with a point of service product
Serving: All of Puerto Rico
Enrollment in this Plan is limited. You
must live in our geographic service area to enroll. See page 7 for requirements.
Enrollment codes for this Plan:
891 Self Only 892 Self and Family
RI 73-016
For changes in benefits see page
8. 1
1
Page 2 3
2
2 Page 3 4
2002 Triple-S Table of Contents 2
Table of
Contents
Introduction………………………………………………………………….............................................................
4
Plain Language
......................................................................................................................................................
4
Inspector General Advisory
....................................................................................................................................
4
Section 1. Facts about this HMO
plan....................................................................................................................
6
We also have point-of service (POS) benefits
........................................................................................
6
How we pay providers
..........................................................................................................................
6
Who provides my health care?
.............................................................................................................
6
Your Rights
..........................................................................................................................................
6
Service Area
.........................................................................................................................................
7
Section 2. How we change for 2002………………………………………..
............................................................ 8
Program-wide
changes
..........................................................................................................................
8
Changes to this
Plan..............................................................................................................................
8
Section 3. How you get care
.................................................................................................................................
9
Identification cards
...............................................................................................................................
9
Where you get covered care
..................................................................................................................
9
Plan
providers.................................................................................................................................
9 Plan facilities
..................................................................................................................................
9
What you must do to get covered care
...................................................................................................
9
Primary care
...................................................................................................................................
9 Specialty care
.................................................................................................................................
9
Hospital
care..................................................................................................................................
10 Circumstances beyond our
control........................................................................................................
10
Services requiring our prior
approval....................................................................................................
10
Section 4. Your costs for covered services
............................................................................................................
12
Copayments...................................................................................................................................
12
Coinsurance...................................................................................................................................
12
Your out-of-pocket maximum
..............................................................................................................
12
Section 5. Benefits
...............................................................................................................................................
13
Overview
.............................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals........... 14
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ....... 24
(c)
Services provided by a hospital or other facility, and ambulance services
.................................... 28
(d) Emergency services/ accidents
....................................................................................................
31
(e) Mental health and substance abuse benefits
................................................................................
34
(f) Prescription drug
benefits...........................................................................................................
36
(g) Special
features..........................................................................................................................
39
Flexible Benefits Option 24 hours 7 days a week call center
Blue Card Program Centers of excellence for transplants/ heart surgery/
etc.
High risk pregnancies program Blue Card Worldwide
Mental
Health Management (h) Dental
benefits...........................................................................................................................
41 3
3 Page 4 5
2002 Triple-S Table of Contents 3
Table of
Contents (Continued)
(i) Point of service benefits
............................................................................................................
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
.................................................................................................................
47
Section 9. Coordinating benefits with other coverage
............................................................................................
49
When you have…
Other health
coverage....................................................................................................................
49
What is Medicare?
........................................................................................................................
49
The Original Medicare Plan (Part A or Part
B)...............................................................................
49
Medicare managed care plan
.........................................................................................................
51
If you do not enroll in Medicare Part A or Part B
........................................................................... 52
TRICARE/ Workers' Compensation/ Medicaid
......................................................................................
52
When other Government agencies are responsible for your
care............................................................ 52
When
others are responsible for injuries
...............................................................................................
52
Section 10. Definitions of terms we use in this brochure
.......................................................................................
53
Section 11. FEHB facts
........................................................................................................................................
55
Coverage
information.........................................................................................................................
55
No pre-existing condition limitation
..............................................................................................
55 Where you get information about enrolling in the FEHB
Program.................................................. 55
Types of coverage available for you and your family
..................................................................... 55 When
benefits and premiums start
.................................................................................................
56
Your medical and claims records are confidential
.......................................................................... 56
When you retire
............................................................................................................................
56
When you lose
benefits.......................................................................................................................
56
When FEHB coverage
ends...........................................................................................................
56 Spouse equity coverage
.................................................................................................................
56
Temporary Continuation of Coverage (TCC)
.................................................................................
56 Converting to individual coverage
.................................................................................................
57
Getting a Certificate of Group Health Plan Coverage
..................................................................... 57
Long Term Care Insurance is coming later in 2002
................................................................................................
58
Department of Defense/ FEHB Demonstration
Project............................................................................................
59
Index
.........................................................................................................................................................
61
Summary of benefits
.............................................................................................................................................
62
Rates………………………………………………………………………………………………………….. Back cover 4
4 Page 5 6
2002 Triple-S 4 Introduction/ Plain Language/
Inspector General Advisory
Introduction
Triple-S, Inc.
(Triple-S) 1441 Roosevelt Avenue
San Juan, Puerto Rico 00920
This
brochure describes the benefits of Triple-S under our contract (CS-1090) 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. Brochures are available in Spanish. You can get a
copy by calling 787-749-4777.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family
member; "we" means Triple-S.
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 787-749-4777, and explain
the situation. 5
5 Page
6 7
2002 Triple-S 5
Introduction/ Plain Language/ Inspector General Advisory
Inspector
General Advisory (Continued)
If we do not resolve the issue,
call or write
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The
United States Office of Personnel Management
Office of the Inspector General
Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if the person tries to obtain
services for a person 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. 6
6 Page 7 8
2002 Triple-S 6
Section 1
Section 1. Facts about this HMO plan
This Plan
is a health maintenance organization (HMO). We require you to see those
physicians, hospitals, and other providers that contract with us. These Plan
providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practices when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments and coinsurance described in this brochure. When you receive
emergency services from non-Plan
providers, you may have to submit claim
forms.
You should join an HMO because you prefer the plan's benefits, not
because a particular provider is available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
We also have Point-of-Service (POS) benefits:
Our HMO offers
Point-of-Service (POS) benefits. This means you can receive covered services
from a non-Plan provider within our service area. These out-of-network benefits
have higher out-of-pocket costs than our in-network
benefits. Out of the service area, we will pay benefits only when the
services are due to an emergency or have been preauthorized by us. In general,
we will only authorize care, equipment, or professional services out of the
service
area when they are not available from a Plan provider in the service
area.
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. When you get services out-of-network, we pay non-Plan providers
in Puerto Rico based on the "medical benefits schedule" and we pay non-Plan
providers outside of Puerto Rico based on usual, customary, and reasonable
charges.
Who provides my health care?
Triple-S is an
individual practice prepayment plan. You can receive care from any Plan doctor.
A Plan doctor is a doctor of medicine (M. D.) licensed to practice in the
Commonwealth of Puerto Rico who has agreed to accept the
Triple-S established fees as payment in full for surgery and certain other
services. If you use a non-Plan doctor (except for speech or occupational
therapy) you must pay the difference between the non-Plan doctor's charge and
the
amount paid to you by Triple-S. A non-Plan doctor is any licensed doctor
of medicine (M. D.) who is not a Plan doctor. Non-Plan doctors do not have to
accept Triple-S established fees as payment in full. Most doctors practicing
in Puerto Rico are Plan doctors.
You can also receive services from a
Plan hospital. This is a licensed general hospital in Puerto Rico that has
signed a contract with Triple-S to render hospital services to persons insured
by Triple-S. A non-Plan hospital is any licensed
institution that is not a Plan hospital and that is engaged primarily in
providing bed patient with diagnosis and treatment under the supervision of
physicians with 24-hour-a-day registered graduate nursing services. You must pay
any difference between the non-Plan hospital's charges and the amount paid
to you by Triple-S.
Benefits in Puerto Rico are paid according to the
"medical benefits schedule". This is the schedule of established fees on which
this Plan's payment of covered medical expense is based, when the services are
rendered within the service
area. When preauthorized or emergency services are rendered outside Puerto
Rico, this Plan pays based on usual, customary and reasonable charges.
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.
7
7 Page 8 9
2002 Triple-S 7 Section 1
Section
1. Facts about this HMO plan (Continued)
If you want more
information about us, call 787/ 749-4777, or write to P. O. Box 363628, San
Juan, Puerto Rico, 00936-3628. You may also contact us by fax at 787/ 749-4108
or visit our website at www. ssspr. com.
