Serving: Chicagoland area
Enrollment in this Plan is
limited. You must live or work in our Geographic service area to enroll. See
page 7 for requirements.
Enrollment codes for this Plan:
171 Self Only 172 Self and Family
This Plan has commendable accreditation
from the NCQA. See the 2002
Guide for
more information on accreditation.
RI 73-029
For changes
in benefits see
page 8. 1
1 Page 2 3
2002 UNICARE HMO Table of Contents 2
Table of Contents
Introduction………………………………………………………………….
............................................................... 4
Plain Language………………………………………………………………
............................................................... 4
Inspector General
Advisory………………………………………………………………............................................
4
Section 1. Facts about this HMO plan
..........................................................................................................................
5
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.............................................................................................................
11
Services requiring our prior approval
........................................................................................................
11
Section 4. Your costs for covered services
.................................................................................................................
12
Copayments.........................................................................................................................................
12
Deductible............................................................................................................................................
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........ 23
(c)
Services provided by a hospital or other facility, and ambulance
services...................................... 27
(d)
Emergency services/
accidents.........................................................................................................
30
(e) Mental health and substance abuse
benefits....................................................................................
32
(f) Prescription drug
benefits................................................................................................................
34 2
2 Page 3 4
2002 UNICARE HMO Table of Contents 3
(g) Special
features...............................................................................................................................
38
Flexible benefits option
Services for the deaf and hearing impaired
(h) Dental
benefits................................................................................................................................
39
(i) Non-FEHB benefits available to Plan
members.............................................................................
40
Section 6. General exclusions --things we don't
cover.............................................................................................
41
Section 7. Filing a claim for covered
services............................................................................................................
42
Section 8. The disputed claims
process......................................................................................................................
44
Section 9. Coordinating benefits with other
coverage................................................................................................
46
When you have…
Other health
coverage..........................................................................................................................
46
Original
Medicare................................................................................................................................
46
Medicare managed care plan
...............................................................................................................
48
TRICARE/ Workers' Compensation/
Medicaid..........................................................................................
49
Other Government
agencies......................................................................................................................
49
When others are responsible for
injuries...................................................................................................
49
Section 10. Definitions of terms we use in this
brochure...........................................................................................
50
Section 11. FEHB
facts..............................................................................................................................................
51
Coverage
information..............................................................................................................................
51
No pre-existing condition limitation
................................................................................................
51
Where you get information about enrolling in the
FEHB Program.................................................. 51
Types of coverage available for you and your
family......................................................................
51
When benefits and premiums start
...................................................................................................
52
Your medical and claims records are confidential
...........................................................................
52
When you
retire................................................................................................................................
52
When you lose benefits
...........................................................................................................................
52
When FEHB coverage
ends............................................................................................................
52
Spouse equity coverage
..................................................................................................................
52
Temporary Continuation of Coverage
(TCC).................................................................................
52
Converting to individual coverage
.................................................................................................
53
Getting a Certificate of Group Health Plan Coverage
.................................................................... 53
Long term care insurance is coming later in 2002
...................................................................................
54
Index
........................................................................................................................................................
55
Summary of benefits
................................................................................................................................
57
Rates............................................................................................................................................
back cover 3
3 Page
4 5
2002 UNICARE HMO Introduction/ Plain Language 4
Introduction
UNICARE Health Plans of the Midwest, Inc. d/ b/ a UNICARE HMO, Sears
Tower, 233 S. Wacker Drive, 39 th floor,
Chicago, Illinois 60606-6309
This brochure describes the benefits of UNICARE HMO under our contract (CS
1656) with the Office of Personnel
Management (OPM), as authorized by the
Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the
benefits, limitations, and exclusions of
this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 8. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family
member, "we" means UNICARE HMO.
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. 4
4 Page 5 6
2002 UNICARE HMO Advisory 5
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 312/ 234-8855 or 888/
234-8855 (outside of the Ameritech local calling area) and explain
the situation.
If we do not resolve the issue, call or write:
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office
of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate anyone who
uses an ID card if the person tries to obtain
services for someone who is not an
eligible family member, or is no longer
enrolled in the Plan and tries to obtain
benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 UNICARE HMO Section 1 6
Section 1. Facts about this HMO
plan
This Plan is a health maintenance organization (HMO). We require
you to see specific physicians, hospitals, and
other providers that contract
with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations,
in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services
from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is
available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one
physician,
hospital, or other provider will be available and/ or remain under contract with
us.
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.
Who provides my health care?
UNICARE HMO is an Independent
Physician Association (IPA) model HMO Plan with a broad network of
physicians who practice at contracted medical groups. Federal employees who
enroll in our Plan can select a doctor
from among more than 2,800 primary
care physicians associated with more than 90 hospitals throughout the greater
Chicago metropolitan area.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information
about us, our
networks, providers and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the
required information is listed below.
UNICARE Health Plans of the Midwest, Inc. is licensed in both the State of
Illinois and the State of Indiana and we are compliant with the laws of each
state as they pertain to HMO plans.
UNICARE HMO has been in existence since
1993. We have a commendable accreditation from the National Committee of Quality
Assurance (NCQA) that reviews
health plans.
If you want more information
about us, call 312/ 234-8855 or 888/ 234-8855 (outside of the Ameritech local
calling
area). 6
6 Page
7 8
2002 UNICARE HMO Section 1 7
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. Our Service Area is the Chicago Metropolitan
area and
includes the Illinois counties of Cook, DuPage, Kane, Kankakee, Kendall, Lake,
McHenry and Will and the
Indiana counties of Lake and Porter. This is where
our providers practice.
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 urgent or
emergency benefits. We will not pay for any other health care services.
If you or a covered family member moves outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member moves, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office.
