covered services provided by a non-participating provider, GHI will then
pay catastrophic benefits at 100% of reasonable and customary charges as
determined
by the Plan. Out-of-pocket expenses are calculated based upon the reasonable
and
customary charge for covered catastrophic services. Covered catastrophic
services include: 1) surgery, 2) administration of anesthesia, 3) chemotherapy
and radiation
therapy, 4) covered in-hospital service and diagnostic services, and 5)
maternity.
However, expenses for the following services do not count toward
your out-of-pocket maximum:
Home and office visits and related diagnostic services Nursing,
Appliances, Oxygen and Equipment
Dental services Vision services
Prescription drugs 10
10 Page
11 12
2002 GHI Health Plan 11
Section 5
Section 5. Benefits --OVERVIEW
(See page 7
for how our benefits changed this year and page 53 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us
at 212/ 501-(4444) or at our website at www. ghi. com.
(a) Medical
services and supplies provided by physicians and other health care professionals
............................... 11-21
Diagnostic and treatment services
Lab, X-ray, and other diagnostic
tests Preventive care, adult
Preventive care, children
Maternity care Family planning
Infertility services
Allergy care Treatment therapies
Physical and occupational therapies
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices Durable medical
equipment (DME)
Home health services
Chiropractic Educational classes and programs
Alternative treatments
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ........................... 22-26
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other
facility, and ambulance
services............................................................. 27-29
Inpatient hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents
........................................................................................................................................
30-31
Medical emergency Ambulance
(e) Mental health and substance
abuse
benefits.................................................................................................................
32-33
(f) Prescription drug
benefits................................................................................................................................................
34-35
(g) Special features
.......................................................................................................................................................................
37
Flexible benefit options
Large Case Management Customer Service
AnswerLine
Services for deaf and hearing impaired
High risk pregnancies
Centers of excellence for transplants/ heart
surgery/ etc. Travel benefit/ services overseas
(h) Dental
benefits...................................................................................................................................................................
39-40
(i) Point of service
benefits...................................................................................................................................................
41-42
(j) Non-FEHB benefits available to Plan members
................................................................................................................
43
Summary of benefits
......................................................................................................................................................................
59 11
11 Page 12
13
2002 GHI Health Plan 12 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 to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan providers or non-Plan providers can provide or arrange your care.
Limit out-of-pocket costs by using participating providers.
The calendar
year deductible for certain services is:
For nursing services, you pay an
annual deductible of $150 per individual or family.
For appliances, oxygen
or equipment, you pay an annual deductible of $100 per individual or family.
For referred ambulatory laboratory test and diagnostic x-rays, you pay a
$25 deductible per referral.
Catastrophic services, you pay a $5000 annual
deductible.
We added asterisks -* -to show when the calendar year deductible
does not apply.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services*
Professional services of physicians
In physician's office
$15
per visit for participating providers.
POS: 50% of the Plan's fee schedule for non-participating providers, and any
difference between our fee schedule
and the billed amount.
Professional services of physicians
In an urgent care center
Office medical consultations
Second surgical opinion
$15 per visit for participating providers.
POS: 50% of the Plan's fee
schedule for non-participating providers, and any
difference between our fee
schedule
and the billed amount.
During a hospital stay
In a skilled nursing facility
Initial
examination of a newborn child covered under a family enrollment
No copay for participating providers.
POS: 50% of the Plan's fee schedule
for non-participating providers, and any difference between our fee schedule
and the billed amount.
Diagnostic and treatment services continued on next page 12
12 Page 13 14
2002 GHI Health Plan 13 Section 5( a)
Diagnostic and treatment services* (continued) You pay
At home $15 per visit for participating providers.
POS: 50% of the Plan's fee schedule
for non-participating providers, and
any difference between our fee schedule
and the billed amount.
Lab, X-ray and other diagnostic tests*
Tests, such as:
Blood tests
Urinalysis
Non-routine Pap
tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/
MRI
Ultrasound
Electrocardiogram and EEG
$10 per each diagnostic x-ray + laboratory test performed by a
participating provider. A maximum of two diagnostic copays will apply per
date of service
POS: For non-participating providers, you pay any
difference between our fee
schedule and the billed amount.
Preventive care, adult*
Routine screenings, such as:
Total
Blood Cholesterol – once every three years
Colorectal Cancer Screening,
including
– Fecal occult blood test
$10 per each diagnostic x-ray + laboratory test performed by a
participating provider. A maximum of
two diagnostic copays will apply
per date of service
POS: For non-participating providers,
you pay any difference between our
fee schedule and the billed amount.
– Sigmoidoscopy, screening – every five years starting at age 50 $15 per
visit for participating providers.
POS: 50% of the Plan's fee schedule
for non-participating providers, and any difference between our fee schedule
and the billed amount.
Prostate Specific Antigen (PSA test) – one
annually for men age 40
and older
$10 per each diagnostic x-ray +
laboratory test performed by a participating provider. A maximum of
two diagnostic copays will apply per
date of service
POS: For non-participating providers, you pay any difference between our fee
schedule and the billed amount. 13
13 Page 14 15
2002 GHI Health
Plan 14 Section 5( a)
Preventive care, adult* (continued)
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
$10 per each diagnostic x-ray +
laboratory test performed by a
participating provider. A maximum of
two diagnostic copays will apply per
date of service
POS: For non-participating providers, you pay any difference between our fee
schedule and the billed amount.
Not covered: Physical exams required
for obtaining or continuing employment or insurance, attending schools or camp,
or travel. All charges.
Routine immunizations, limited to:
Tetanus-diptheria (Td) booster –
once every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$15 per visit for participating providers.
POS: 50% of the Plan's fee
schedule
for non-participating providers, and any difference between our fee
schedule
and the billed amount.
Preventive care, children* You pay
Childhood immunizations recommended by the American Academy of Pediatrics No
copay for participating providers.
POS: 50% of the Plan's fee schedule
for non-participating providers, and any difference between our fee schedule
and the billed amount.
Well-child care charges for routine examinations, immunizations and care
(through age 22) No copay for participating providers.
POS: 50% of the
Plan's fee schedule for non-participating providers, and any
difference
between our fee schedule and the billed amount.
Examinations, such as:
-Eye exams to determine the need for vision
correction
-Ear exams to determine the need for hearing correction
$15 per visit for participating
providers.
POS: 50% of the Plan's fee schedule for non-participating providers, and any
difference between our fee schedule and the billed amount.
Examinations done on the day of immunizations (through age 22) No copay for
participating providers.
POS: 50% of the Plan's fee schedule for
non-participating providers, and any
difference between our fee schedule
and the billed amount. 14
14 Page 15 16
2002 GHI Health
Plan 15 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 must
precertify your normal delivery. Maternity admissions should be precertified no
later than the second trimester.
You may remain in the hospital up to 48 hours after a regular delivery and
96 hours after a cesarean delivery. We will extend your inpatient
stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits
(Section 5b).
A single $15 copay for all pre-and post-natal care from a participating
provider.
POS: 50% of the Plan's fee schedule for non-participating
providers, and any
difference between our fee schedule and the billed amount.