Service Area
To enroll in this Plan, you must live in our Service
Area. This is where our providers practice. Our service area is: Only Puerto
Rico.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will pay only for emergency care
benefits and hospitalization of authorized special cases. Special case means
care,
equipment or professional services that are not available in our
service area. We will not pay for any other health care services out of our
service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the area (for example, if
your child goes to college in another state), you should consider
enrolling
in a fee-for-service plan or an HMO that has agreements with affiliates in other
areas. This Plan offers reciprocity with the Blue Cross Blue Shield network
through the Blue Card Program. 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. 8
8 Page
9 10
2002 Triple-S 8 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
Your share of the non-Postal premium will
remain as established for year 2001 for Self Only or for Self and Family.
If you are enrolled in the DoD demonstration project your share of the
premium will decrease by 5% for Self Only and for Self and Family.
We
changed our precertification requirements, refer to Section 3.
We
increased speech therapy benefits by removing the requirement that services must
be required to restore functional speech. (Section 5( a)). Speech therapy is now
classified as a treatment therapy instead of a
rehabilitative one. We will cover these services for all conditions where it
is deemed medically necessary.
We will cover walkers and blood glucose
monitors. (Section 5 (a))
We clarified the Preventive care, adult benefits
by removing the entry for blood lead level testing for adults because it is a
test more typically done for children. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b)).
We will
cover medications for treatment of impotence. (Section 5( f)) 9
9 Page 10 11
2002 Triple-S 9 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 787-
749-4777.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and/ or coinsurance, and you
will not have to file claims.
You can also get care from non-Plan providers,
but it will cost you more.
Plan providers Plan providers are
physicians and other health care professionals in our service area that we
contract with to provide covered services to our
members. We credential Plan
providers according to national standards.
We list Plan providers in the
provider directory, which we update periodically. The list is also on our
website.
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 It depends on the type of care you need. First, you
and each family to get covered care member must choose a general
practitioner physician. This decision is
important since your general
practitioner physician provides for most of your health care.
Primary care Your general practitioner physician can be, for
example, a family practitioner. Your physician will provide most of your health
care, or
refer you to a specialist.
If you want to change your general
practitioner physician or if your general practitioner physician leaves the
Plan, call us. We will help you
select a new one.
Specialty care
Your general practitioner physician will refer you to a specialist for
needed care. However, you may see any specialist without a referral.
Here are other things you should know about specialty care:
If you are
seeing a specialist and your specialist leaves the Plan, call us. We will
provide you a list of specialists within your area. You
may receive services
from your current specialist until we can make arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we: 10
10 Page 11 12
2002 Triple-S
10 Section 3
Section 3. How you get care (Continued)
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 general practitioner 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 787-749-4777. 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 provide you with the necessary care.
Services requiring our Your general practitioner physician may refer
you for most services. For prior approval certain services, however, you
or your Plan doctor must obtain approval
from us. Before giving approval, we
consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
We call this review and approval
precertification. Call us at 787-749-4777. 11
11
Page 12 13
2002
Triple-S 11 Section 3
Section 3. How you get care
(Continued)
We will provide benefits for covered services only
when services are medically necessary to prevent, diagnose or treat your illness
or
condition. But you or your Plan doctor must obtain authorization from
this Plan for the following:
Services outside the Service Area, except emergencies;
Rental and
purchase of durable medical equipment;
Skilled Nursing Facility;
Organ and tissue transplants;
Lithotripsy;
Polysomnography;
Osteotomy;
Mammoplasty;
Mental health and substance abuse services
(including hospitalizations) rendered by Plan providers, and non Plan providers
(point of service benefits); and
Growth hormones. 12
12 Page 13 14
2002 Triple-S 12 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 your specialist you pay a copayment of $10 per office
visit.
Coinsurance Coinsurance is the percentage of our negotiated
fee that you must pay for your care.
Example: In our Plan, you pay 25% of
our allowance for laboratory and diagnostic tests.
Your out-of-pocket maximum We do not have an out-of-pocket maximum.
Your out-of-pocket expenses for benefits covered under this Plan are:
The
stated copayments that are required for covered benefits;
Remaining
charges after we reimburse you our established fees for point of service
benefits when non-Plan providers are used; and
The 10% you pay of our established fees when you use non-Plan providers in
our service area.
The 10% you pay of the usual, customary and reasonable
charge when you use non-Plan providers outside of our service area.
The
25% you pay of our established fees when you use a non network pharmacy within
or outside of our service area.
The difference between the cost of the
brand name prescription drug and the cost of the generic bioequivalent
prescription drug, if you choose a
brand name prescription drug, for which a
generic-bioequivalent prescription drug exists. 13
13
Page 14 15
2002
Triple-S Section 5 13
Section 5. Benefits --OVERVIEW
(See
page 8 for how our benefits changed this year and page 62 for a benefits
summary.)
NOTE: This benefits section is broken into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us at 787-749-4777 or at
our website at www. ssspr. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .................................... 14-23
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
Alternative treatments Educational classes and
programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals...................... 24-27
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services .................................................. 28-30
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice Ambulance
(d) Emergency services/
accidents...................................................................................................................
31-33 Medical emergency Ambulance
(e) Mental health and substance abuse
benefits...............................................................................................
34-35
(f) Prescription drug benefits
.........................................................................................................................
36-38
(g) Special features
........................................................................................................................................
39-40 Flexible Benefits Option 24 hours, 7 days a week call center Blue
Card Program Centers of excellence
for transplants/ heart surgeries/ etc High risk pregnancies program Blue
Card Worldwide Mental Health Management Program for Federal Employees
(h) Dental benefits
.........................................................................................................................................
41-42
(i) Point of service benefits
.................................................................................................................................
43
Summary of benefits
.............................................................................................................................................
62 14
14 Page 15
16
2002 Triple-S Section 5( a) 14
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.
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 OR YOUR PLAN DOCTOR MUST GET PRECERTIFICATION OF SOME MEDICAL SERVICES
AND SUPPLIES. Please refer to the precertification
information shown in
Section 3 to be sure which services require precertification and identify which
surgeries require precertification.
If you use a non-Plan doctor or provider, you pay for services rendered and
the Plan will reimburse you 90% of the Plan's established fee, after any
applicable copay,
when services are rendered within the service area, or 90%
of the usual, customary and reasonable charge of the area, after any applicable
copay, when services are
rendered outside the service area. You pay all
remaining charges.
Note: We will pay for services provided by a non-Plan
provider outside the service area only if the services are for an emergency or
if they have been preauthorized. In
general, we will only authorize care,
equipment, or professional services that are not available from a Plan provider
within the service area.
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
$ 7.50 per office visit to your general
practitioner physician
$10 per office visit to a specialist physician
Professional services of
physicians
In an urgent care center or emergency room
During a
hospital stay
In a skilled nursing facility – precertification required
(refer to Section 3)
Office medical consultations by specialists
$10 per office visit
Diagnostic and treatment services – Continued on next page 15
15 Page 16 17
2002 Triple-S Section 5( a) 15
Diagnostic and treatment services (Continued) You pay
Second surgical opinion Nothing
At home $15 per physician visit.
Nothing for nurse or home health aide visit
Not covered:
Private nursing care, except for treatment of
mental illness
All charges
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/ Magnetic resonance (MRI, MRA)
Hepatobiliary ductal system imaging (HIDA)
Polysomnography –
precertification required (refer to Section 3)
Genetic amniocentesis
Ultrasound
Non-invasive vascular and cardiovascular tests, including
electrocardiogram and EEG
25%. Nothing for X-rays.
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol
Colorectal Cancer Screening, including
Fecal
occult blood test
Sigmoidoscopy, screening
$7.50 per office visit to your general practitioner physician , $10
per
office visit to a specialist physician; and 25% for laboratory
tests in lab
facilities and diagnostic tests.
Prostate Specific Antigen (PSA test)
Preventive Care, adult –
Continued on next page 16
16 Page 17 18
2002 Triple-S
Section 5( a) 16
Preventive care, adult (Continued) You
pay
Routine pap test Nothing if you receive these services during your
office visit;
otherwise, $10 per office visit.
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 one or two calendar years
At age 65 and older, one
every two consecutive calendar years
$10 per office visit. Nothing for X-ray.
Routine immunizations, limited to:
Tetanus-diphtheria (Td)
Influenza
Pneumococcal vaccine, annually, age 65 and over
Tetanus
toxoid
Hepatitis B
$10 per office visit. Nothing per vaccine or immunization.