If you need urgent or emergency care when you are away from home, you should
call UNICARE HMO at 800/ 782-
0180. Service is available 24 hours a day, 7
days a week. If your unexpected illness is not an emergency, you
should call
this number before seeking treatment. For life-threatening medical emergencies,
you should seek
treatment from the nearest medical facility and inform the
hospital or physician that you are a member of UNICARE
HMO. You should then
contact UNICARE HMO at 800/ 782-0180 within 24 hours after medical care begins.
7
7 Page 8 9
2002 UNICARE HMO Section 2 8
Section 2.
How we change for 2002
Do not rely on these change descriptions; this
page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure;
any language change not shown here is a
clarification that does not change
benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will increase by 1. 2% for Self Only or
21. 6% for Self and Family. Your office visit copay has increased from $10.00 to
$15.00.
The prescription drug copays have changed to $5.00 generic
formulary, $15 name brand formulary, and $25.00 nonformulary.
The hospital
emergency room copay has increased from $25.00 to $50.00 per visit. We no longer
limit total blood cholesterol tests to certain age groups. (Section 5 (a))
We now cover routine screening for chlamydial infection. (Section 5 (a)) We
changed speech therapy benefits by removing the requirement that services must
be required to restore
functional speech. (Section 5 (a))
We now cover
habilitative as well as rehabilitative speech therapy. (Section 5 (a)) We now
cover chiropractic care when you receive a referral from your doctor. (Section 5
(a))
We now cover certain intestinal transplants. (Section 5 (b)) 8
8 Page 9 10
2002 UNICARE HMO Section 3 9
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it whenever you
receive services from a Plan provider, or obtain 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 312/ 234-8855
or
888/ 234-8855 (outside of the Ameritech local calling area).
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, coinsurance and deductibles and
you will not have to file claims.
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 at http:// www. unicare. com
.
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 primary care
physician. This decision is important since your primary care physician provides
or arranges for
most of your health care. To select a Primary Care Physician, call us at
312/ 234-8855 or 888/ 234-8855 (outside of the Ameritech local calling
area).
Primary care Your primary care physician can be a family practitioner,
internist or pediatrician. Your primary care physician will provide most of your
health
care, or give you a referral to see a specialist.
If you want to
change primary care physicians or if your primary care
physician leaves the
Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must
return to the primary care physician after the
consultation, unless your primary
care physician authorized a certain number
of visits without additional
referrals. The primary care physician must
provide or authorize all follow-up
care. Do not go to the specialist for
return visits unless your primary care
physician gives you a referral.
However, female members may see an
obstetrician/ gynecologist (OB/ GYN),
also known as a "woman's principal
health care provider", who is in the
Plan's network and has been designated by
the member, without a referral.
Although a woman may directly see her
"woman's principal health care
provider," a referral arrangement must exist
between that provider and her
PCP so her care can be coordinated. This will
also eliminate any potential
billing issues. Female members must call the 9
9
Page 10 11
2002
UNICARE HMO Section 3 10
Plan's Customer Services Department for
assistance in designating a provider
where the referral arrangement exists.
.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a
treatment plan that allows you to see your specialist for a certain number
of
visits without additional referrals. Your primary care physician will use
our criteria when creating your treatment plan (the physician may have to
get an authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if
you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for you to see a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist.
You may receive services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program
and
you enroll in another FEHB 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 FEHB
Program,
contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access
to
your specialist based on the above circumstances, you can continue to see
your
specialist until the end of your postpartum care, even if it is beyond
the 90
days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled
nursing or other type of facility.
If you are in the
hospital when your enrollment in our Plan begins, call our
Customer Services
Department immediately at 312/ 234-8855. If you are new
to the FEHB Program,
we will arrange for you to receive care. 10
10
Page 11 12
2002
UNICARE HMO Section 3 11
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 hospital benefit 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
prior approval Your primary care physician
has authority to refer you for most services. For certain services, however,
your physician 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 process precertification. Your physician
must
obtain preauthorization for the following services:
Surgical procedures that must be performed in ambulatory surgery unit or
hospital operating room, or if the procedure requires anesthesia;
23 hour
hospital observations; Skilled Nursing Facility Care
Home health care;
Durable medical equipment and prosthetic devices;
Certain prescription drugs
such as human growth hormone or drugs to treat sexual dysfunction; and
Any
services performed by a non-participating provider. Temporomandibular joint
dysfunction treatment 11
11 Page 12 13
2002 UNICARE
HMO Section 4 12
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 primary care physician you pay a copayment of
$15 per office visit.
Deductible The calendar year deductible is a fixed expense you must
incur for certain covered services and supplies before we start paying benefits
for them.
Copayments do not count toward any deductible.
We have a deductible for Durable Medical Equipment and prosthetic devices.
NOTE: When you change plans, you must begin a new deductible under your
new plan.
Coinsurance Coinsurance is the percentage of charges that you must pay
for your care. Coinsurance doesn't begin until you meet your deductible.
Example: In our Plan, you pay 20% of our allowance for durable medical
equipment after you have satisfied the durable medical equipment deductible.
Your catastrophic protection After your copayments and coinsurance
total $2,900 per person or
out-of-pocket maximum for $7,000 per
family enrollment in any calendar year, you do not have to
deductibles,
coinsurance, and pay any more for covered services. However, copayments for
the
copayments following services do not count toward your
out-of-pocket maximum, and you must continue to pay copayments for these
services:
Prescription drugs
Be sure to keep accurate records of your copayments
and coinsurance since
you are responsible for informing us when you reach
the maximum. 12
12 Page
13 14
2002 UNICARE HMO Section 5
13
Section 5. Benefits --OVERVIEW
(See page 8 for how
our benefits changed this year and page 57 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind
at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claim forms, claims filing
advice, or more information about our benefits, contact
us at 312/ 234-8855
or at our website at www. unicare. com.