Not covered: Routine sonograms to determine fetal age, size or sex. If
enrollment in the Plan is terminated during pregnancy, benefits will not be
provided after coverage under the plan has ended.
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 injectable fertility drugs under medical benefits and
oral fertility
drugs under the prescription drug benefit.
$15 per visit for participating providers.
POS: 50% of the Plan's fee
schedule
for non-participating providers, and any difference between our fee
schedule
and the billed amount.
Not covered: reversal of voluntary surgical sterilization, genetic
counseling. All charges. 15
15 Page 16 17
2002 GHI Health
Plan 16 Section 5( a)
Infertility services* You pay
Diagnosis and treatment of infertility, such as:
In vitro
fertilization (limited to three transfers per lifetime)
Embryo transfer
Artificial insemination Intravaginal insemination
Intracervical insemination Intrauterinal insemination
Fertility drugs
Note: We cover injectable fertility drugs under medical
benefits and oral fertility drugs under the prescription drug benefit.
$15 per visit for participating
providers.
POS: 50% of the Plan's fee schedule for non-participating providers, and any
difference between our fee schedule and the billed amount.
Not covered: Cost of donor sperm All charges.
Allergy care* You
pay
Testing and treatment
Allergy injections
Treatment materials (such as allergy serum)
$15 per visit for participating providers.
POS: 50% of the Plan's fee
schedule
for non-participating providers, and any difference between our fee
schedule
and the billed amount.
Not covered: Provocative food testing and
sublingual allergy desensitization All charges.
Treatment therapies* You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under Organ/ Tissue
Transplants on page 24.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
In a doctor's office, nothing for a participating provider.
POS: In a
doctors office, 50% of the Plan's fee schedule, for non-participating
providers, and any
difference between our fee schedule and the billed
amount.
High-tech nursing and infusion therapy
-IV infusion therapy
-Parenteral and enteral therapy
-Other home IV therapies
Note:
Contact us at (212) 615-4662 prior to receiving services to ensure
coverage.
Intermittent home nursing service
-Provided by a Registered Nurse or
Licensed Practitioner
-Authorized and supervised by a doctor
-Intermittent visits less than 2 hours per day
Nothing for a participating provider.
POS: All charges for
non-participating
providers. 16
16 Page 17 18
2002 GHI Health
Plan 17 Section 5( a)
Treatment therapies* (continued)
You pay
Growth hormone therapy (GHT). This benefit is provided
under our Prescription Drug Benefits. Generic drug: $10 copay per prescription
or refill
Name brand drug, listed on formulary:
$20 copay per prescription or
refill
Name brand drug not on formulary: $50 copay per prescription or refill
Not covered:
Treatment for experimental or investigational
procedures.
Therapy necessary for transsexual surgery.
All charges.
Physical and occupational therapies* You pay
60 visits per
condition for the services of each of the following:
qualified physical
therapist;
occupational therapist.
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.
Occupational therapy is limited to services that assist the member to
achieve and maintain self-care and improved functioning in other daily
living activities.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction.
$15 per visit for participating providers.
POS: 50% of the Plan's fee
schedule for non-participating providers, and any
difference between our fee
schedule
and the billed amount.
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
60 visits per condition $15 per visit for
participating providers.
POS: 50% of the Plan's fee schedule for non-participating providers, and any
difference between our fee schedule
and the billed amount.
Hearing services (testing, treatment, and supplies)*
Hearing
testing $15 per visit for participating providers.
POS: 50% of the Plan's fee schedule
for non-participating providers, and
any difference between our fee schedule
and the billed amount.
Not covered: hearing aids All charges. 17
17 Page 18 19
2002 GHI Health Plan 18 Section 5( a)
Vision services (testing, treatment, and supplies)* You pay
Medical and surgical benefits for diagnosis and treatment of diseases of the
eye. $15 per visit for participating provider.
For non-participating
providers, you pay 50% of the Plan's fee schedule and
any difference between our fee schedule and the billed amount.
Examination of the eyes to determine if glasses are required: once each
calendar year.
One set of single vision or bifocal lenses (toric kryptok
or flat top 22mm): once each calendar year.
One pair of basic frames from
available styles: one every two years.
Contact lenses for certain unusual
medical conditions (such as post cataract surgery or keratoconus treatment).
Replacement of broken lenses with lenses of the same prescription and
material originally supplied.
Nothing for services provided by
participating opticians, optometrists
and vision centers.
POS: For non-participating providers,
you pay any difference between our
fee schedule and the billed amount.
Not covered:
Frames at any time unless lenses are also
provided.
Replacement or repair of frames.
Certain
bifocals and trifocals, tinted, plastic and oversized lenses and sunglasses and
frames other than basic frames; contact lenses for
cosmetic purposes.
Charges in excess of the maximum GHI
allowance.
All charges.
Foot care*
Podiatric services, including the routine treatment of
corns, calluses,
and bunions, and the partial removal of toenails, are
limited to 4 visits per calendar year.
$15 per visit for participating
provider.
For non-participating providers, you pay 50% of the Plan's fee schedule and
any difference between our fee
schedule and the billed amount.
Not covered:
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)
Orthodic devices for
the feet.
All charges. 18
18 Page 19 20
2002 GHI Health
Plan 19 Section 5( a)
Orthopedic and prosthetic devices You
pay
Artificial limbs and eyes; stump hose.
Externally worn
breast prostheses and surgical bras, including necessary replacements, following
a mastectomy.
Orthopedic devices, such as braces.
Ostomy supplies.
Internal
prosthetic devices, such as artificial joints, pacemakers, cochlear implants,
and surgically implanted breast implant
following mastectomy.
20% of the Plan's fee schedule for a participating provider.
POS: 50% of
the Plan's fee schedule
and any difference between our allowance and the
billed amount for a
non-participating provider.
Note: $100 deductible applies per individual
or family. There is a
combined maximum of $25,000 per
year per person with these benefits and
private duty nursing.
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel
cups
lumbosacral supports
corsets, trusses, elastic
stockings, support hose, and other supportive devices
corrective appliances for treatment of tempormandibular joint (TMJ) pain
dysfunction syndrome.
All charges.
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, including repair and adjustment, of durable medical equipment prescribed
by your Plan physician, such as
oxygen and dialysis equipment. Under this
benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at (212) 615-4662 as soon as your Plan physician
prescribes
this equipment. We will arrange with a healthcare provider to rent or sell you
durable medical equipment at discounted rates and
will tell you more about this service when you call.
20% of the Plan's fee scheduled for a participating provider.
POS: 50% of
the Plan's fee schedule
and any difference between our allowance and the
billed amount for a
non-participating provider.
Note: $100 deductible applies per individual
or family. There is a
combined maximum of $25,000 per
year per person with these benefits and
private duty nursing.
Not covered
Hearing aids and air purification devices
Alarm and Alert Services
All charges. 19
19 Page 20 21
2002 GHI Health
Plan 20 Section 5( a)
Home health services* You pay
The following conditions must be met:
Home health care must be
provided and billed by a certified home health agency, which has an agreement
with GHI to provide home
health care services.
You must remain under the care of a medical
doctor.