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics, such as
Diphtheria-tetanus-pertussis (Dtp)
Diphtheria-tetanus toxoids (Dt)
Measles, mumps and rubella (Mmr)
Varicella and varivax
Hemophilus influenza B
Influenza
Tetanus toxoid
Hepatitis B
$10 per office visit. Nothing per vaccine or immunization.
Well-child care charges for routine examinations, immunizations and care
Examinations, such as:
Eye exams to determine the need for vision
correction.
Ear exams to determine the need for hearing correction
Examinations done on the day of immunizations
$10 per office visit. Nothing per vaccine or immunization 17
17 Page 18 19
2002 Triple-S Section 5( a) 17
Maternity
care You Pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things
to keep in mind:
You do not need to precertify your normal delivery.
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 5( c)) and
Surgery
benefits (Section 5( b)).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Intrauterine devices (IUDs)
Note: We cover oral contraceptive and devices such as diaphragms, under the
prescription drug benefit (Section 5( f)).
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling All charges 18
18 Page 19 20
2002 Triple-S
Section 5( a) 18
Infertility services You Pay
Diagnosis and
treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
$10 per office visit
Not covered:
Infertility services after voluntary
sterilization.
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization
embryo transfer,
gamete GIFT and zygote ZIFT
Zygote transfer
Services
and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
Fertility drugs
All charges
Allergy care
Testing and treatment
Allergy vaccine
$10 per
office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone marrow transplants is
limited to those transplants listed under
Organ/ Tissue Transplants on pages
26 and 27.
Respiratory and inhalation therapy up to a maximum of 20
sessions per year
Dialysis – Hemodialysis and peritoneal dialysis
$10 per office visit and/ or respiratory therapy session
Treatment therapies – Continued on next page 19
19 Page 20 21
2002 Triple-S Section 5( a) 19
Treatment
therapies (Continued) You pay
Intravenous (IV)/ Infusion
Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we
precertify the treatment. You or your Plan doctor should call 787-749-4777 for
precertification.
We will ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin
treatment;
otherwise, we will only cover GHT services from the date you submit the
information. If you do not ask or if we determine GHT
is not medically
necessary, we will not cover the GHT or related services and supplies. See
Services requiring our prior approval in
Section 3.
$10 per office visit and/ or respiratory therapy session
Not covered: Services not shown as covered All charges
Physical
and occupational therapies
Physical and occupational therapies
Up to two consecutive months per
condition, if significant improvement can be expected, for the services ordered
by a physician of each of the
following:
Physical therapy
rendered by qualified physical
therapists supervised by a physician specialized in physical therapy;
Occupational therapy
rendered by certified occupational therapists.
$10 per office visit and/ or physical or occupational therapy
For
occupational therapy you should pay the provider's claim
and seek
reimbursement from us as we explain in the introduction of
Section 5( a).
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
activities
of daily living.
Not covered:
long-term rehabilitative therapy
exercise programs
cardiac rehabilitation
All charges 20
20 Page 21 22
2002 Triple-S
Section 5( a) 20
Speech Therapy You Pay
Speech therapy
rendered by certified speech therapist up to two consecutive months per
condition. $10 per office visit and/ or speech therapy
For speech therapy you should pay the provider's claim and seek
reimbursement from us as we explain in the introduction of
Section 5(
a).
Hearing services (testing, treatment and supplies)
Hearing
testing performed by a Plan physician for adult and children (see Preventive
care, children) $10 per office visit
Not covered:
Hearing aids, testing and examinations for them
Supplies
Timpanometry
All charges
Vision services (testing, treatment and supplies)
In addition to
medical and surgical benefits provided for diagnosis and treatment of diseases
of the eye, annual eye refractions (that
include the written lens
prescription) may be obtained from Plan providers.
$10 per office visit
Lenses following cataract removal $10 per office visit
Eye exam to
determine the need for vision correction for children (see preventive care) $10
per office visit
Not covered:
Eyeglasses or contact lenses, corrective lenses,
frames, fitting of contact lenses
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
Optometrist services
Supplies
All charges
Foot care
Routine foot care performed by a Plan doctor when you
are under active treatment for a metabolic or peripheral vascular disease, such
as
diabetes.
$10 per office visit
Not covered:
Treatment of weak, strained or flat feet
Podiatric services
All charges 21
21 Page 22 23
2002 Triple-S
Section 5( a) 21
Orthopedic and prosthetic devices You Pay
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following
mastectomy. Note: We pay internal prosthetic devices as hospital benefits; see
Section 5 (c) for payment information. See 5
(b) for coverage of the surgery
to insert the device.
Nothing if provided by a Plan doctor or provider
If provided by a
non-Plan doctor, provider or medical equipment
supplier, you should pay the
provider's claim and seek
reimbursement from this Plan. Plan reimburses you
90% of
established fees.
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
artificial limbs and eyes; stump hose
All charges
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician, such as
oxygen and other respiratory equipment. Under this
benefit, we also cover:
hospital type beds;
wheelchairs
iron lungs;
walkers,
blood glucose monitors,
oxygen equipment; and
other
respiratory equipment
Note: You must obtain a precertification from us.
Refer to Section 3. Call us at 787-749-4777 as soon as your Plan physician
prescribes this
equipment to obtain a precertification. We will arrange with a health care
provider to rent or sell you durable medical equipment at
discounted rates
and will tell you more about this service when you call.
Nothing
Duirable medical equipment (DME) – Continued on next page 22
22 Page 23 24
2002 Triple-S Section 5( a) 22
Durable
medical equipment (DME) (Continued) You Pay
Not
covered:
Crutches
Insulin pumps
Other
durable medical equipment not shown above.
All charges
Home health services
Home health care ordered by a Plan
physician (who will periodically review the program for continuing
appropriateness and need) and
provided by nurses or home health aides.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the
convenience of, the patient or the patient's family;
home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative;
services primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication;
homemaker services.
All charges
Chiropractic
No benefit All charges
Alternative treatments
Not covered:
naturopathic
services
hypnotherapy
biofeedback
osteopathic services
acupuncture
podiatric services
All charges 23
23 Page 24 25
2002 Triple-S
Section 5( a) 23
Educational classes and programs You Pay
Our
disease management programs are addressed to deal with pregnancy and asthma
conditions. They provide individual education
by using recognized protocols
of professional entities. Counseling from professional specialists is also
available.
Asthma program – Addressed to enhance the quality of life of the asthmatic
by teaching them self health care and illness management.
Pregnancy
educational program – Provides education about pregnancy during prenatal,
delivery and postnatal stages.
Emphasizes risk factors that every women
should know to have a healthy delivery and to avoid complications.
Both programs coordinate services with the case management program when the
insured needs service alternatives to handle
his/ her health care.
Individual education also includes the distribution of written literature.
Nothing 24
24 Page
25 26
2002 Triple-S Section 5( b)
24
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 in Section 5 (c) for
charges associated with the
facility (i. e. hospital, surgical center,
etc.).
YOU OR YOUR PLAN DOCTOR 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.
If you use a non-Plan doctor or provider, you pay for services rendered and
the Plan will reimburse you 90% of the Plan's established fee, after any
applicable copay,
when services are rendered within the service area, or 90%
of the usual, customary and reasonable charge of the area, after any applicable
copay, when services are
rendered outside the service area. You pay all
remaining charges.
Note: We will pay for services provided by a non-Plan
provider outside the service area only if the services are for an emergency or
if they have been preauthorized. In general, we will
only authorize care,
equipment, or professional services that are not available from a Plan provider
within the service area.
I M
P O
R T
A N
T
Benefit Description You pay
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)
Nothing
Surgical procedures --Continued on next page 25
25
Page 26 27
2002
Triple-S Section 5( b) 25
Surgical procedures (Continued)
You pay
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.
Lithotripsy procedure
Voluntary sterilization
Treatment of
burns
Insertion of internal prosthetic devices. See 5( a) – Orthopedic –
and prosthetic devices for device coverage information.
Note: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital benefits for a
pacemaker
and Surgery benefits for insertion of the pacemaker.
Nothing
For insertion of internal prosthetic devices member pays nothing
if
provided by a Plan doctor or provider. If provided by a non-Plan
doctor, provider or medical equipment supplier, you should
pay the
provider's claim and seek reimbursement from us. We will
reimburse you 90%
of our established fees.
Not covered:
Reversal of voluntary sterilization
Surgical assistants
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.