(a) Medical services and supplies
provided by physicians and other health care
professionals........................... 14-22
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 ....................... 23-26
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services ..................................................... 27-29
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
.................................................................................................................
30-31
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
............................................................................................
32-33
(f) Prescription drug benefits
...............................................................................................................................
34-37
(g) Special features
....................................................................................................................................................
38
Flexible benefits options Services for deaf and hearing impaired
(h) Dental benefits
.....................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
..................................................................................................
40
Summary of benefits
...................................................................................................................................................
57 13
13 Page 14
15
2002 UNICARE HMO 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians
and
other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have a $100
calendar year deductible per person for durable medical equipment and prosthetic
devices.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office
Medical consultations
Second Surgical Opinion
$15 per office visit
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
Nothing
At home $15 per visit
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing 14
14 Page
15 16
2002 UNICARE HMO 15
Section 5( a)
Preventive care, adult You Pay
Routine
screenings, such as:
Chlamydial Infection Screening
Total Blood
Cholesterol – once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
$15 per office visit
Sigmoidoscopy, screening – every five years starting at age 50
Prostate
Specific Antigen (PSA test) – one annually for men age 40 and older $15 per
office visit
Routine pap test
Note: The office visit is covered if pap test is
received on the same day;
see Diagnosis and Treatment, above.
$15 per office visit
Mammograms – covered for women age 35 and older, as follows:
From age 35
through 39, one baseline mammogram during this five year period
At age 40 and older, one routine mammogram every calendar year
$15 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges
Routine immunizations, such as:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$15 per office visit
Not covered: Immunizations required for obtaining or continuing
employment or insurance, attending schools or camp, or travel
All
charges
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $15 per office visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
-Eye exams through age 17 to determine
the need for vision
correction.
-Ear exams through age 17 to determine the need for hearing
correction
-Examinations done on the day of immunizations (up to age 22)
$15 per office visit 15
15 Page 16 17
2002 UNICARE
HMO 16 Section 5( a)
Maternity care You pay
Complete
maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant
who requires non-routine treatment only if we cover the infant under a Self
and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery benefits
(Section
5b).
$15 for initial maternity office
visit and nothing for
subsequent
maternity office
visits
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Injectable contraceptive drugs
(such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE:
We cover oral contraceptives under the prescription drug benefit
$15 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges 16
16 Page 17 18
2002 UNICARE
HMO 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
In vitro
fertilization
Uterine embryo lavage
Embryo transfer
Gamete
intrafallopian tube transfer
Zygote intrafallopian tube transfer
Low
tubal ovum transfer
Artificial insemination:
intravaginal
insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We
cover injectable fertility drugs under medical benefits when
administered in
the doctor's office (not self-injected) subject to the $15 office
visit
copay. Non-fertility self-injectables and oral fertility drugs are covered
under the prescription drug benefit.
$15 per office visit
Not covered:
Collection and storage of sperm, oocytes (eggs),
or embryos for later use
Services and supplies in connection with the
reversal of voluntary sterilization or sex change
Cost of donor sperm
Cost of donor egg
All charges
Allergy care
Testing and treatment
Allergy injection
$15
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges 17
17 Page 18 19
2002 UNICARE HMO 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplant is limited to those transplants listed under Organ/ Tissue
Transplants
on page 26.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Note: Growth hormone therapy (GHT) is covered under Prescription Drug
Benefits (Section 5f) as self-injectable drug.
$15 per office visit
Physical and occupational therapies
Sixty (60) visits per
condition for the services of each of the following:
qualified physical
therapists; and
occupational therapists.
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.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided up to sixty visits if determined to be
medically necessary.
Note: 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. Rehabilitation is based on
medical necessity.
$15 per office or
outpatient visit
Nothing per visit during
covered inpatient admission.
Not covered:
long-term rehabilitative therapy
exercise programs
All charges
Speech Therapy
Sixty (60) visits per condition for the services of
a qualified speech therapist $15 per office or outpatient visit
Hearing services (testing, treatment, and supplies)
Hearing
testing only when necessitated by accidental injury
Hearing testing for
children through age 17 (see Preventive care, children)
$15 per office visit
Not covered:
all other hearing testing
hearing aids,
testing and examinations for them
All charges 18
18 Page 19 20
2002 UNICARE
HMO 19 Section 5( a)
Vision services (testing, treatment, and
supplies) You pay
Eye exam to determine the need for vision correction
for children through age 17 (see preventive care)
One eye refraction every
24 months for enrollees age 18 and older
$15 per office visit
Not covered:
Eyeglasses or contact lenses or the fitting of
either
Eye exercises and orthoptics
Radial keratotomy and
other refractive surgery
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$15 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges 19
19 Page 20 21
2002 UNICARE
HMO 20 Section 5( a)
Orthopedic and prosthetic devices You pay
External prosthetic devices, such as artificial limbs and eyes and
lenses (following cataract removal); stump hoses; and
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as
artificial joints, pacemakers, insulin pumps, and surgically implanted breast
implant( s) 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. The internal
prosthetic device must be
medically necessary to restore bodily function and
require a surgical
incision (as opposed to an external prosthetic device).
Note: Call us at 312/ 234-8855 as soon as your Plan physician
prescribes
this equipment. 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.
20% of the charges after you have
satisfied a calendar year
deductible of $100 per Self Only
enrollment and $300 per Self and
Family enrollment.