The services are provided according to a plan of treatment
approved by the attending medical doctor.
Medical evidence substantiates that you would have required further
inpatient care had the home health care not been available. .
The following
services are covered:
Part-time or intermittent nursing care by a
registered professional nurse (R. N.) or a home health aide under the
supervision of a
registered professional nurse.
Physical therapy.
Respiration or
inhalation therapy.
Prescription drugs.
Medical supplies which serve
a specific therapeutic or diagnostic purpose.
Other medically necessary services or supplies that would have been
provided by a hospital if the subscriber were still hospitalized.
Nothing for a participating provider.
POS: All charges for a
non-participating provider.
Private Duty Nursing services rendered at home or in the hospital by a
registered nurse (R. N.) or when an R. N. is not available by a licensed
practical nurse (L. P. N).
Nothing for a participating provider.
POS: 50% of the Plan's fee schedule
and any difference between our
allowance and the billed amount for a
non-participating provider.
Note: $150 annual deductible applies per person or family. There is a
combined maximum of $25,000 per calendar year per person with these
benefits and Durable Medical
Equipment.
Not covered:
Homemaking services, including housekeeping,
preparing meals, or acting as a companion or sitter.
Services and supplies related to normal maternity care.
Services and supplies provided following a noncovered hospital admission or
admission to a facility that is not a participating facility.
Services and supplies provided when the subscriber would not have
required continued inpatient care.
Services and supplies provided
by a non-participating facility for home health care.
High-tech
nursing and infusion therapy.
All charges. 20
20 Page 21 22
2002 GHI Health
Plan 21 Section 5( a)
Chiropractic*
Manipulation of
the spine and extremities
Adjustment procedures such as ultrasound,
electrical muscle
stimulation, vibratory therapy, and cold pack application.
$15 per visit for participating providers.
POS: 50% of the Plan's fee schedule
for non-participating providers, and
any difference between our fee schedule
and the billed amount.
Not covered:
naturopathic services
hypnotherapy
biofeedback
acupuncture
All charges.
Alternative treatments You pay
No Benefit All charges
Educational classes and programs
Coverage is limited to:
Diabetes self-management Cholestoral Management
Arthritis Asthma
Hepatitis C Multiple Sclerosis
Depression
Osteoporosis
Nothing 21
21 Page
22 23
2002 GHI Health Plan 22
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 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. 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 at Section 5 (c) for
charges associated with
facility (i. e., hospital, surgical center, etc.).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which
services
require precertification and identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
NOTE: The calendar year deductible applies
to almost all benefits in this Section. We say "No Benefit" when
it does not
apply.
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia
and strabismus
Endoscopy procedures
Biopsy procedures
Removal
of tumors and cysts
Correction of congenital anomalies (see reconstructive
surgery)
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.
$15 per office procedure for a participating provider.
Nothing for a
participating provider in a hospital or a participating ambulatory
surgery
center.
POS: 50% of the Plan's fee schedule and any difference between our
fee
schedule and the billed amount for non-participating
providers. 22
22 Page 23 24
2002 GHI Health Plan 23 Section 5( b)
Surgical procedures (continued) You pay
Voluntary
sterilization
Treatment of burns
$15 per office procedure for
participating providers.
Nothing for a participating provider in the hospital or a participating
ambulatory surgery center.
POS: 50% of the Plan's fee schedule and any
difference
between our fee schedule and the
billed amount for non-participating
providers.
Not covered:
Reversal of voluntary sterilization.
Elective cosmetic surgery.
Cost of donor sperm.
Stand-by services.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery.
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.
$15 per office procedure for
participating providers.
Nothing for a participating provider in the hospital or a participating
ambulatory surgery center.
POS: 50% of the Plan's fee schedule and any
difference
between our fee schedule and the billed amount for non-participating
providers.
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).
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours
after the procedure.
$15 per office procedure for participating providers.
Nothing for a
participating provider
in the hospital or a participating ambulatory surgery
center.
POS: 50% of the Plan's fee schedule
and any difference between our fee
schedule and the billed amount for non-participating
providers.
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges 23
23 Page 24 25
2002 GHI Health
Plan 24 Section 5( b)
Oral and maxillofacial surgery
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, and
Removal of impacted teeth
Other surgical procedures that do not
involve the teeth or their supporting structures.
$15 per office procedure for participating providers.
Nothing for a
participating
provider in the hospital or a participating ambulatory
surgery center.
POS: 50% of the Plan's fee schedule and any difference
between our fee schedule and the
billed amount for non-participating
providers.
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 other procedures involving the teeth or intra-oral areas surrounding
the teeth are not covered, including any dental care involved in the
treatment of teporomandibular joint (TMJ) pain dysfunction syndrome.
All charges. 24
24 Page 25 26
2002 GHI Health
Plan 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Human Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach,
and pancreas.
National Transplant Program (NTP) – We will cover
transplants approved as safe and effective for a specific disease by the Federal
Drug
Administration (FDA) or National Institute of Health, or which our
Medical Director determines is medically necessary, appropriate and
advisable on a case-by-case basis. We will cover the medical and
hospital services, and related organ acquisition costs. Eligibility for
transplants will be determined and approved in advance solely by our Medical
Director upon recommendation of your PCP. Additionally, all
transplants must be performed at hospitals specifically approved and
designated by us to perform these procedures. Specialty physician experts
from our designated centers of excellence will provide clinical
review and support to the Medical Director's decision.
Limited Benefits –
Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may
be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the
Plan's medical director in accordance with the Plan's protocols.
$15 per office procedure for participating providers.
Nothing for a
participating provider
in the hospital or a participating ambulatory surgery
center.
POS: 50% of the Plan's fee schedule
and any difference between our fee
schedule and the billed amount for non-participating
providers. 25
25 Page
26 27
2002 GHI Health Plan 26
Section 5( b)
Organ/ tissue transplants (continued) You pay
We cover:
We cover related medical and hospital expenses of the
donor when we cover the recipient up to a maximum of $10, 000 per transplant.
Travel expenses up to a maximum of $150 per person per day and $10,000 per
lifetime of the recipient if the recipient patient lives more
than 75 miles
from the transplant center. This includes food and lodging for the recipient
patient and one adult family member (two, if the
recipient is a minor) to
the city where the transplant takes place.
Note: The benefit period begins five (5) days prior to surgery and extends
for a period of up to one year from the date of surgery. There is
a separate
lifetime maximum benefit up to $1,000,000 per recipient for each type of covered
transplant.
See previous page.
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
Professional services provided in –
Hospital
(inpatient)
Nothing for a participating provider in the hospital or a
participating
ambulatory surgery center.
POS: Any difference between our fee schedule
and the billed amount for non-participating
providers
Professional
services provided in –
Hospital outpatient department
Skilled
nursing facility
Hospital ambulatory surgical center
Nothing for a participating provider in the hospital or a participating
ambulatory surgery center.
POS: Any difference between our fee schedule
and the billed amount for non-participating
providers.
Not covered:
Office
Services administered by the same practitioner
performing surgery
All charges 26
26 Page 27 28
2002 GHI Health
Plan 27 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 to remember 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.
Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the facility 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
addressed in Section 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to
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: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing for a Plan facility.
Nothing for a Plan facility Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed
drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
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
Medical
supplies, appliances, medical equipment, and any covered items billed by a
hospital for use at home (Note: calendar year deductible
applies.) vices 27
27 Page
28 29
2002 GHI Health Plan 28
Section 5( c)
Inpatient hospital (continued): You pay
Not covered:
Custodial care, rest cures, domiciliary or
convalescent care
Non-covered facilities, such as nursing homes and
schools
Personal comfort items, such as telephone, television,
barber services, guest meals and beds
Private nursing care
Long term rehabilitation
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.
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Administration of blood, blood plasma, and other biologicals
Pre-surgical
testing
Dressings, casts, and sterile tray services
Medical
supplies, including oxygen
Anesthetics and anesthesia service
Nothing for a Plan facility.
Diagnostic laboratory tests, X-rays, and pathology services $25 copayment
Chemotherapy and radiation Nothing for chemotherapy and radiation provided
in a participating
facility.
POS: 50% of the Plan's fee schedule and any
difference
between our fee schedule and the
billed amount for non-participating
providers.
Note: Limited benefits for inpatient dental procedures – Hospitalization for
certain dental procedures is covered when a doctor determines there
is need
for hospitalization for reasons totally unrelated to the dental procedure; the
Plan will cover the hospitalization, but not the cost of the
professional
dental services. Conditions for which hospitalization would
be covered
include hemophilia, impacted teeth, and heart disease; the need for anesthesia,
by itself, is not such a condition.
Not covered: blood and blood derivatives not replaced by the member All
charges 28
28 Page
29 30
2002 GHI Health Plan 29
Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You pay
Skilled nursing facility (SNF): Limited to 30
days:
Bed, board and general nursing care
Drugs, biologicals,
supplied and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by your doctor
as governed by Medicare guidelines.
Nothing for a participating provider.
POS: All charges for a
non-participating provider.
Not covered:
custodial care
All charges
Hospice care
Supportive and palliative care for a terminally ill
member in the home or hospice facility. Services include:
inpatient/ outpatient care; and
family counseling under the direction
of a doctor.
Note: Your provider must certify that you are in the terminal stages of
illness, with a life expectancy of approximately six months or less. The
hospice must have an agreement with us or recognized by Medicare as a
hospice.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Ambulance services for each trip to or from a
hospital for medically necessary services. This includes the use of an ambulance
for
emergency outpatient care and maternity care, to the nearest facility.
All charges in excess of $100.
Not covered:
Air ambulance
Ambullette services
All charges 29
29 Page 30 31
2002 GHI Health
Plan 30 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.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe
endangers your life or could result in serious
injury or disability, and requires immediate medical or surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more
serious; examples include deep cuts and broken bones. Others are emergencies
because they are
potentially life-threatening, such as heart attacks,
strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are
many other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
If you are in an emergency
situation, please call your doctor. In extreme emergencies, if you are unable to
contact your doctor, contact the local emergency system (e. g., the 911
telephone system) or go to the nearest
hospital emergency room. It is your responsibility to ensure that the Plan
has been promptly notified.
Emergencies within the service area:
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would result in death,
disability or significant
jeopardy to your condition.
Emergencies outside the service area:
Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness.
Note: If you were admitted to the hospital from the Emergency Room the $50
copay is waived. A participating GHI provider must provide your follow-up care.
We cover care provided by a non-participating
provider at 50% of the Plan's
fee schedule. 30
30 Page
31 32
2002 GHI Health Plan 31
Section 5( d)
Benefit Description You pay
Emergency within our
service area
Emergency medical/ surgical care at a doctor's office
Emergency
medical/ surgical care at an urgent care center
Emergency care as an
outpatient or inpatient at a hospital, including doctors' services
Note: Copay waived if admitted to the hospital. If private physicians
who
are not hospital employees provide the emergency care, you may receive a
separate bill for these services, which we will process as a
medical benefit.
$15 per office visit for a
participating provider.
POS: Any difference between our fee schedule
and the billed amount for a non-participating provider.
$50 copay and any charges
that exceed the emergency fee schedule.
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency medical/
surgical care at a doctor's office
Emergency medical/ surgical care at an
urgent care center
$15 per visit for a
participating provider.
POS: 50% of the Plan's fee schedule and any difference
between our fee
schedule and the billed amount for non-participating
providers
Emergency care as an outpatient or inpatient at a hospital, including doctors'
services
Note: Copay waived if admitted to the hospital. If private physicians
who
are not hospital employees provide the emergency care, you may receive a
separate bill for these services, which we will process as a
medical benefit.
POS: $50 copay and 20% of charges per hospital
emergency room visit or
urgent care center visit for non-participating facilities.
Note: For emergency services
billed for by a doctor, you pay any
difference between our fee
schedule and the billed
amount
Not covered:
Elective care or non-emergency care
All
charges.
Ambulance
Professional ambulance service to or from a hospital for
medically necessary services. This includes the use of an ambulance for
emergency outpatient care and maternity care, to the nearest facility.
See 5( c) for non-emergency service.
All charges in excess of $100.
Not covered: air ambulance and ambullette services All charges. 31
31 Page 32 33
2002 GHI Health Plan 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve,
cost-sharing and limitations for Plan 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.
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 OF THESE SERVICES. See the instructions
after the benefits description below.
Only services rendered by a Participating Provider are covered.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services obtained from a Plan provider and
contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this
brochure
Note: Plan 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
$15 per visit for outpatient care.
Diagnostic tests Nothing
Services provided by a Plan hospital or
other Plan facility
Services in approved alternative care settings such as
partial hospitalization, half-way house, residential treatment, full-day
hospitalization, or facility based intensive outpatient treatment
Nothing
$15 per visit 32
32 Page 33 34
2002 GHI Health
Plan 33 Section 5( e)
Mental health and substance abuse
benefits (continued)
Not covered:
Services we have not
approved.
Facility charges of a non-participating general hospital or facility.
Treatment by a non-participating provider.
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.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all of our network authorization processes on
pages 9 and 32.
Contact us at 1-( 800) 692-7311 33
33 Page 34 35
2002 GHI Health Plan 34 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
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
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 doctor must write the
prescription.
Where you can obtain them. You must fill the
prescription at a pharmacy that participates under the program through PAID
Prescription Inc. Coordinated Care Network III. You must fill the
prescription at a Plan pharmacy, or by mail for a maintenance medication.
We use a formulary. A formulary is a list of carefully-selected
medications that can assist in maintaining quality care for patients while
helping to lower the cost of prescription drug benefits.
An independent
Pharmacy and Therapeutic Committee, brought together by Merck-Medco, review
each drug on the list for safety and effectiveness. Many different
pharmaceutical companies, including Merck-Medco, make these drugs.
We administer an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your physician may
prescribe a name brand drug from a formulary list.
This list of name brand
drugs is a preferred list of drugs that we selected to meet patient needs at a
lower cost. To order a prescription drug brochure, call 1( 800) 272-PAID.