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)
Nothing
Reconstructive surgery --Continued on next page 26
26 Page 27 28
2002 Triple-S Section 5( b) 26
Reconstructive surgery (Continued) You Pay
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.
Nothing
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
Oral and maxillofacial surgery
Oral surgical procedures,
performed only when medically necessary, 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
Other surgical procedures that do not involve the teeth or their supporting
structures.
Nothing
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva, and alveolar bone)
All charges
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Nothing
Organ and tissue transplants --Continued on next page 27
27 Page 28 29
2002 Triple-S Section 5( b) 27
Organ/
tissue transplants (Continued) You Pay
Liver
Lung:
Single –Double
Intestinal transplant (small intestine) and the small
intestine with the liver or small intestine with multiple organs such as the
liver,
stomach, and 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
You or your Plan doctor
must obtain a precertification from us before an organ and tissue transplant.
Refer to Section 3.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Living donors for intestine
transplant in adults and children.
Transplants not listed as
covered
All charges
Anesthesia
Professional services provided in –
Hospital
(inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing 28
28 Page
29 30
2002 Triple-S Section 5( c)
28
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.
For maximun benefits Plan physicians should provide or arrange your care
and you should be hospitalized in a Plan facility.
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 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 covered in Section 5( a) or (b).
If you use a non-participating hospital in the service area, we will
reimburse according to the Plan's established fees, except for hospitalization
due to
accidental injury or a medical emergency as shown on pages 31and 32.
Note: We will pay for services provided by a non-participating hospital
outside the service area only if it is an emergency or if it is preauthorized.
In general, we
will authorize out of area hospitalizations only for special
cases that require equipment, mode of treatment or specialist care not available
in Puerto Rico.
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 per inpatient admission to a Plan hospital. Plan reimburses
you the established fees for an inpatient admission to a non-Plan
hospital in the service area. You pay all remaining charges.
Inpatient hospital – Continued on next page 29
29 Page 30 31
2002 Triple-S Section 5( c) 29
Inpatient
hospital (Continued) You pay
Other hospital services and
supplies, such as:
Operating, recovery, maternity, and other treatment
rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and
X-rays
Administration of blood and blood products
Nothing
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
Medical
supplies, appliances, medical equipment, and any covered items billed by a
hospital for use at home
Not covered:
Custodial care, rest cures, domiciliary or
convalescent care
Non-covered facilities, such as nursing homes,
schools
Personal comfort items, such as telephone, television,
barber services, guest meals and beds
Private nursing care
All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration
of blood and blood plasma, and other biologicals
Blood or blood plasma, if
not donated or replaced
Pre-surgical testing
Dressings, casts, and
sterile tray services
Medical supplies, including oxygen
Anesthetics
and anesthesia service
NOTE: – We cover hospital services and supplies
related to dental procedures when necessitated by a non-dental physical
impairment. We
do not cover the dental procedures.
Nothing 30
30 Page
31 32
2002 Triple-S Section 5( c)
30
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF): Unlimited medically appropriate care,
including bed, board and general nursing care; drugs, biologicals,
supplies
and equipment ordinarily provided or arranged by the skilled nursing facility
when prescribed by a Plan doctor. You or your Plan
doctor must obtain
authorization from your Plan before Skilled Nursing
Facility confinement, as
discussed on pages 10 and 11.
Nothing
Not covered: custodial care, rest cures, domicile or convalescent care.
All charges
Hospice care
Not covered: Independent nursing,
homemaker services, hospice care All charges
Ambulance
Local professional ambulance service authorized by a
Plan doctor when medically appropriate
Air ambulance services within the Service Area when rendered by a Plan
provider.
You should submit the provider's claim and seek reimbursement
from
us. We pay all charges. You pay nothing.
Nothing
Not covered:
Air ambulance outside of the Service
Area.
Air ambulance services not rendered by a Plan provider.
All charges 31
31 Page 32 33
2002 Triple-S
Section 5( d) 31
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?
Emergencies within our service area:
We have available a 24 hour toll free number. Call 1-800-255-4375
for professional medical advise regarding your condition. Also, you can
contact your general practitioner physician. In extreme emergencies, if you are
unable to
contact your general practitioner physician or the 24 hour toll
free number, contact the local emergency system (e. g., the 911 telephone system
or 787-343-2550) or go to the nearest hospital emergency room. When you call the
24
hour toll free number and receive a precertification from there, the $5
copay is waived. Also, if the emergency results in admission to a hospital, you
pay nothing for the inpatient admission.
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.
When non-Plan
providers are used this Plan pays 90% of Plan's established fees for doctor's
services and full coverage for other services to the extent the services would
have been covered if received from Plan providers.
Emergencies outside our service area:
You can contact the local
emergency system (e. g., the 911 telephone system) or go to the nearest hospital
emergency room. Benefits are available for any medically necessary health
service that is immediately required because of
injury or unforeseen illness
through Blue Cross and Blue Shield plan providers. When non-Plan providers are
used this Plan pays 90% of usual, customary and reasonable charges for the area
in which the emergency services are
rendered. 32
32 Page 33 34
2002 Triple-S 32 Section 5( d)
Section 5 (d). Emergency services/ accidents (Continued)
With your authorization, this Plan will pay benefits directly to
non-Plan providers of your emergency care upon receipt of their claims. Non-Plan
physician claims should be submitted on the HCFA 1500 claim form. If you
are
required to pay for the services, submit itemized bills and your receipts to
this Plan along with an explanation of the services and the identification
information from your ID card.
Payment will be sent to you (or the provider if you did not pay the bill),
unless the claim is denied. If it is denied, you will receive notice of the
decision, including the reasons for the denial and the provisions of the
contract on which denial was based. If you disagree with this Plan's
decision, you may request reconsideration in accordance with the disputed claims
procedure described on page 47.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at emergency
room and an urgent care center
Emergency care as an inpatient at a
hospital, including doctors' services.
$10 per office visit
$5; if we precertify, the copayment is waived
Nothing
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
Emergency care at a
doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
You should submit the provider's claim and seek reimbursement
from
this Plan. Plan reimburses you 90% of usual, customary and
reasonable
charges for the area in which emergency services are
rendered, after any
applicable copay. With your authorization,
this Plan will pay benefits
directly to non-Plan providers of your
emergency care upon receipt of their
claims.
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of
a baby outside the service area
All charges
Emergency outside our service area --Continued on next page 33
33 Page 34 35
2002 Triple-S 33 Section 5( d)
Ambulance You pay
Local professional ambulance service when
medically appropriate. See 5( c) for non-emergency service. Nothing.
You
should submit the provider's claim and seek reimbursement
from us. We pay all charges.
Air ambulance services within the
Service Area when rendered by a Plan provider Nothing
Not covered:
Air ambulance outside of the Service Area.
Air ambulance services not rendered by a Plan provider.
All charges 34
34 Page 35 36
2002 Triple-S
34 Section 5( e)
Section 5 (e). Mental health and substance
abuse benefits
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 OR YOUR PLAN DOCTOR MUST GET PRECERTIFICATION OF THESE SERVICES.
See the instructions after the benefits description below.
This Plan
pays its established fees for necessary professional services. If you use a
non-Plan doctor or provider, you pay for services rendered and the Plan will
reimburse you 90% of the Plan's established fee, after any applicable
copay,
when services are rendered within the service area; or 90% of the usual,
customary and reasonable charge of the area in which the services are rendered,
after any applicable copay, when services are rendered outside the
service
area. Note: We will pay for services provided by a non-Plan provider outside the
service area only if the services are for an emergency or if they have been
preauthorized. In general, we will only authorize care,
equipment, or
professional services that are not available from a Plan provider within the
service area.
You must obtain our approval before services are rendered.
You can
access information about Mental Parity Act by visiting our website at http://
www. ssspr. com.
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by 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 illness
or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$10 per office visit and/ or therapy
Diagnostic tests 25% laboratory and diagnostic tests. Nothing for X-rays.
See Lab,
X-ray and other diagnostic tests (Section 5a).
Services provided by a hospital or other facility
Services in
approved alternative care settings such as partial hospitalization, half-way
houses, residential treatment, full-day
hospitalization, facility based
intensive outpatient treatment
Nothing
Mental health and substance abuse benefits --Continued on next page 35
35 Page 36 37
2002 Triple-S 35 Section 5( e)
Mental health and substance abuse benefits (Continued)
You pay
Not covered: Services we have not approved.