Not covered:
orthopedic and corrective shoes (unless
permanently attached to an approved device)
arch supports
foot orthotics
braces
heel
pads and heel cups
lumbosacral supports
cochlear implant
devices
corsets, trusses, elastic stockings, support hose, and other
supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
All ostomy supplies including bags, adhesives and skin
protectants
All charges 20
20 Page 21 22
2002 UNICARE
HMO 21 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, of durable medical equipment
prescribed by your Plan physician, such as oxygen and dialysis
equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers; and
blood
glucose monitors
Note: Call us at 312/ 234-8855 as soon as your Plan
physician
prescribes this equipment. 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.
20% of the charges after you have
satisfied a calendar year
deductible of $100 per Self Only
enrollment or $300 per Self and
Family enrollment
Not covered:
CAM walkers
Scooters
Blood
Pressure cuffs
Breast pumps
All charges
Home health services
Home health care ordered by a Plan physician
and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.),
licensed
vocational nurse (L. V. N.), or home health aide.
Services
include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family;
services primarily for hygiene, feeding, exercising, moving the patient,
homemaking, companionship or giving oral medication.
home care
primarily for personal assistance that does not include a medical component and
is not diagnostic, therapeutic, or
rehabilitative.
All charges 21
21 Page 22 23
2002 UNICARE
HMO 22 Section 5( a)
Chiropractic You Pay
Manipulation
of the spine and extremities
Adjunctive procedures such as ultrasound,
electrical muscle stimulation, vibratory therapy, and cold pack application
$15 per office visit
Alternative treatments
We do not cover alternative treatment.
Not covered:
naturopathic services
hypnotherapy
acupuncture
biofeedback
All charges
Educational classes and programs
Diabetes self-management $15 per
office visit if performed in physician's office
Smoking cessation classes in the service area. Members should call 312/
234-7037 for times and locations. Nothing 22
22
Page 23 24
2002
UNICARE HMO 23 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other
health care
professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5 (c) for charges associated with the facility charge (i. e. hospital,
surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME
SURGICAL PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which
services require precertification and identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment
of fractures, including casting
Normal pre-and post-operative care by the
surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of
congenital anomalies (see reconstructive surgery)
Surgical treatment of
morbid obesity --a condition in which an individual weighs 100 pounds or 100%
over his or her normal weight
according to current underwriting standards; eligible members must
be age
18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
Nothing
Surgical procedures continued on next page. 23
23 Page 24 25
2002 UNICARE HMO 24 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization
Treatment of burns
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
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
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)
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, services, drugs and supplies related to sex transformation
All charges 24
24 Page 25 26
2002 UNICARE
HMO 25 Section 5( b)
Oral and maxillofacial surgery You Pay
Oral surgical procedures, limited to:
Reduction of fractures of the
jaws or facial bones;
Surgical correction of cleft lip, cleft palate or
severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures.
Nothing
Surgical treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
due to acute trauma or systemic disease
Note: We must approve your treatment
TMJ plan in advance.
50% of charges for approved
treatment of TMJ pain dysfunction
syndrome
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
Any dental care involved in the treatment of temporomandibular joint (TMJ)
pain dysfunction syndrome
All charges 25
25 Page 26 27
2002 UNICARE
HMO 26 Section 5( b)
Organ/ tissue transplants You pay
Transplants are covered when approved by the Plan's Medical Director.
Transplants are limited to:
Cornea
Heart
Kidney
Liver
Allogeneic (donor) bone marrow
transplants
Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach
and pancreas
Note: We cover related medical and hospital expenses of the
donor
when we cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges
Anesthesia
Professional services provided in –
Hospital
(inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing 26
26 Page
27 28
2002 UNICARE HMO 27
Section 5( c)
Section 5 (c). Services provided by a hospital or
other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must 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
Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require
precertification
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations;
general
nursing care; and
meals and special diets.
Private accommodations or
private duty nursing care when a Plan doctor determines it is medically
necessary
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 27
27 Page 28 29
2002 UNICARE HMO 28 Section 5( c)
Inpatient hospital (Continued) You pay
Other
hospital services and supplies, such as:
Operating, recovery, maternity, and
other treatment rooms
Prescribed drugs and medicines
Diagnostic
laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma
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
Nothing
Not covered:
Custodial care
Non-covered facilities,
such as nursing homes, schools
Personal comfort items, such as
telephone, television, barber services, guest meals and beds
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, blood plasma, and other biologicals
Blood and
blood plasma
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
Not covered: blood and blood derivatives not replaced by the member All
charges 28
28 Page
29 30
2002 UNICARE HMO 29
Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You pay
Skilled nursing facility (SNF):
We cover
up to 120 days of skilled nursing facility care per calendar
year when we
determined that full-time skilled nursing care is medically
necessary. You
and your Plan doctor must obtain our prior approval.
All necessary services
are covered, 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.
Nothing
Not covered: custodial care, rest cures, domiciliary or convalescent
care
All charges
Hospice care
We cover support and palliative care for a terminally
ill member in the
home or hospice facility. Coverage is provided up to a
maximum
benefit of $10,000 per period of care. Services include:
Inpatient and outpatient care
Family counseling
Note: Covered hospice
services are provided under the direction of a
Plan doctor who certifies
that the patient is in the terminal stages of
illness, with a life
expectancy of approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service ordered or
authorized by a Plan
doctor.
Nothing 29
29
Page 30 31
2002
UNICARE HMO 30 Section 5( d)
Section 5 (d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe
endangers your life or could result in serious
injury or disability, and requires immediate medical or
surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more
serious; examples include deep cuts and broken bones. Others are
emergencies because they are
potentially life threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability
to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
local
emergency system (e. g. the 911 telephone system) or go to the nearest
hospital emergency room. Be sure
to tell the emergency room personnel that
you are a Plan member so they can notify us. You or a family
member must
notify us within 48 hours unless it was not reasonably possible to do so. It is
your
responsibility to ensure that we have been timely notified.