These are the dispensing limitations. Prescription drugs prescribed
by a doctor and obtained at a pharmacy that participates under the program
through PAID Prescriptions, Inc. Coordinated Care
Network III will be
dispensed for up to a 31-day supply. Drugs are prescribed by doctors and
dispensed in accordance with the Plan's drug formulary. You pay a $10 copay
for a generic drug, a $20 copay per prescription unit or refill for a name brand
drug listed on the preferred prescriptions
drug formulary and a $50 copay per prescription unit or refill for a name
brand drug not listed on the
preferred prescription drug formulary. A
generic equivalent will be dispensed if it is available, unless your physician
specifically requires a name brand. If you receive a name brand drug when a
Federally-approved generic drug is available, and your physician has not
specified "dispense as
written" for the name brand drug, you have to pay the
brand name copay.
Mandatory Mail: Your prescription coverage also includes a mandatory
mail program. All maintenance medications must be sent to Merck Medco Rx
Services. Two refills per
prescription will be allowed at any local "preferred" TelePAID pharmacy. When
a new maintenance medication is prescribed the patient should request 2
prescriptions. The initial
for a 31-day supply to be filled at a retail
pharmacy, and the second, for up to a 90-day
supply, to be submitted to
Merck Medco Rx Services. For all existing maintenance medications at a retail
pharmacy, the patient is required to obtain a new prescription, for up to
a 90-day supply, to be sent to Merck Medco Rx Services. 34
34 Page 35 36
2002 GHI Health Plan 35 Section 5( f)
Prescription drug benefits (Continued)
Maintenance Drug Program: The maintenance drug program permits long-term
prescriptions to be filled for up to a 90-day supply. You pay a $20 copay
for a generic drug, and a $40 copay per prescription unit for a name brand drug
listed
on the preferred prescriptions drug formulary and a $60 copay per
prescription
unit or refill for a name brand drug not listed on the
preferred prescription drug formulary.
Why use a generic drug?
-A generic drug contains the same active
ingredients in the same dosage form as its brand name counterpart. It produces
the same effect on the body as the brand name
drug, but is sold under its
chemical or "generic" name.
-Generic drugs are priced from 40% to 60% less
than their brand name counterparts.
-If you start using generic drugs
whenever possible, you can reduce prescription drug
costs for your health
plan, and ultimately for you.
When you have to file a claim. For drugs obtained at a
non-participating pharmacy in an emergency call 1( 800) 272-PAID and obtain a
claim form. 35
35 Page
36 37
2002 GHI Health Plan 36
Section 5( f)
Benefit Description You pay
Covered medications
and supplies
Each new enrollee will receive a description of our
prescription drug program, a combined prescription drug/ Plan identification
card, a mail order form/ patient
profile and a preaddressed reply envelope.
We cover the following medication and supplies prescribed by a physician
from
either a Plan pharmacy or by mail. Note: Mandatory mail requirements
apply for maintenance drugs:
Drugs for which a prescription is required by law. FDA-approved
prescription drugs and devices for birth control.
Fertility drugs. Drugs
to treat sexual dysfunction (Viagra is limited to six tablets per every
thirty-one days).
Diabetic supplies, including insulin syringes,
needles, glucose test tablets and test tape.
Disposable needles and syringes needed for injection of covered prescribed
medication.
Smoking cessation drugs and medication, including nicotine
patches (up to 90-day supply).
Intravenous fluids and medications for home use through our Participating
Provider network for home infusion therapy
Network Retail:
$10 generic
$20 brand name listed on the
preferred prescription drug formulary
$50 brand name drug not
listed on the preferred prescription drug
formulary.
Network Mail Order:
$20 generic
$40 brand name listed on the
preferred prescription drug
formulary
$60 brand name drug not listed on the preferred
prescription drug formulary.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand
drug when a Federally-approved generic drug is available, and your
physician has not specified "dispense as written" for the name brand drug,
you have to pay the brand name copay.
We administer an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your physician
may
prescribe a name brand drug from a formulary list. This list of name brand drugs
is a preferred list of drugs that we selected to meet patient
needs at a
lower cost. To order a prescription drug brochure, call 1( 800) 272-PAID.
Not covered:
Nonprescription medications Drugs
obtained at a non-participating pharmacy, except for emergencies.
Vitamins and nutritional substances that can be purchased without a
prescription.
Medical supplies such as dressings and antiseptics.
Drugs for cosmetic purposes. Drugs to enhance athletic
performance.
All Charges 36
36 Page 37 38
37
Section
5 (g). Special features
Feature 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.
Large Case Management The Plan provides a large case management
program that seeks to provide alternatives for improving the quality and cost
effectiveness of care. The
large case management program focuses on
catastrophic illnesses — for
example, major head injury, high-risk infancy,
stroke and severe amputations. The large case management process begins when we
are
notified that you or covered family member has experienced a specific illness
or injury with potential long-term effects or changes in lifestyle. Case
Managers evaluate individual needs, and the full range of treatment and
financial exposures, from the onset of a condition or illness to recovery or
stabilization. They review the efforts of the health care team and family
with the goal of helping the patient return to pre-illness/ injury functioning
or of
lessening the burden of a chronic or terminal condition. Case Managers
provide the family with support and advice ranging from referral to family
counseling. If it is determined that involvement of a Case Manager would be
both care-and cost-effective, we will obtain the necessary authorization from
the patient to proceed. Throughout the process, we will maintain strict
confidentiality.
Customer Service
AnswerLine
For information and assistance 24 hours a day, 7 days a week, access our
automated telephone AnswerLine at 212/ 501-4GHI (4444).
Services for deaf and hearing impaired If you have a question
concerning Plan benefits or how to arrange for care, contact (212) 721-4962
(Hearing impaired — TDD) or you may write to us at
Post Office Box 1701, New
York, NY 10023-9476 or contact our office nearest you. You may also contact the
Plan at its website at
http:// www. ghi. com.
High risk pregnancies The Plan provides an intensive large case
management program as described above. 37
37
Page 38 39
2002
GHI Health Plan Section 5( g) 38
Centers of excellence for
transplants/ heart surgery/ etc.
We have a special network of hospitals that perform a broad range of cardiac
care and organ transplants. These centers are recognized leaders in their
respective specialties and their services are available to you at no
out-of-pocket
expense. Call GHI Managed Care at least 10 days before the hospital
admission to pre-certify coverage and for details on how to use this
program.
Travel benefit/ services overseas As a GHI subscriber, you are not
restricted to just using members of our provider network. However, if you go
outside the network, your out-of-
pocket expenses will increase
significantly. You will receive 50% of our fee schedule if you use a
non-participating provider — you are responsible for
the balance of the provider's charge. Also, unlike when you use a network
provider, you are responsible for paying the non-participating provider up
front and filing a claim form with us for reimbursement. 38
38 Page 39 40
2002 GHI Health Plan 39 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.
We cover hospitalization for certain dental
procedures only when a nondental physical impairment exists which makes
hospitalization necessary to safeguard
the health of the patient; we do not cover the dental procedure unless it is
described below. We will cover the hospitalization, but not the cost of the
professional dental
services. Conditions for which hospitalization would be
covered include
hemophilia, impacted teeth, and heart disease; the need for
anesthesia, by itself, is not such a condition.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage,
including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You Pay
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 caused by external means and services
must be completed within one year.