Note:
OPM will base its review of disputes about a treatment plan 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
Precertification To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
you or your Plan doctor or provider should call 1-800-660-4896 for
assistance. This is a 24 hour toll free number to help you obtain the
precertification and the most appropriate care for your mental or substance
abuse condition.
POS mental health and substance abuse benefits
This Plan pays its
established fees for necessary professional services.
If you use a
non-Plan doctor or provider, you pay for services rendered and the Plan will
reimburse you 90% of the Plan's established fees, after any applicable copay,
when services are rendered within the service area;
If you use a non-Plan hospital, you pay for services rendered and we will
reimburse you, according to the Plan's established fees, when services are
rendered within the service area; or
If you use a non-Plan doctor or
provider, including hospital, you pay for services rendered and the Plan will
reimburse you 90% of the usual, customary and reasonable charge of the area in
which the services are rendered,
after any applicable copay, when services
are rendered outside the service area.
Note: We will pay for services
provided by a non-Plan provider outside the service area only if the services
are for an emergency or if they have been preauthorized. In general, we will
only authorize care, equipment, or professional
services that are not
available from a Plan provider within the service area.
You must obtain our
approval before services are rendered.
Special nursing care for each 8-hour
period not to exceed 72 consecutive hours, when ordered by the attending
psychiatrist.
Psychological tests if performed by a qualified psychologist.
Plan reimburses you $18 per period for a registered nurse; $12 per
period for a licensed practical nurse; $12 per period for a
psychiatric
aide. You pay the remaining charges.
Plan reimburses you up to $35 for a full battery of tests. You pay the
remaining charges.
Not covered: POS services we have not approved,
half-way home, residential treatment and services related to a drug detection
and
rehabilitation program.
All charges 36
36 Page 37 38
2002 Triple-S 36 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. Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
If you use a non-Plan pharmacy, this Plan will reimburse you 75% of this
Plan's established fees for prescription drugs and you pay all remaining
charges.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist
must write the prescription.
Where you can obtain them. You may
fill the prescription at a network pharmacy or a non-network pharmacy. We pay a
higher level of benefits when you use a network pharmacy.
We use a formulary. A formulary is a list of medicines that
represents a previous evaluation of the Plan's Pharmacy and Therapeutics
Committee regarding their efficiency, safety and cost
effectiveness; that
guarantee the therapy quality, minimizing inadequate utilization that could
affect the patient's health.
Benefits are provided to the member and member's covered dependents, for
medications prescribed by a doctor or a dentist after applicable copays are
paid.
We have 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 list of drugs that we selected to meet patient needs at a lower cost.
To order a prescription drug formulary list, call 787-749-4777.
These are the dispensing limitations. Federal Drug Administration
(FDA) guidelines are used by this Plan to manage the pharmacy coverage. These
include dosing, generic bioequivalent
medications and new drug
classification, among others.
We cover prescription drugs dispensed within
six months of a doctor or dentist's original prescription not to exceed the
normal 34 days supply. The pharmacy network will not dispense any order too
soon after the last one was filled. If this is your case, the pharmacy will
contact the Plan to obtain an authorization. Also, the pharmacy will contact the
Plan to obtain an authorization for dose changes
and for charges over $500
per dispensed prescription.
When you are planning a trip and need a
prescription drug refill in advance, you must show the pharmacy the
prescription, along with the airline tickets, to allow the pharmacy to contact
the Plan to
obtain an authorization.
A generic bioequivalent 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
exists, and your physician has not specified Dispense as Written for
the name brand drug, you have to pay the brand name copay and the difference in
cost between the name brand drug and the
generic. If a generic bioequivalent
is not available, you still have to pay the brand copay.
Prescription
drug benefits begin on the next page. 37
37
Page 38 39
2002
Triple-S 37 Section 5( f)
Section 5 (f). Prescription drug
benefits (Continued)
Why use generic drugs?
Generic
drugs are lower-priced drugs that are the therapeutic equivalent to more
expensive brand-name drugs. They must contain the same active ingredients and
must be equivalent in strength and
dosage to the original brand-name product. The U. S. Food and Drug
Administration sets quality standards for generic drugs to ensure that these
drugs meet the same standards of quality and strength
as brand-name drugs.
You can save money by using generic drugs. However, you and yor plan
physician have the option to request a name-brand if a generic option is
available. Using the most cost-effective medication
saves money.
When you have to file a claim.
You must file a
claim whenever you use a non-network pharmacy. The Plan reimburses 75% of its
established fees for prescription drugs and you pay the remaining charges.
Submit your itemized bill
and/ or receipts to us. Also read Section 7 Filing a claim for covered
services for required information.
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician or dentist and obtained from a Plan pharmacy:
We will cover prescription drugs based on a formulary. You will pay the brand
name copay and the difference between the cost of the brand
name
prescription drug and the cost of the generic bioequivalent prescription drug,
if you choose a brand name prescription drug, for which
a generic
bioequivalent prescription drug is available. Covered prescription drugs and
accessories include:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those
listed as Not
covered.
Insulin
Disposable needles and syringes for the
administration of covered medications
Contraceptive drugs and devices
Drugs for sexual disfunction
Vitamins only if they include the legend: "Federal law prohibits dispensing
without a prescription"
Smoking cessation drugs, including nicotine patches
Note: Intravenous
fluids and drugs for home use, implantable drugs, and some injectable drugs are
covered under the Medical and Surgical Benefits
(also covered under the Medical and Surgical Benefits provided as part of a
home health service program).
You will pay the following in-formulary copayments:
$2 for
bioequivalent prescription drug unit or refill
$5 for preferred brand
prescription drug unit or refill
$10 for brand name unit or refill.
Note: If you choose a brand name prescription drug, for which a
generic
bioequivalent prescription drug exists, you will pay the brand
name copay
and the difference between the cost of the brand name
prescription drug and
the cost of the generic bioequivalent prescription
drug.
You will pay
the following out of the formulary copayment:
$2 for bioequivalent prescription drug unit or refill.
20% or $10,
whichever is higher, for out of formulary
brand name prescription drug unit
or refill.
Covered medications and supplies -Continued on next page 38
38 Page 39 40
2002 Triple-S 38 Section 5( f)
Covered medications and supplies (Continued) You Pay
Note: If a generic bioequivalent does not exist, you will still have
to pay the brand name copay.
Note: If you choose a brand name
prescription drug out of the
formulary, for which a generic bioequivalent prescription drug
exists,
you will pay the brand name copay and the difference
between the cost of the
brand name prescription drug and the
cost of the generic bioequivalent
prescription drug.
Not covered:
Drugs and supplies for cosmetic purposes
Nutrients and food supplements even if a physician prescribes or
administers them
Drugs available without a prescription or for which there is a
nonprescription equivalent available
Medical supplies such as
dressings and antiseptics
Drugs supplied by pharmacies located
outside of Puerto Rico, the United States and its territories, except for
emergencies
Drugs for treatment of infertility
Drugs to enhance
athletic performance
Drugs that are experimental or investigational
unless approved by the Federal Drug Administration (FDA)
All Charges 39
39 Page 40 41
2002 Triple-S
Section 5( g) 39
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.
24 hours, 7 days a week call center We offer these services so the
members can have immediate access to clinical advice to help them decide when to
go to the emergency room
immediately, and how to avoid a visit to emergency
room for routine care. Scientifically based protocols are entered into a
computer and are
followed consistently. Members are oriented on how to reduce risk and manage
their disease. Call us at 1-800-255-4375.
Blue Card Program Blue Card Program is available to all members
insured with a Blue Cross and Blue Shield Association Plan. When you need
hospital and
medical services in any state out of the service area, you can
receive them through the Plan providers of this Program. Call 1-800-810-2583
or 787-749-4777 for additional information.
Centers of excellence for transplants/ heart
surgery/ etc
We offer you the benefit of the Blue Quality Centers for Transplant which is
a cooperative effort among the Blue Cross and/ or Blue Shield
Plans, Blue
Cross and Blue Shield Association and Participating Institutions to facilitate
the provision of quality care in a cost-effective
manner from leading
institutions for six transplant types: heart, single or bilateral lung,
combination heart-bilateral lung, liver, simultaneous
pancreas-kidney, and
bone marrow/ stem cell (autologous/ allogeneic). Call 1-800-981-4860 or
787-749-4949 extensions 4361 or 4312 for
additional information.