If you need to be hospitalized in a non-Plan facility, we must be notified
within 48 hours or on the first
working day following admission, unless it
was not reasonably possible to notify us within that time. If
you are
hospitalized in a non-Plan facility and Plan doctors believe care can be
provided in a Plan hospital,
we will transfer to a Plan facility when
medically feasible. We will cover any ambulance charges in full.
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.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by
the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need urgent or emergency medical care when you're away from home, you
should call UNICARE
HMO AT 800/ 782-0180. Service is available 24 hours a
day, 7 days a week. If your unexpected illness is
not an emergency, you must
call this number before seeking treatment. For life-threatening medical
emergencies, you should seek treatment from the nearest medical facility and
inform the hospital or
physician that you are a member of UNICARE HMO. You
should then contact the Plan at 800/ 782-0180
within 24 hours after medical
care begins.
If you need to be hospitalized, you must notify us within 48 hours or on the
first working day following
your admission, unless it was not reasonably
possible to do so within that time. If a Plan doctor believes
care can be
provided in a Plan hospital, we will transfer you to a Plan facility at our
expense. We must
approve all follow-up care recommended by a non-Plan
provider or you must receive the follow-up care
from a Plan provider. 30
30 Page 31 32
2002 UNICARE HMO 31 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care in a hospital emergency room
Note: We waive the
copay if you are admitted as an inpatient to the
hospital.
Note: We pay reasonable charges for emergency services to the extent
the
services would have been covered if received from Plan providers
$15 per office visit
$50 per urgent care center
visit
$50 per
hospital emergency
room visit.
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 in a
hospital emergency room
Note: We waive the copay if you are admitted as an
inpatient to the
hospital.
Note: We pay reasonable charges for emergency services to the extent the
services would have been covered if received from Plan providers
$15 per office visit
$50 per urgent care center
visit
$50 per hospital emergency
room visit.
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 full-term delivery of a baby
outside the service area
All charges
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing
Not covered: air ambulance All charges 31
31
Page 32 33
2002
UNICARE HMO 32 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than for
similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
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
$15 per office visit
Mental health and substance abuse benefits -Continued on next page 32
32 Page 33 34
2002 UNICARE HMO 33 Section 5( e)
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, half-way house,
residential treatment, full-day
hospitalization, facility based intensive
outpatient
Nothing
Not covered:
Services we have not approved
Marriage
and lifestyle counseling
Psychiatric evaluation or therapy on court
order or as a condition of parole or probation unless determined by a Plan
doctor to be
necessary and appropriate.
Note: OPM will base its review of disputes
about treatment plans on the
treatment plan's clinical appropriateness. OPM
will generally not
order us to pay or provide one clinically appropriate
treatment plan in
favor of another.
All charges
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and the follow the following authorization process:
You must contact Magellan Behavioral Health at 1-800-746-6294 before
seeking Mental Health or Substance Abuse treatment. Magellan Behavioral
Health will review your treatment needs. They will provide you and the
provider with written authorization (certification letter) for your initial
visit
and any ongoing care.
Limitation We may limit your benefits if you do not obtain a treatment
plan 33
33 Page 34
35
2002 UNICARE HMO 34 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or referral doctor
must write the prescription.
Where you can obtain them. You must fill
the prescription at a plan pharmacy, or by mail for a maintenance medication. To
obtain a list of Plan pharmacies call UNICARE's Customer Services
Department at 312/ 234-8855 or 888/ 234-8855 (outside the Ameritech local
calling area). To order
maintenance medications by mail, call UNICARE's
Customer Services Department to obtain the
necessary forms. Complete or have
your Plan doctor complete the prescription order form. Mail the
Plan
doctor's written prescription for up to a 90-day supply of the maintenance drug,
along with the
completed prescription order form and the appropriate copay
amount to the mail order pharmacy
provider. Additional refills may be
obtained the same way provided the strength and dosage of the
medication
remain the same.
We use a formulary. A formulary is a list of prescription medications
that we cover when your doctor prescribes them for you. These drugs were
selected because they have been proven safe and
effective. They are included in the formulary because most doctors prefer
them over other choices.
Drugs are dispensed in accordance with the Plan's
drug formulary. However, we do cover non-formulary
drugs when prescribed by
a Plan doctor. Your physician must obtain our approval for
non-formulary
drugs.
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
preferred list of drugs that we selected to meet patient needs at a lower
cost. To order a prescription drug brochure, call UNICARE Customer Services
at 312/ 234-8855 or
888/ 234-8855 (outside the Ameritech local calling
area).
These are the dispensing limitations.
Pharmacy supply limits:
up to a 30-day supply or 100-unit supply whichever is less; or
240
milliliters of liquid (8oz); or
60 grams of ointment, creams or topical
preparation; or
or one commercially prepared unit (i. e. one inhaler)
You pay a $5 copay per prescription unit or refill of generic formulary
drugs and $15 per prescription
unit or refill of name brand formulary drugs.
If a generic drug is available and your doctor does not
require the use of a
name brand drug, you pay the $15 name brand copay plus the difference in cost
between the generic and name brand drugs. When generic substitution is not
available, you pay the
brand name copay.
For non-formulary drugs obtained at a Plan pharmacy you pay a $25 copay. When
generic
substitution is permissible (e. g. a generic drug is available and
the prescribing doctor does not require
the use of a name brand drug), but
you request the name brand drug, you pay the $25 non-formulary
copay plus
the difference between the cost of the generic drug and the cost of the name
brand drug. 34
34 Page
35 36
2002 UNICARE HMO 35
Section 5( f)
Mail Order:
You may obtain up to a 90-day supply of
formulary maintenance drugs from our mail order
pharmacy program. You pay 2
times the per unit copay.