Any difference between our fee schedule and the actual charges.
Not covered:
Therapeutic service.
Other dental
services not shown as covered.
Charges which exceed the Plan's fee
schedule.
All charges
Dental benefits
This Plan provides the following program of dental
coverage. The emphasis is on prevention, with preventive and diagnostic dental
services covered with no copayments through Participating Plan Dentists.
Services by non-participating
dentists are covered in accordance with the
fees listed below.
Service You Pay
Examinations (maximum 2 per
calendar year) Nothing for a participating provider.
POS: All charges in
excess of $10.00
Prophylaxes (under 12 years -maximum 2 per calendar year) Nothing for a
participating provider.
POS: All charges in excess of $7.00
Prophylaxes
(over 12 years maximum 2 per calendar year) Nothing for a participating
provider.
POS: All charges in excess of $10.00
Emergency visits for
relief of pain (1 per calendar year) Nothing for a participating provider.
POS: All charges in excess of $10.00
X-rays (Full-mouth series, 1 every 3 years) Nothing for a participating
provider.
POS: All charges in excess of $20.00
Dental benefits
continue on the next page. 39
39 Page 40 41
2002 GHI Health
Plan 40 Section 5( h)
Dental benefits (continued)
Service You pay
Bitewings (4 per calendar year) Nothing for a
participating provider.
POS: All charges in excess of $2.50
per each
bitewing
Space maintainers Nothing for a participating provider.
POS: All charges
in excess of $65.00
Fluoride Treatments – dependent children to age 22 Nothing for a
participating provider.
POS: All charges in excess of $5.00 40
40 Page 41 42
2002 GHI Health Plan 41 Section 5( i)
Section 5 (i). Point of service benefits
Point of Service
(POS) Benefits
Facts about this Plan's POS option At your option, you may
choose to obtain benefits covered by this Plan from non-participating doctors
and hospitals
whenever you need care, except for those benefits listed below
which are available only through plan providers. Benefits not covered under
Point of Service must be received from Plan doctors to be covered.
What is covered
All services are covered under our POS except:
High-tech nursing and infusion therapy
Skilled nursing care facility
confinements
Home health care services
Mental conditions and
substance abuse
Prescription drugs
Remember, only participating providers have agreed to accept the Plan's
allowance, except for any applicable copayments, as payment in full. If you
choose to receive benefits not covered through non-participating or
out-of-network
providers, you will be reimbursed at the POS level that in
most cases is 50% of the Plan's allowance.
Covered POS benefits are available whether the services are received within
or outside the GHI Health Plan's Service
Area.
All non-emergency hospital admissions including inpatient admissions for
maternity care and skilled nursing facilities
must be pre-certified.
There is a $150 annual deductible for nursing services and a $100 annual
deductible for appliances, oxygen and
equipment. There is also a $25
deductible, per referral, for ambulatory laboratory test and diagnostic X-rays.
In most cases, the POS coinsurance is any amount in excess of 50% of the
Plan's fee schedule. The Plan's fee schedule
is set at approximately 50% of
the New York State 1999 HIAA mean. Members, when receiving POS services, will be
responsible for 50% of the Plan's fee schedule plus any difference between our
fee schedule and the billed amount.
After your out-of-pocket expenses total $5000 per person in any calendar year
for covered services provided by a non-participating provider, GHI will then pay
catastrophic benefits at 100% of reasonable and customary charges as
determined by the Plan. Out-of-pocket expenses are calculated based upon the
reasonable and customary charge for
covered catastrophic services. Covered
catastrophic services include: 1) surgery, 2) administration of anesthesia, 3)
chemotherapy and radiation therapy, 4) covered in-hospital services and
diagnostic services, and 5) maternity.
However, expenses for the following services do not count toward your
out-of-pocket maximum, and you must continue
to pay coinsurance and
deductibles for these services:
Home and office visits and related diagnostic services
Nursing,
appliances, oxygen and equipment
Dental services
Vision services
Prescription drugs 41
41 Page 42 43
2002 GHI Health
Plan 42 Section 5( i)
If you are in a true emergency situation,
POS benefits are available within or outside the GHI's Health Plan's
service
area.
Emergencies within the service are:
Benefits are available for
care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your
condition.
Plan pays Emergency fee schedule for emergency care services to the extent
the services would have been covered if received from Plan providers.
You
pay $50 per hospital emergency room visit or urgent care center visit for
emergency services that are covered benefits of this Plan. You also pay charges
that exceed the Plan's emergency fee schedule. If the emergency care is
provided by private physicians who are not hospital employees, you may
receive a separate bill for these services,
which will be processed as a
medical benefit.
Emergencies outside the service area:
Benefits are available for
any medically necessary health service that is immediately required because of
injury or unforeseen illness.
Plan pays full emergency fee schedule for emergency care services to the
extent the services would have been covered if received from Plan providers; 80%
of charges from a non-participating hospital.
You pay $50 plus 20% of
charges per hospital emergency room visit or urgent care center visit for
non-participating facilities and nothing for emergency services billed for by a
doctor, except charges which exceed the Plan's emergency
fee schedule, for
services which are covered benefits of this Plan. If the emergency care is
provided by private
physicians who are not hospital employees, you may
receive a separate bill for these services, which will be processed as a medical
benefit.
What is covered
Emergency care at a doctor's office or an urgent
care center.
Ambulance service (see page 29).
Emergency care as an
outpatient or inpatient at a hospital, including doctors' services.
If the medical/ surgical care received from non-participating providers is
not due to a medical emergency as defined above, the Plan will pay 50% of its
fee schedule. Follow-up care after an emergency is covered in full only if
received
from participating providers. 42
42
Page 43 44
2002
GHI Health Plan 43 Section 5( j)
The benefits on this page are
not part of the FEHB contract or premium, and you cannot file an FEHB
disputed claim about them. Fees you pay for these services do not count
toward FEHB deductibles or out-of-pocket
maximums.
Dental services
are available at reduced fees
If you should require additional dental
services, a GHI dental provider participating in the benefit offer will provide
these services at reduced fees. All reduced fees for dental services must be
paid directly to the participating dental provider. You must verify that your
provider is still participating in the program.