High risk pregnancies program Our pregnancy educational program
provides information about the prenatal, delivery and postnatal stages.
Emphasizes risk factors that
every women should know to have a healthy
delivery and to avoid complications. Call 787-749-4949 extension 4286 for
additional
information.
Blue Card Worldwide Blue Card Worldwide is available to all members
insured with a Blue Cross and Blue Shield Association Plan. When you need
emergency
hospital and medical services out of the service area or the
United States of America, you can receive them through the Plan providers of
this
Program in other countries. Call 1-800-810-2583 for additional information.
Special Features -Continued on next page 40
40 Page 41 42
2002 Triple-S 40 Section 5( g)
Section 5 (g). Special Features (Continued)
Feature
Description
Mental Health Management Program for Federal
Employees
This program is available to all Federal employees and their family members
24 hours a day, 7 days a week. The program includes some
technological
features to ensure quality service:
Interactive Voice Response (IVR):
Through the IVR your provider can register your care, verify eligibility,
and register your visits
through the phone key pad.
The Diary of My Recovery: This is a
guide or daily register designed to help you obtain better results from your
treatment and to measure
the progress you are making during the recovery process. Contact your Case
Manager at 1-800-660-4896.
Questions?: This service is open for receiving information regarding
your services, orientation, comments or any other question you might
have.
Our electronic address is available for you at: federalesss@ valueoptions. com.
41
41 Page 42 43
2002 Triple-S Section 5( h) 41
Section 5
(h). Dental benefits
I M
P O
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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 dental procedures
only when a non-dental physical impairment exists which makes hospitalization
necessary to safeguard the
health of the patient; we do not cover the dental procedure unless it is
described below.
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. An injury
caused by chewing is not considered an accidental injury.
Nothing
Dental benefits You pay
If a non-Plan dentist is used, you pay a
30% coinsurance and any remaining difference between this Plan's payment of 90%
of its established fee and the actual charge for services rendered in Puerto
Rico. For care outside of Puerto
Rico, the member will pay the 30%
coinsurance and any remaining difference between 100% of this Plan's payment
established fee and the actual charge. The following list shows the dental
services covered by this Plan.
Note: We will pay for services provided by a non-Plan provider outside the
service area only if the services are for an emergency or if they have been
preauthorized. In general, we will only authorize care, equipment, or
professional
services that are not available from a Plan provider within the
service area.
Plan dentist means a duly authorized dentist with a regular
license issued by the designated entity of the government of Puerto Rico, and
who is a bona fide member of the "Colegio de Cirujanos Dentistas de Puerto
Rico", who has
signed a contract with Triple-S to render dental services. Non-Plan dentist
means a duly authorized dentist with a regular license, who has not signed a
contract with Triple-S to render dental services.
Dental coverage is limited to:
Diagnostic
Periodic oral evaluation
Limited oral evaluation
Comprehensive oral evaluation
Periapical and bitewing X-rays (limited to six periapical X-rays and no more
than two bitewing X-rays per calendar year)
Preventive Prophylaxis (adult and child)
Fluoride treatment, one
every six month. Fluoride treatment is limited to members under 19 years of age.
Nothing
Dental benefits --Continued on next page 42
42 Page 43 44
2002 Triple-S 42 Section 5( g)
Dental benefits (Continued) You pay
Restorative
Amalgam restorations
Plastic, porcelain or composite (anterior and
posterior tooth)
Other restorative services (pin retention per tooth, in
addition to restorations)
Sedative filling
Adjunctive General Services
Application of
desensitizing medicament
Gingival curettage, surgical (emergency
treatment), for one or two teeth in the same quadrant
Treatment of complications (post-surgical-unusual circumstances, by report)
Endodontics
Pulp capping-direct (excluding final restoration)
Pulp capping-indirect (excluding final restoration)
Oral Surgery
Extractions
Surgical removal of erupted teeth
Surgical removal of
residual tooth roots
Incision and drainage of abscess -intra-oral soft
tissue
Surgical removal of impacted teeth
30%
30%
30%
30%
Not covered: Other dental services not shown as covered. All charges
43
43 Page 44
45
2002 Triple-S 43 Section 5( i)
Section 5 (i). Point of service benefits
Facts about this Plan's
POS option
At your option, within our service area (Puerto Rico) you may
choose to obtain benefits covered by this Plan from non-Plan doctors and
hospitals whenever you need care, except for the benefits listed below under
"What
is not covered." Outside of our service area, only emergency care or care
that has been preauthorized will be covered under the POS option. In general, we
will only authorize coverage outside of our service area for care,
equipment, or professional services that are not available from a Plan
provider.
Point of Service (POS) Benefits
You can receive care
from any non-Plan doctor within our service area without a referral. A non-Plan
doctor is any licensed doctor of medicine (M. D.) who is not a Plan doctor.
Non-Plan doctors do not have to accept Triple-S
established fees as payment in full. If you use a non-Plan doctor (except for
speech or occupational therapy) you must pay the difference between the non-Plan
doctor's charge and the amount paid to you by us.
You can also receive services from a non-Plan hospital within our service
area. A non-Plan hospital is any licensed institution that is not a Plan
hospital and that is engaged primarily in providing bed patient with diagnosis
and
treatment under the supervision of physicians with 24-hour-a-day
registered graduate nursing services. A non-Plan hospital does not have to
accept Triple-S established fees as payment in full. You must pay any difference
between
the non-Plan hospital's charges and the amount paid to you by us. We
reimburse you according to our established fee for non-Plan hospital inpatient
admissions.
Benefits are paid according to the "medical benefits schedule". This is the
schedule of established fees on which this Plan's payment of covered medical
expense is based, when the services are rendered within the
service area,
Puerto Rico. When services are rendered outside the service area, the Plan's
payment is based on usual, customary and reasonable charges.
If you use a non-Plan doctor or provider, you pay for services rendered and
we will reimburse you 90% of the Plan's established fees, after any applicable
copay, when services are rendered within the service area, or 90%
of the
usual, customary and reasonable charge of the area in which the services are
rendered, after any applicable copay, when services are rendered outside the
service area.
Non-Plan providers are under no obligation to accept our established fees as
payment in full. You pay all charges remaining for outpatient care above our
established fees when non-Plan providers are used, in addition
to the
copayments. For all other care under this benefit you pay all remaining charges
after we have paid benefits.
What is covered
Point of service benefits are described in Section
5 of this brochure.
Precertification
Read Section 3 for services requiring our prior
approval.
What is not covered
Point of service benefits exclusions are
described in Section 5 of this brochure. 44
44
Page 45 46
2002
Triple-S 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 or condition and we agree, as discussed
under What Services Require Our Prior Approval on pages 10
and 11.
We do not cover the following:
Care by non-Plan providers outside of
our service area, except for authorized referrals or emergencies (see Emergency
Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest;
Services, drugs,
or supplies related to sex transformations;
Services, drugs, or supplies
you receive from a provider or facility barred from the FEHB Program;
Physical exams required for obtaining or continuing employment or insurance,
attending schools or camp, or travel; or
Drug detection tests for employment purposes. 45
45 Page 46 47
2002 Triple-S 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 or
coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, hospital and drug benefits In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance Claim Form.
Facilities will file on the UB-92 form. For
claims questions and assistance, call us at 787-749-4777.
When you must file a claim --such as for out-of-area care --submit it on 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.
For prescription drugs also include:
Prescription
drug name;
Daily dosage;
Prescription number;
Dispensed
supply; and
National drug Code (NDC)
Submit your claims to:
Triple-S
P. O. Box 363628
San Juan, Puerto Rico 00936-3628 46
46 Page 47 48
2002 Triple-S 46 Section 7
Section 7. Filing a claim for covered services (Continued)
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 information Please reply promptly when we ask for additional
information. We may delay processing or deny your claim if you do not respond.
47
47 Page 48 49
2002 Triple-S 47 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 precertification:
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: Triple-S, P. O. Box 363628,
San Juan, Puerto Rico 00936-3628; 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. 20415-3620.