Maintenance medications are drugs used on a continual basis for treatment of
chronic health
conditions, such as high blood pressure, ulcers or diabetes
and that are packaged and intended for
self-administration by the patient.
Additionally, you may obtain insulin and select oral
contraceptives may be
obtained through the pharmacy mail order program.
To order maintenance medications by mail, call UNICARE'S Customer Services
Department to
obtain the necessary forms. Complete or have your Plan doctor
complete the prescription order
form. Mail the Plan doctor's written
prescription for up to a 90-day supply of the maintenance drug,
along with
the completed prescription order form and the appropriate copay amount to the
mail order
pharmacy provider. Additional refills may be obtained the same
way provided the strength and
dosage of the medication remain the same.
All drugs are not available by mail order. You cannot obtain antibiotics,
cough syrup, and self-injected
drugs (except insulin) by mail.
Please note that we will only refill prescriptions within 12 months of the
date of the initial prescription
from your Plan doctor. Also, we will not
refill a prescription less than 10 days prior to its completion
Drugs to treat sexual dysfunction have dispensing limits and require prior
approval. Please contact us
for details.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a
name brand. If you receive a name brand
drug when a Federally-approved generic drug is available, and
your physician
has not specified Dispense as Written for the name brand drug, you have to pay
the
difference in cost between the name brand drug and the generic.
Why use generic drugs? Generic drugs 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. Generics cost less than the equivalent
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.
When you have to file a claim. You normally won't have to submit
claims to us unless you receive emergency services from a provider who doesn't
contract with us. If you file a claim, please 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. Either
OPM or we can extend this deadline if you show that
circumstances beyond
your control prevented you from filing on time. Please mail your claims to
UNICARE HMO, P. O. Box 5597, Chicago, Illinois 60680-5597.
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 UNICARE HMO 36 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as excluded
below.
Insulin
Disposable needles and syringes for the administration
of covered medications
Drugs for sexual dysfunction
Oral contraceptive drugs
Smoking
cessation prescription drugs and medication, including but not limited to
nicotine patches and sprays
Note: Drugs for sexual dysfunction have pill limits and require
preauthorization.
$ 5 per generic formulary
prescription unit or refill
$ 15 per name brand formulary
prescription unit or refill
$ 25 per generic or name brand
non-formulary prescription unit or
refill
Note: If there is no generic equivalent
available, you will still have to
pay
the name brand copay.
Self-injectable drugs
Self-injectable fertility drugs
Note: Fertility
drugs administered in the doctor's office (not self-injected),
intravenous
fluids and medication for home use, implantable drugs,
contraceptive
devices, and injectable drugs that can only be administered by
a physician
are covered under Medical and Surgical Benefits.
Note: Drugs prescribed for sexual dysfunction have dispensing limitations.
For complete details, please call UNICARE Customer Services.
50% of the cost of the drug up to the
$2,500 out-of-pocket maximum per
calendar year. We then cover self-injectable
drugs at 100% for the rest
of that year. 36
36 Page
37 38
2002 UNICARE HMO 37
Section 5( f)
Covered medications and supplies (continued)
You pay
Not covered:
Drugs and supplies for
cosmetic purposes
Vitamins, nutrients and food supplements even if a
physician prescribes or administers them
Nonprescription medicines or medicines for which there is a
non-prescription equivalent
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs
to enhance athletic performance
Drugs consumed in an inpatient
setting
Replacement of lost or stolen medications or the replacement
of medications damaged by improper storage
Drugs used for the purpose of weight loss or weight gain
All Charges 37
37 Page 38 39
2002 UNICARE
HMO 38 Section 5( g)
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.
Services for deaf and
hearing impaired
UNICARE's TDD (Telecommunication Device for the Deaf)
machine is
available to communicate with our hearing-impaired
members. Messages
received by our TDD machine are returned
and resolved quickly by a Customer
Services Representative. The
TDD telephone number is 312/ 234-7770. 38
38 Page 39 40
2002 UNICARE HMO Section 5( h) 39
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. 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. Restorative services must be initiated
within 60 days of the reported injury, unless the member's medical
condition is such that a delay in initiating treatment is required. The
injury must be reported to the Plan as soon as reasonably possible after
the accident.
Nothing
Dental benefits
We do not cover any other dental benefits. 39
39 Page 40 41
2002 UNICARE HMO Section 5( i) 40
Section 5 (i). Non-FEHB benefits available to Plan members
The
benefits on this page are not part of the FEHB contract or premium, and you
cannot file an FEHB disputed
claim about them. Fees you pay for these
services do not count toward FEHB deductibles or out-of-pocket
maximums.
Dental Benefits
As a UNICARE HMO member, you and your family are
automatically eligible for DNoA Select, a dental network offered
by the
Dental Network of America (DNoA). By taking advantage of this non-FEHB benefit,
you and your family will be
able to choose a dental provider from an
extensive network of participating, credentialed dental providers in the
Chicagoland area. And you will be able to receive a 10% to 40% discount on a
wide range of preventive and specialty
care services from participating
dental providers, including orthodontists. After you enroll in UNICARE HMO, we
will
send you a DNoA identification card. You must call DNoA at 800/
367-1203 to select a convenient dental office near you.
If you have
questions you may also contact UNICARE HMO Customer Services at 312/ 234-8855 or
888/ 234-8855
(outside of the Ameritech local calling area).