Dental services available in the reduced fee program include:
DOWNSTATE*
You Pay UPSTATE** You Pay
DIAGNOSTIC RESTORATIVE (Fillings)
Resin (anterior) 1 surface
Resin (anterior) 2 surface Resin (anterior) 3 surface
$52.00
$69.00
$86.00
$38.00
$48.00 $59.00
PROSTHODONTICS REMOVAL
Complete denture (upper or lower)
Partial denture resin base (Bilateral Chrome) Add tooth to existing partial
Add clasp to existing partial
$660.00
$664.00 $65.00
$73.00
$441.00
$453.00 $54.00
$59.00
PROSTHODONTICS FIXED
Bridge pontic (cast metal)
Porcelain fused to metal
Full cast crown with porcelain, veneer backing
$520.00 $510.00
$552.00
$409.00 $399.00
$432.00
ORAL SURGERY
Extraction (completely covered by bone) Soft tissue extraction $269.00
$172.00 $210.00 $118.00
PERIODONTICS (Gum Treatment)
Gingivectomy (per quadrant)
Osseous Surgery (per quadrant)
$200.00
$470.00
$169.00
$382.00
ENDODONTICS (Root Canal)
Therapeutic pulpotomy Root
canals (3 canals)
Apicoectomy (first root)
$82.00 $466.00
$306.00
$50.00 $466.00
$314.00
ORTHODONTICS (Braces)
Diagnostic and planning fee
Active Treatment Maximum $912.00 $2,220.00 $686.00 $1,680.00
Benefits on this page are not part of the FEHB contract. *
Downstate includes New York, Bronx, Kings, Queens, Richmond, Nassau, Suffolk,
Putnam, Orange, Rockland and Westchester Counties
and New Jersey ** Upstate
includes Eastern, Central, and Western New York Counties.
Section 5 (j). Non-FEHB benefits available to Plan members 43
43 Page 44 45
2002 GHI Health Plan 44 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 your Plan doctor
determines 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 services
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, or
Services or supplies you receive from a provider or facility barred from the
FEHB Program. 44
44 Page
45 46
2002 GHI Health Plan 45
Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment,
coinsurance, or deductible.
You will only need to file a
claim when you receive services from non-plan providers. If you need to file the
claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file the form HCFA-1500, Health Insurance
Claim Form. Facilities
will file the UB-92 form. For claims questions and
assistance, call us at
212 /501-4GHI (4444).
When you must file a claim, submit the HCFA-1500 or a claim form that
includes the information shown below. Bills and receipts should be
itemized
and show:
Covered member's name and ID number
Name and address of the physician
or facility that provided the service or supply
Dates you received the services or supplies
Diagnosis
Type of
each service or supply
The charge for each service or supply
A copy
of the explanation of benefits, payments, or denial from any primary payer
--such as the Medicare Summary Notice (MSN), and
Receipts, if you paid for your services.
Submit your claims to:
Group Health Inc.
P. O. Box 2832 New York, New York 10116-2832
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more informationPlease reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 45
45 Page
46 47
2002 GHI Health Plan 46
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:
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: 88 West End Avenue, New York,
NY 10023; 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 2, 1900 E Street, NW, Washington, D. C. 20415-3630.
46
46 Page 47 48
2002 GHI Health Plan 47 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 (212) 615-4662 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. 47
47
Page 48 49
2002
GHI Health Plan 48 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 if you have automobile insurance that pays health
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 managed care plan you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the
United States. It is the way everyone used to get Medicare benefits and is the
way most people get their Medicare Part A and Part B benefits now. You 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.
We will waive some copayments, coinsurance, and deductibles 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 the $15
copay for office visits and deductible and coinsurance for durable medical
equipment.
The Original Medicare Plan (Part A or Part B) 48
48 Page 49 50
2002 GHI Health Plan 49 Section 9
The following chart illustrates whether Original Medicare 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 …
OriginalMedicare 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, or……………………………… ………..
b) The position is not excluded from FEHB………………………….
(Ask your employing
office which of these applies to you.)
…………………….. ………
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (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,
(exceptforclaims relatedtoWorkers'
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, or
b) Are an active employee or
c) Are a former spouse of an annuitant or
d) Are a former spouse of an active employee
49
49 Page 50 51
2002 GHI Health Plan 50 Section 9
Claims process when you have The Original Medicare Plan – 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.
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 212/
501-4GHI (4444), or access our web site at
http:// www. ghi. 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
the
$15 copay for office visits and deductible and coinsurance for durable medical
equipment.
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. These are
health care choices (like HMOs) in some
areas of the country. In most Medicare managed care plans, you can only go to
doctors, specialists, or
hospitals that are part of the plan. Medicare
managed care plans provide all the
benefits that Original Medicare covers.
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. 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+ Choice service area. 50
50 Page 51 52
2002 GHI Health Plan 51 Section 9
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.
Once OWCP or a similar agency pays its maximum benefits for your treatment,
we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies are responsible for your care We do
not cover services and supplies when a local, State, 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.
If you do not enroll in Medicare Part A or part B 51
51 Page 52 53
2002 GHI Health Plan 52 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.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 10.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 10.
Covered services Care we provide benefits for, as described in this
brochure.
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 10.
Experimental or investigational services Experimental treatment is a
treatment that has not been tested in human beings; or that is being tested but
has not yet been
approved for general use; or that is subject to review or
approval
by an Institutional Review Board.
Investigational treatment includes, but is not limited to, services or
supplies which are under study or in a clinical trial to evaluate
their toxicity, safety and efficiency for a particular diagnosis or set of
indications.
Clinical trials include, but are not limited to, controlled experiments
having a clinical event as an outcome measurement
involving persons having a
specific disease or health condition; or involving the administration of
different study treatments in a
parallel treatment design done to evaluate
the efficacy and safety
of a test measurement. Clinical trials include Phase
I, Phase II, and Phase III studies. Clinical trials also include randomized
trials or studies.
Plan allowance 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:
The Plan allowance is the fee schedule or negotiated rate that GHI uses as
payment in full for covered services rendered by participating providers.
Us/ We Us and we refer to Group Health Incorporated
You You
refers to the enrollee and each covered family member. 52
52 Page 53 54
2002 GHI Health Plan 53 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 circums tances,
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.
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'
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.
When benefits and
premiums start 53
53
Page 54 55
2002
GHI Health Plan 54 Section 11
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.
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 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
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.
Temporary Continuation
of Coverage (TCC) 54
54 Page 55 56
2002 GHI Health Plan 55 Section 11
You may convert to a non-FEHB individual policy if:
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.
The Health Insurance Portability and Accountability Act of 1996
(HIPPA)
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.
OPM pamphlet RI 79-27, Temporary Continuation of Coverage
(TCC) under the FEHB Program. 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
information
about Federal and State agencies you can contact for more
information.
Getting a Certificate of
Group Health plan Coverage
Converting to individual coverage 55
55
Page 56 57
2002
GHI Health Plan 56 Section 11
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:
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 nursing home care, care in an assisted
living facility, care in your home, adult day care, hospice care,
and more.
It can supplement care provided by family members, reducing the burden you place
on them.
Welcome to the club!
76% of Americans believe they will never need
long term care, but the facts are that about half 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 everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their financial and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year.
And
that's before inflation!
Long term care can easily exhaust your savings. Long term care insurance
can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a stay in
an
assisted living facility or a continuing need for a home health aide to
help you get in and out of bed and with other activities of daily living.
Limited stays in
skilled nursing facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest
level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully
disabled. It also has a 100 day limit.
Medicaid
covers long term care for those who meet their state's poverty guidelines, but
has restrictions on covered services and where they can be
received. Long
term care insurance can provide choices of care and preserve your independence.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need?