Send OPM the following information:
A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (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. 48
48 Page 49 50
2002 Triple-S
48 Section 8
Section 8. The disputed claims process
(Continued)
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 precertification/ prior approval, then call us at 787-749-4777 and we will
expedite our review; or
(b) We denied your initial request for care or
precertification/ 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 2 at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 49
49
Page 50 51
2002
Triple-S 49 Section 9
Section 9. Coordinating benefits with
other coverage
When you have other health coverage You must tell us if
you are covered or a family member is covered under another group health plan or
have automobile insurance that pays
medical 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 as 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 The Original Medicare Plan (Original
Medicare) is available everywhere (Part A or Part B) 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.
(Primary payer chart begins on next page.) 50
50 Page 51 52
2002 Triple-S 50 Section 9
Section 9. Coordinating benefits with other coverage
(Continued)
The following chart illustrates whether the Original
Medicare Plan or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or
a covered family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then
the primary payer is… A. When either you --or your covered spouse --are age 65
or over and …
Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, 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,
(except for claims
related to Workers'
Compensation.)
B.
When you --or a covered family member --have Medicare based on end stage renal
disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, 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 51
51 Page 52 53
2002 Triple-S 51 Section 9
Section 9. Coordinating benefits with other coverage
(Continued)
Claims process when you have the Original Medicare
Plan --You probably will never have to file a claim form when you have both
our
Plan and the Original Medicare Plan.
When we are the primary
payer, we process the claim first.
When Original Medicare is the primary
payer, Medicare processes your claim first. In most cases, your claims will be
coordinated
automatically and we will pay the balance of covered charges.
You will not need to do anything. To find out if you need to do
something
about filing your claims, call us at 787-749-4777.
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 A and
Part B we will
waive copays and coinsurance.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a
Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary even out of the managed
care Plan's network and/ or service
area. If you use our Plan providers, we will waive our copayments and
coinsurance.
If you enroll in a Medicare managed care plan, tell us. We will need to know
whether you are in the Original Medicare Plan or in a Medicare
managed care
plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your
FEHB coverage to
enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does
not contribute to your Medicare
managed care plan premium). For information
on suspending your FEHB enrollment, contact your retirement office. If you later
want to re-enroll
in the FEHB Program, generally you may do so only at the
next open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area. 52
52
Page 53 54
2002
Triple-S 52 Section 9
Section 9. Coordinating benefits with
other coverage (Continued)
If you do not enroll in If
you do not have one or both Parts of Medicare, you can still be covered
Medicare Part A or Part B under the FEHB Program. We will not require you
to enroll in Medicare
Part B and, if you can't get premium-free Part A, we
will not ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third
party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your treatment, we will cover your care. You must use our
providers. If
medical benefits provided under such law are exhausted, we
will be financially responsible for services or supplies that are otherwise
covered
by us. We are entitled to be reimbursed by OWCP for services we
provided that were later found to be payable by OWCP.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or for injuries 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. 53
53 Page
54 55
2002 Triple-S 53 Section
10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new
enrollees, the calendar year begins on the effective date of their enrollment
and ends on
December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Treatment or services, regardless of who recommends them or where they are
provided, that could be rendered safely and reasonably by a
person not
medically skilled, or that are designed mainly to help the patient with daily
living activities. These activities include but are not
limited to:
personal care such as help in: walking; getting in and out of bed; bathing;
eating by spoon, tube or gastrostomy; exercising; dressing;
homemaking, such as preparing meals or special diets;
moving the
patient;
acting as a companion or sitter;
supervising medication
that can usually be self-administered; or
treatment or services that any
person may be able to perform with minimal instruction, including but not
limited to recording
temperature, pulse, and respirations, or administration
and monitoring of feeding systems.
Experimental or This Plan considers factors which it determines to be
most relevant under investigational services the circumstances, such as:
published reports and articles in the
authoritative medical, scientific, and
peer review literature; or written protocols used by the treating facility or
being used by another facility
studying substantially the same drug, device,
or medical treatment. This Plan also considers Federal and other governmental
agency approval as
essential to the treatment of an injury or illness by,
but not limited to, the following: American Medical Association, U. S. Surgeon
General, U. S.
Department of Public Health, the Food and Drug
Administration, or the National Institutes of Health. 54
54 Page 55 56
2002 Triple-S 54 Section 10
Section 10. Definitions of terms we use in this brochure
(Continued)
Medically necessary Services, drugs, supplies,
or equipment provided by a hospital or covered provider of health care services
that the Plan determines:
are appropriate to diagnose or treat the
patient's condition, illness or injury;
are consistent with standards of
good medical practice in the United States;
are not primarily for the
personal comfort or convenience of the patient, the family, or the provider;
are not a part of or associated with the scholastic education or
vocational training of the patient; and
in the case of inpatient care,
cannot be provided safely on an outpatient basis.
The fact that a covered
provider has prescribed, recommended, or approved a service, supply, drug, or
equipment does not, in itself, make it
medically necessary.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in
different ways. We determine our allowance as follows: the
plan allowance in our service area, Puerto Rico, is the medical benefits
schedule, the fees Plan doctors have agreed to accept as payment in full.
The Plan allowance outside of the service area is the usual, customary
and
reasonable charge.
Us/ We Us and we refer to Triple-S.
You You refers to the
enrollee and each covered family member. 55
55
Page 56 57
2002
Triple-S 55 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition
before you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office about enrolling in the can answer your questions, and give you
a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances,
you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period
in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please
tell us immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child
under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by another
FEHB plan. 56
56 Page
57 58
2002 Triple-S 56 Section
11
Section 11. FEHB facts (Continued)
When benefits
and The benefits in this brochure are effective on January 1. If you joined
premiums start 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.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as
other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends
You will receive an additional 31 days of coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact
your ex-spouse's employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary
Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage choices.
Temporary continuation If you leave Federal service, or if you lose
coverage because you no of coverage (TCC) 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 loose your job, if you are a covered
dependent child and you turn 22 or marry, etc.. 57
57
Page 58 59
2002
Triple-S 57 Section 11
Section 11. FEHB facts
(Continued)
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.
Converting
to You may convert to a non-FEHB individual policy if: individual
coverage
Your coverage under TCC or the spouse equity law ends. (If you canceled
your coverage or did not pay your premium, you cannot
convert);
You
decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is
losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a
Federal law that offers limited Federal protections for
health coverage
availability and continuity to people who lose employer group coverage. If you
leave the FEHB Program, we will give you a
Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You can use
this certificate when getting
health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods, limitations,
or exclusions for health
related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have
been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA"
frequently asked questions. These highlight HIPAA rules, such
as the
requirement that Federal employees must exhaust any TCC eligibility as one
condition for guaranteed access to individual health
coverage under HIPAA,
and have information about Federal and State agencies you can contact for more
information. 58
58 Page
59 60
2002 Triple-S 58 Long
Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How
are YOU planning to pay for the future custodial or chronic care you may need?
You should consider buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance? It's insurance to help pay
for long term care services you may need if you can't take care of yourself
because of an extended illness or injury, or an
age-related disease such as
Alzheimer's. LTC insurance can provide broad, flexible benefits for nursing
home care,
care in an assisted living facility, care in your home, adult day
care, hospice care, and more. LTC insurance can supplement care provided by
family
members, reducing the burden you place on them.
I'm
healthy. I won't need long term care. Or, will I? Welcome to the club!
76% of Americans believe they will never need long term care, but the
facts are that about half of them will. And it's not just the old folks. About
40%
of people needing long term care are under age 65. They may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a
plan just in case. Many people now consider long term care insurance to be
vital to their financial and retirement planning.
Is long term
care expensive? Yes, it can be very expensive. A year in a nursing home
can exceed $50,000. Home care for only three 8-hour shifts a week can exceed
$20,000
a year. And that's before inflation! Long term care can easily exhaust your
savings. Long term care insurance
can protect your savings.
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?
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.
When will I get more information on how to apply for
this new
insurance coverage?
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.
How can I find out
more about the program NOW? 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. 59
59 Page 60 61
2002 Triple-S
59 DoD/ FEHB Demonstration Project
Department of Defense/ FEHB
Demonstration Project
What is it? The Department of Defense/ FEHB
Demonstration Project allows some active and retired uniformed service members
and their dependents to enroll in the FEHB
Program. The demonstration will
last for three years and began with the 1999 open season for the year 2000. Open
season enrollments will be effective January
1, 2002. DoD and OPM have set
up some special procedures to implement the Demonstration Project, noted below.