Vision Care
As a UNICARE HMO member, you and your family are entitled to
discounts off the retail price on eye wear from more
than 50 Cole Vision
Centers in the Chicagoland area. These discounts are in addition to any covered
eye refraction
explained in the previous pages. Cole Vision Centers are
conveniently located in most Sears, Montgomery Ward, JC
Penney and Carson
Pirie Scott stores. Call the Cole Vision Customer Service Center at 800/
334-7591 to find a convenient
location near you. Then just present your HMO
ID card at a Cole Vision Center to receive your discount. If you have
questions you may also contact UNICARE HMO Customer Services at 312/
234-8855 or 888/ 234-8855 (outside of the
Ameritech local calling area). 40
40 Page 41 42
2002 UNICARE HMO Section 6 41
Section 6.
General exclusions --things we don't cover
The exclusions in this
section apply to all benefits. Although we may list a specific service as a
benefit, we
will not cover it unless your Plan doctor determines it is
medically necessary to prevent, diagnose, or
treat your illness, disease,
injury, or condition, and we agree, as discussed under Services Requiring
our
Prior Approval on page 11.
We do not cover the following:
Care by non-Plan providers 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; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 41
41 Page 42 43
2002 UNICARE
HMO 42 Section 7
Section 7. Filing a claim for covered
services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at
Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive 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 relating to medical and hospital claims,
call us at 312/ 234-
8855 or 888/ 234-8855 (outside the local Ameritech
calling area) and for
prescription drugs claims questions call us at 888/
218-4844.
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.
Submit your claims to:
Medical and hospital UNICARE HMO, P. O. Box 06200, Chicago, IL
60606-6309
Submit your claims to:
Prescription drugs UNICARE HMO, P. O. Box 9085, Claim Services,
Oxnard, CA 93031-9085 42
42 Page 43 44
2002 UNICARE
HMO 43 Section 7
Other supplies or services In most cases,
you will not have to file a claim because our providers will handle the process
for you. If you must file a claim for services such as
durable medical
equipment or prosthetic devices, use the procedure and
address above.
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. 43
43 Page
44 45
2002 UNICARE HMO 44
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on
your claim or request for services, drugs, or
supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: UNICARE HMO, Attn: Appeals Department, 233 S. Wacker Drive,
Suite
3900, Chicago, IL 60606-6309; 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 3,
1900 E Street, NW, Washington, DC
20415-3630. 44
44 Page
45 46
2002 UNICARE HMO 45
Section 8
The Disputed Claims Process
Send OPM the following
information:
A statement about why you believe our decision was wrong, based
on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies, or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
312/ 234-8855 or 888/
234-8855 (outside of the local Ameritech calling area) and we will expedite our
review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 45
45
Page 46 47
2002
UNICARE HMO 46 Section 9
Section 9. Coordinating benefits with
other coverage
When you have other You must tell us if you are covered
or a family member is covered under
health coverage another group
health plan or have automobile insurance that pays healthcare expenses without
regard to fault. This is called "double
coverage."
When you have double coverage, one plan normally pays its
benefits in
full as the primary payer and the other plan pays a reduced
benefit as the
secondary payer. We, like other insurers, determine which
coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older
Some people with disabilities, under 65
years of age
People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free
Part A
insurance. (Someone who was a Federal employee on January
1, 1983 or since
automatically qualifies.) Otherwise, if you are age 65
or older, you may be
able to buy it. Contact 1-800-MEDICARE for
more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for
Medicare, you may have choices in how you get
your health care. Medicare +
Choice is the term used to describe the
various health plan choices
available to Medicare beneficiaries. The
information in the next few pages
shows how we coordinate benefits
with Medicare, depending on the type of
Medicare managed care plan
you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere in (Part A or Part B) 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.
Your care must continue to be authorized by your primary care
physician.
We will not waive copayments, deductibles, or coinsurance.
(Primary payer chart begins on next page.) 46
46 Page 47 48
2002 UNICARE HMO 47 Section 9
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 !
b) Or, 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,
a) And are an annuitant !
b) Are an active employee, or !
c) Are a former spouse of an annuitant, or !
d) Are a former spouse of an
active employee !
Please note: if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare. 47
47
Page 48 49
2002 UNICARE HMO 48 Section 9
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 at 312/ 234-8855 or
888/ 234-8855
(outside the local Ameritech calling area).
We do not waive out-of-pocket costs when you have Medicare.
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 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)
but we will not waive any of
our copayments, coinsurance, or
deductibles. If you enroll in a Medicare
managed care plan, tell us. We
will need to know whether you are in the
Original Medicare Plan or in a
Medicare managed care plan so we can
correctly coordinate benefits with
Medicare.
Suspended FEHB coverage and 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.
Enrollment in Note: If you choose not to enroll in Medicare Part B,
you can still be Medicare Part B covered under the FEHB Program. We
cannot require you to enroll in
Medicare.
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. 48
48 Page 49 50
2002 UNICARE HMO 49 Section 9
TRICARE TRICARE is the health care program for members, 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.
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 hospital
for injuries 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. 49
49 Page 50 51
2002 UNICARE
HMO 50 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
Care that provides a level of routine maintenance for the purpose of meeting
personal needs. This is care that can be provided by a layperson
who does
not have professional qualifications, skills, or training.
Examples include
help in walking, dressing, getting in to and out of bed,
and help in
functions of daily living.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services. See page 12.
Experimental or
investigational services A procedure that is
determined to be experimental or investigational based on Plan review of medical
records, current reviews of medical
literature and scientific evidence, results of current studies or clinical
trials, research protocols, reports or opinions of authoritative medical
bodies, and opinions of independent outside experts and approvals
granted by regulatory bodies.