You should consider buying long-term care insurance. 56
56 Page 57 58
2002 GHI Health Plan 57 Section 11
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin
in mid-2002. In the meantime, you can learn more about the program on our web
site at www. opm. gov/ insure/ ltc
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 57
57 Page 58 59
2002 GHI Health Plan 58
Index
Index
Do not rely on this page; it is for your convenience and
does not explain your benefit coverage.
Accidental injury
............................ 30 Allergy tests
.................................... 16
Ambulance....................................... 29 Anesthesia
....................................... 26
Autologous bone marrow
transplant................................. 25
Blood and blood
plasma................ 28 Breast cancer screening................. 14
Casts
................................................. 22 Catastrophic
protection................. 10
Changes for 2002
............................. 7 Chemotherapy................................. 16
Childbirth......................................... 15 Chiropractic
..................................... 21
Cholesterol tests
............................. 13 Claims
.............................................. 45
Coinsurance..................................... 10 Colorectal cancer
screening.......... 13
Congenital anomalies .................... 22
Contraceptive devices and drugs....... 15/ 34
Coordination of
benefits................ 48 Covered charges ............................. 10
Covered providers ............................ 8
Crutches
........................................... 19 Deductible
....................................... 52
Definitions....................................... 52 Dental care
....................................... 39
Diagnostic services
........................ 12 Disputed claims review................. 46
Donor
expenses (transplants)....... 25 Durable medical equipment
(DME)
.......................................... 19 Educational classes
and
programs ............................... 21 Effective date of
enrollment......... 52
Emergency....................................... 30
Experimental or investigational... 52
Eyeglasses
....................................... 18 Family planning
............................. 15
Fecal occult blood test...................
13 General exclusions......................... 44
Hearing
services ............................. 17 Home health services
.................... 20
Hospice care .................................... 29
Home nursing care ......................... 20
Hospital............................................ 27
Immunizations................................ 14
Infertility.......................................... 16 Inhospital
physician care............... 12
Inpatient hospital benefits............. 27
Insulin............................................... 36
Laboratory
and pathological
services..................................... 13
Magnetic Resonance Imagings
(MRIs)....................................... 13
Mail order prescription
drugs ....... 34 Mammograms .................................. 14
Maternity
benefits........................... 15 Medicaid
........................................... 51
Medically necessary
....................... 42 Medicare ...........................................
49
Members ........................................... 52 Mental conditions/
substance
abuse benefits .......................... 32 Neurological
testing ....................... 13
Newborn care
................................... 15 Non-FEHB Benefits .......................
43
Nurse Licensed Practical Nurse........... 20
Nurse midwife
............................... 8 Nurse practitioner ......................... 8
Registered nurse.......................... 20 Nursery
charges............................... 15
Obstetrical care
............................... 15
Occupational
therapy...................... 17 Office
visits...................................... 12
Oral and maxillofacial surgery ..... 24 Orthopedic devices
......................... 19
Ostomy and catheter supplies ....... 19
Out-of-pocket expenses ................. 10
Outpatient facility care
................... 28 Oxygen.............................................. 19
Pap test............................................. 13
Physical
examination................ 12/ 14 Physical
therapy.............................. 17
Physician .......................................... 12 Point-of-Service
(POS).................. 41
Pre-admission testing..................... 28
Precertification .................................. 9
Preventive care, adult
..................... 13 Preventive care,
children............................... 14
Prescription
drugs........................... 34 Preventive services
......................... 13
Prior
approval.................................... 9 Prostate cancer
screening.............. 13
Prosthetic devices ........................... 19
Psychologist..................................... 32
Psychotherapy................................. 32 Radiation
therapy............................ 16
Rehabilitation therapies
................. 17 Renal dialysis ................................... 16
Room and board .............................. 27 Second surgical
opinion................. 12
Skilled nursing facility care .......... 29
Smoking cessation ......................... 36
Speech
therapy................................ 17 Splints
............................................... 19
Subrogation...................................... 51 Substance
abuse.............................. 32
Surgery
............................................. 22 Anesthesia
................................... 26
Oral............................................... 24
Outpatient.................................... 28
Reconstructive............................ 23
Syringes............................................ 36
Temporary
continuation of
coverage................................... 54
Transplants....................................... 25
Treatment therapies........................ 16 Vision services
................................ 18
Well child care
................................ 14
Wheelchairs
..................................... 19 Workers' compensation.................
51
X-rays............................................... 13 58
58 Page 59 60
2002 GHI Health Plan 59 Summary
Summary of benefits for the GHI Health Plan -2002
Do not
rely on this chart alone. All benefits are provided in full unless indicated
and 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.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the
office................................................................................................
$15 per visit for a Participating Provider.
POS: 50% of the Plan's fee
schedule and any difference between
our fee schedule and the billed amount
for a non-participating provider.
12
Services provided by a hospital:
Inpatient................................................................................................
Outpatient................................................................................................
Nothing
Note: $25 deductible per referral for ambulatory laboratory test
and diagnostic X-rays when referred and rendered.
27
28
Emergency benefits:
In-area................................................................................................
Out-of-area................................................................................................
$50 per hospital emergency room visit or urgent care center visit
and
charges that exceed the Plan's emergency fee schedule.
$50 plus 20% of charges per hospital emergency room visit or
urgent care
center visit for non-participating facilities.
30
30
Mental health and substance abuse treatment................................
Regular cost sharing. 32
Prescription drugs prescribed by a doctor and
obtained at a participating
pharmacy................................................................
Mandatory Mail
...............................................................................................
$10 copay for generic drugs; $20 copay per prescription unit or refill for
name brand drugs listed on the preferred prescription
drug formulary, and
$50 copay per prescription unit or refill for a
name brand drug not listed
on the preferred prescription drug
formulary. For mail-order maintenance you
pay a $20 copay for
generics and a $40 copay for name brand name drug listed
on the preferred prescription drug formulay and $60 copay for a name
brand drug not listed on the preferred prescription drug formulay
All maintenance medications must be sent to Merck Medco Rx
Services. Two
refills per prescription will be allowed at any local
"preferred" TelePAID
pharmacy.
34
Dental Care
................................................................................................
Nothing for preventive services provided by Participating
Providers. For
non-participating providers, you pay any
difference between GHI's fee
schedule and the billed amount.
39
Vision Care
................................................................................................
One refraction annually. Lenses (annually) and frames (every two
years).
Nothing to Participating Vision Centers. 18
Special features: Large Case Management, High Risk Pregnancies, Centers of
Excellence for
Transplants/ Heart/ Surgery/ etc., Travel Benefits/ Services
Overseas
37
Point-of-Service benefits --Yes 41
Protection against catastrophic costs
(your out-of-pocket
maximum)................................................................
Nothing after $5,000 per person per year
Some costs do not count toward this protection 10 59
59 Page 60
2002
GHI Health Plan 60
2002 Rate Information for
GHI Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB
Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United
States Postal Service Employees,
RI 70-2. Different postal rates apply and special FEHB guides are published for
Postal Service Nurses (see RI 70-2B); and for Postal Service Inspectors and
Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal
employee organization. Refer to the
applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only 801 $97.86 $46.28 $212.03 $100.27 $115.52 $28.62
Self and
Family 802 $223.41 $136.93 $484.06 $296.68 $263.75 $96.59 60