Otherwise, the provisions described in this
brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired uniformed service member and are eligible for
Medicare;
You are a dependent of an active or retired uniformed service
member and are eligible for Medicare;
You are a qualified former spouse of
an active or retired uniformed service member and you have not remarried; or
You are a survivor dependent of a deceased active or retired uniformed
service member; and
You live in one of the geographic demonstration areas.
If you are eligible to enroll in a plan under the regular Federal Employees
Health Benefits Program, you are not eligible to enroll under the DoD/ FEHBP
Demonstration Project.
The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico
Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX
Humboldt County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA Coffee County, GA
When you can join You may
enroll under the FEHB/ DoD Demonstration Project during the 2001 open season,
November 12, 2001, through December 10, 2001. Your coverage
will begin
January 1, 2002. DoD has set-up an Information Processing Center (IPC) in Iowa
to provide you with information about how to enroll. IPC staff will
verify
your eligibility and provide you with FEHB Program information, plan brochures,
enrollment instructions and forms. The toll-free phone number for the
IPC is
1-877/ DOD-FEHB (1-877/ 363-3342).
You may select coverage for yourself
(Self Only) or for you and your family (Self and Family) during open season.
Your coverage will begin January 1, 2002.
If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your coverage
will
begin. 60
60 Page
61 62
2002 Triple-S 60 DoD/
FEHB Demonstration Project
Department of Defense/ FEHB Demonstration
Project (Continued)
DoD has a web site devoted to the
Demonstration Project. You can view information such as their Marketing/
Beneficiary Education Plan, Frequently
Asked Questions, demonstration area
locations and zip code lists at www. tricare. osd. mil/ fehbp. You can also view
information about the
demonstration project, including "The 2002 Guide to
Federal Employees Health Benefits Plans Participating in the DoD/ FEHB
Demonstration Project," on the
OPM web site at www. opm. gov.
Temporary Continuation See Section 11, FEHB Facts; it explains
temporary continuation of coverage of Coverage (TCC) (TCC). Under this
DoD/ FEHB Demonstration Project the only individual eligible
for TCC
is one who ceases to be eligible as a "member of family" under your self and
family enrollment. This occurs when a child turns 22, for example, or if you
divorce and your spouse does not qualify to enroll as an unremarried former
spouse under title 10, United States Code. For these individuals, TCC begins the
day after their enrollment in the DoD/ FEHB Demonstration Project ends. TCC
enrollment terminates after 36 months or the end of the Demonstration Project,
whichever occurs first. You, your child, or another person must notify the
IPC when a family member loses eligibility for coverage under the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/
FEHB Demonstration Project area, you cancel your coverage, or your coverage is
terminated for any reason. TCC is
not available when the demonstration
project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project. 61
61 Page 62 63
2002 Triple-S 61 Index
Index
Do not rely on this page; it is for your convenience and may not show
all pages where the terms appear.
Accidental injury 41 Allergy tests
18
Allogeneic (donor) bone narrow transplant 27
Alternative treatment 22
Ambulance 30, 33
Anesthesia 27 Autologous bone marrow
transplant 27
Biopsies 24
Blood and blood plasma 29 Breast cancer screening 16
Casts 29 Changes for 2002 8
Chemotherapy 18 Childbirth 17
Cholesterol tests 15 Claims 45-46
Coinsurance 12, 53 Colorectal cancer
screening 15
Congenital anomalies 24 Contraceptive devices and drugs 37
Covered services 13-44, 53 Coordination of benefits 49-52
Crutches 22
Custodial care 30, 53
Definitions 53-54 Dental care 41-42
Diagnostic services 14, 15, 29, 34, 41
Disputed claims review 47-48
Donor expenses (transplants) 27
Dressings 29 Durable medical equipment
(DME) 21, 22 Educational classes and programs
23 Effective date
of enrollment 55
Emergency 31-33 Experimental or investigational 38,
44,
53 Eyeglasses 20
Family planning 17 Fecal occult blood test 15
General Exclusions 44 Hearing services 20
Home health
services 22 Home nursing care 22
Hospice care 30 Hospital 28
Immunizations 16 Infertility 18, 38
In-hospital physician care 24
Inpatient Hospital Benefits 28,
31, 34 Insulin 22, 37
Laboratory
and pathological services 15, 29, 34
Magnetic Resonance Imaging
(MRI) 15
Mammograms 15, 16 Maternity Benefits 17
Medicaid 52 Medically
necessary 10, 11, 14,
24, 28, 41, 54 Medicare 49-52
Mental Conditions/
Substance Abuse Benefits 34-35, 40
Newborn care 16, 17 Nurse 15, 22, 35
Licensed Practical Nurse 35 Nurse Anesthetist 29
Nurse Practitioner 35
Psychiatric Nurse 35
Registered Nurse 35 Nursery charges 17
Obstetrical care 17 Occupational therapy 19
Ocular injury 20
Office visits 14
Oral and maxillofacial surgery 26 Orthopedic devices 21
Out-of-pocket expenses 12 Outpatient facility care 29
Oxygen 21, 29
Pap test 16 Physical therapy 19
Physician 6 Point of service (POS)
6, 35,
43 Precertification 10, 11, 35, 43
Preventive care, adult 15-16
Preventive care, children 16
Prescription drugs 37-38 Preventive services
15-16, 41
Prior approval 10, 43 Prostate cancer screening 15
Prosthetic
devices 21, 25 Psychologist 34, 35
Radiation therapy 18 Renal
dialysis 18
Room and board 28 Second surgical opinion 15
Skilled
nursing facility care 14, 30
Smoking cessation 37 Speech therapy 20
Splints 29 Sterilization procedures 17, 25
Subrogation 52 Substance
abuse 34-35
Surgery 24-27 Anesthesia 27, 29
Oral 42 Outpatient 29
Reconstructive 25 Syringes 37
Temporary continuation of
coverage 56
Transplants 11, 26-27, 39 Treatment therapies 18-19
Vision services 16, 20 Well child care 16
Wheelchairs 21
Workers' compensation 52
X-rays 15, 29, 34, 41 62
62 Page 63 64
2002 Triple-S 62 Summary
Summary
of benefits for the Triple-S 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 ................
Office visit copay:$ 7.50 general
practitioner; $10 specialist, 25%
for laboratory and diagnostic
tests; nothing for X-rays. 14
Services provided by a hospital:
Inpatient
.......................................................................................
Outpatient.....................................................................................
Nothing
Nothing
28
29
Emergency benefits:
In-area
.........................................................................................
Out-of-area
..................................................................................
Emergency room $5; waived if precertified. Nothing for hospital.
10%
31-33
Mental health and substance abuse treatment
..................................... Regular benefits 34
Prescription drugs
.............................................................................
In-formulary: $2 for bioequivalent prescription
drug unit or refill; $5 for
preferred brand prescription
drug unit or refill; and $10 for brand name
unit or refill.
Out of the formulary: $2 for bioequivalent prescription
drug unit or
refill; 20% or $10, whichever is higher, for
out of formulary brand
prescription drug unit or
refill.
36
Dental
Care...................................................................................
Nothing for diagnostic services; 30% all other services. 41
Vision
Care...................................................................................
$10 per office visit 20
Special features: Flexible benefits option 24
hours, 7 days a week call center Blue Card Program Centers of excellence for
transplants/ heart surgeries/ etc High risk pregnancies program Blue Card
Worldwide Mental Health Management Program for Federal Employees
39
Point of Service benefits --Yes 35, 43 63
63
Page 64
2001 Triple-S 63
Summary
2002 Rate Information for ABC Benefit Plan
Non-Postal
rates apply to most non-Postal enrollees. If you are in a special enrollment
category, refer to the FEHB Guide for that category or contact the agency that
maintains your
health benefits enrollment.
Postal rates apply to
career Postal Service employees. Most employees should refer to the FEHB Guide
for United States Postal Service Employees, RI 70-2. Different postal rates
apply
and special FEHB guides are published for Postal Service Nurses, RI
70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Standard Option
Self Only 891 $68.36 $ 22.79 $148.12 $49.37 $80.90
$10.25
Standard Option
Self and Family 892 $146.82 $48.94 $318.11 $106.04
$173.74 $22.02 64