Medical necessity Medical services provided for the diagnosis or the
treatment of a sickness or injury or for the maintenance of a person's good
health. Also, the
medical services are furnished by a provider with the
appropriate
training, experience, staff and facilities to furnish the
service. And the
established opinion with the appropriate specialty of the
United States
medical profession is that the services are safe and effective
for the
intended use.
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 the reasonable
and
customary charge.
Us/ We Us and we refer to UNICARE Health Plans of the Midwest, Inc.
You You refers to the enrollee and each covered family member. 50
50 Page 51 52
2002 UNICARE HMO 51 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. 51
51 Page
52 53
2002 UNICARE HMO 52
Section 11
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 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 lose your job, if you are a covered
dependent child and you turn 22
or marry, etc..
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct. 52
52 Page
53 54
2002 UNICARE HMO 53 Section 11
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 website www. opm. gov/ insure/ health; refer
to the "TCC and
HIPAA" frequently asked questions. These highlight HIPAA
rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and it has information about Federal and State
agencies you can contact for more information. 53
53 Page 54 55
2002 UNICARE HMO 54 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
website at
www. opm. gov/ insure/ ltc. 54
54
Page 55 56
2002
UNICARE HMO 55 Index
Index
Do not rely on this page;
it is for your convenience and does not explain your benefit coverage.
Accidental injury 39
Allergy tests 17
Alternative treatment 22
Allogeneic donor) bone marrow
transplant 26
Ambulance 29
Anesthesia 26
Autologous bone marrow
transplant 26
Biopsies
23
Blood and blood plasma 28
Breast cancer screening 16
Casts 29
Catastrophic protection 11
Changes for 2002 8
Chemotherapy 18
Childbirth 16
Cholesterol tests 15
Claims 43
Coinsurance 12
Colorectal cancer screening 15
Congenital anomalies 23
Contraceptive
devices and drugs
16
Coordination of benefits 47
Covered charges 12
Covered providers 9
Crutches 21
Deductible 12
Definitions
50
Dental care 39
Diagnostic services 14
Disputed claims review 45
Donor expenses (transplants) 26
Dressings 28
Durable medical
equipment
(DME) 21
Educational classes and programs
22
Effective date of enrollment 52
Emergency 30
Experimental or
investigational 50
Eyeglasses 19
Family planning 16
Fecal occult blood test 15 General
Exclusions 41
Hearing services 18
Home health services 21
Hospice care 29
Home nursing care 29
Hospital 10 Immunizations
15
Infertility 17
Inhospital physician care 14
Inpatient
Hospital Benefits 27
Insulin 36
Laboratory and pathological
services 14
Long Term Care 54
Machine diagnostic tests 14
Magnetic Resonance Imagings
(MRIs) 14
Mail Order Prescription Drugs
35
Mammograms 15
Maternity Benefits 16
Medicaid 49
Medically
necessary 50
Medicare 46
Members 9
Mental Conditions/ Substance
Abuse Benefits 32
Neurological testing 33
Newborn care 16
Non-FEHB Benefits 40
Nurse
Licensed Practical Nurse 21
Nurse
Anesthetist 28
Registered Nurse 21
Nursery charges 16
Obstetrical
care 16
Occupational therapy 18
Office visits 14
Oral and
maxillofacial surgery 25
Orthopedic devices 20
Ostomy and catheter
supplies 20
Out-of-pocket expenses 12
Outpatient facility care 29
Oxygen 21 Pap
test 15
Physical
examination 15
Physical therapy 18
Physician 9
Pre-admission testing
28
Precertification 11
Preventive care, adult 15
Preventive care,
children 15
Prescription drugs 34
Preventive services 15
Prior
approval 11
Prostate cancer screening 15
Prosthetic devices 20
Psychologist 32
Radiation therapy 18
Renal dialysis 18
Room and board 27
Second surgical opinion 14
Skilled nursing
facility care
29
Smoking cessation 36
Speech therapy 18
Splints
28
Sterilization procedures 16
Subrogation 49
Substance abuse 32
Surgery 23
Anesthesia 26 Oral 25
Outpatient 28 Reconstructive 24
Syringes 36
Temporary
continuation of
coverage 52
Transplants 26
Treatment therapies
18 Vision
services 19
Well child care 15
Wheelchairs
21
Workers' compensation 49
X-rays 14 55
55 Page 56 57
2002 UNICARE HMO Notes 56
NOTES: 56
56 Page 57 58
2002 UNICARE HMO Summary 57
Summary of
benefits for the UNICARE HMO -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.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
Office visit copay: $15 primary care; $15 specialist 14
Services provide d by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
Nothing
Nothing
27
28
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$50 per emergency room visit
$50 per emergency room visit
30
31
Mental health and substance abuse
treatment..................................... Regular cost sharing. 32
Prescription drugs
................................................................................
$5 per generic formulary
prescription unit or refill /$ 15 per
name
brand formulary
prescription unit or refill
formulary/$ 25 per name
brand
non-formulary prescription unit or
refill
34
Dental Care
.......................................................................................
Accidental injury benefit only
No benefit 39
Vision Care
.......................................................................................
One eye refraction every 24 months
$15 copay 19
Protection against catastrophic costs
(your out-of-pocket
maximum).........................................................
Nothing after $2,900/ Self Only or
$7,000/ Family enrollment per year
Some costs do not count toward
this protection
12 57
57 Page
58
2002 UNICARE HMO Rates
Form #UHP0005445 (10/ 01)
58
2002 Rate Information for
UNICARE HMO
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
Self Only 171 $ 63.04 $ 21.01 $136.58 $ 45.53 $ 74.59 $ 9.46
Self and
Family 172 $196.55 $ 65.52 $425.87 $141.95 $232. 59 $ 29.48 58