Group Health Plan http:// www. ghp. com
Plan acquired Health Partners of the Midwest. Current members of Health
Partners of the Midwest who do not elect another plan
will automatically be
enrolled with Group Health Plan effective January 1, 2002. See "How we change
for 2002" on page 8.
RI 73 104
Authorized for distribution by the:
http :// www. opm. gov/ insur e
United
States
Office of Personnel Management
Retirement and Insurance Service
A Health Maintenance Organization
Serving: Greater St. Louis and
17 Illinois Counties
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:
MM1 Self Only MM2 Self and Family
SPECIAL NOTICE: Effective January 1, 2001 Group Health
2002
For changes
in benefits,
see page 8. 1
1 Page 2 3
2002 Group Health Plan 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….
............................................................... 4
Plain
Language………………………………………………………………...............................................................
4
Inspector General
Advisory………………………………………………………………............................................
4
Section 1. Facts about this HMO plan
..........................................................................................................................
6
How we pay providers
.................................................................................................................................
6
Who provides my
healthcare?……………………………………………………………………………… 6
Your
Rights..................................................................................................................................................
7
Service
Area.................................................................................................................................................
7
Section 2. How we change for
2002………………………………………..................................................................
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.......................................................................................................................................
10
Hospital care
........................................................................................................................................
11
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
(g) Special features
...............................................................................................................................
36
Flexible benefits option
(h) Dental benefits
................................................................................................................................
37 2
2 Page 3 4
2002 Group Health Plan 3 Table of Contents
(i) Non-FEHB benefits available to Plan members
.............................................................................
38
Section 6. General exclusions --things we don't
cover.............................................................................................
39
Section 7. Filing a claim for covered services
...........................................................................................................
40
Section 8. The disputed claims
process......................................................................................................................
42
Section 9. Coordinating benefits with other
coverage
...............................................................................................
44
When you have…
Other health coverage
.......................................................................................................................
44
Original Medicare
.............................................................................................................................
44
Medicare managed care
program......................................................................................................
46
TRICARE/ Workers' Compensation/ Medicaid
..........................................................................................
47
Other Government agencies
......................................................................................................................
47
When others are responsible for
injuries...................................................................................................
47
Section 10. Definitions of terms we use in this
brochure...........................................................................................
48
Section 11. FEHB
facts..............................................................................................................................................
49
Coverage information…
No
pre-existing condition limitation
...............................................................................................
49
Where you get information about enrolling in the
FEHB Program................................................ 49
Types of coverage available for you and your
family.....................................................................
49
When benefits and premiums
start..................................................................................................
50
Your medical and claims records are confidential
..........................................................................
50
When you
retire..............................................................................................................................
50
When you lose benefits
...........................................................................................................................
50
When FEHB coverage ends
............................................................................................................
50
Spouse equity
coverage..................................................................................................................
50
Temporary Continuation of Coverage (TCC)
................................................................................
50
Converting to individual coverage
.................................................................................................
51
Getting a Certificate of Group Health Plan
Coverage...................................................................
51
Long Term Care Coverage is Coming Later in 2002
..…………………………………………………………….... 52
Index
………..............................................................................................................................................................
53
Summary of benefits
...................................................................................................................................................
55
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2002 Group Health Plan 4 Introduction/ Plain Language
Introduction
Group Health Plan
111 Corporate Office Drive
Suite 400
Earth City, MO 63045
This brochure describes the benefits of Group Health Plan under its contract
(CS1930) with the Office of Personnel
Management (OPM), as authorized by the
Federal Employees Health Benefits (FEHB) 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 premiums with each plan annually. Benefit changes
are effective January 1, 2002, and
are shown 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 Group Health Plan
(GHP).
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the
Office of Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation Division,
1900 E Street, NW Washington, DC
20415-3650
Inspector General Advisory
Fraud increases the cost of health care
for everyone. If you suspect that a
physician, pharmacy, or hospital has
charged you for services you did not
receive, billed you twice for the same
service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 800/ 755-3901
and explain
the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
Stop health care fraud! 4
4 Page 5 6
2002 Group Health Plan
5 Introduction/ Plain Language
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 Group Health
Plan 6 Section 1
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 healthcare
Group Health Plan is an IPA model
Health Maintenance Organization (HMO). Your care is provided by the primary
care doctor you select. Adults may select either an internal medicine
doctor, a family practice doctor, or general
practice doctor as a Primary
Care Physician. For children, you may choose a pediatrician or family practice
doctor.
The first and most important decision each member must make is the selection
of a primary care doctor. The decision
is important since it is through this
doctor that all other health services, particularly those of specialists, are
obtained.
It is the responsibility of your primary care doctor to obtain any
necessary authorizations from the Plan before
referring you to a specialist
or making arrangements for hospitalization. See "How you get care" section for
services
that you can receive without a referral from your primary care
doctor. Due to Illinois law, Illinois residents may select
a "Woman's
Principal Health Care Provider" in addition to a Primary Care Physician. A
"Woman's Principal Health
Care Provider" is a physician licensed to practice
medicine in all its branches and specializing in obstetrics and
gynecology
or family practice. A Woman's Principal Health Care Provider may be seen for
care without a referral
from a Primary Care Physician. You may select a
Woman's Principal Health Care Provider upon initial enrollment or
at any
other time. Selecting a Woman's Principal Health Care Provider is optional.
The Plan's provider directory lists primary care doctors (generally family
practitioners, pediatricians, and internists),
with their locations and
phone numbers, and notes whether or not the doctor is accepting new patients.
Directories are
updated on a regular basis and are available at the time of
enrollment or upon request by calling the Member Services
Department at
1-800-755-3901; You can also find out if your doctor participates with this Plan
by checking directly
with the provider or by calling us at the above number.
If you are interested in receiving care from a specific provider who is
listed in the directory, call the provider to verify
that he or she still
participates with the Plan and is accepting new patients.
Should you decide to enroll in the Plan, you will be asked to select a
primary care doctor for you and each family
member. Plan personnel are
available to help you select a doctor. Members may change their doctor selection
at any
time, except when the member is hospitalized or undergoing certain
types of treatment. Changes received before the
15 th of the month will
become effective on the first of the following month. This may be done by
calling Member
Service at 1-800-755-3901. 6
6
Page 7 8
2002 Group Health Plan 7 Section 1
Your Rights
OPM requires that all FEHB Plans to provide certain information to their
FEHB members. You may get information
about
your health plan, 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.
Group Health Plan is in compliance with the state requirements of Missouri
and Illinois. In addition, Coventry has
had a comprehensive system in place
to identify and prevent medical errors and to ensure that all providers
credentialed are competent. Through the Quality Improvement Program, medical
errors and other adverse events are
monitored to identify patterns of
preventable events and events related to individual network providers. Patterns
or
individual cases are investigated and action is taken to make
improvements.
If you want more information about us, call 1-800-755-3901, or write to 111
Corporate Office Drive, Suite 400 / Earth
City, MO 63045. You may also
contact us by fax at 314/ 506-1959 or visit our website at www. ghp. com.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. This is where our providers practice. Our service area is: the
Metropolitan St. Louis area. Specifically:
St. Louis City and the Missouri counties of Crawford, Franklin,
Gasconade, Jefferson, Lincoln, St. Charles, Ste. Genevieve, and Warren.
The
Illinois counties of Calhoun, Christian, Clinton, Cole, Franklin, Jersey,
Johnson, Macoupin, Madison, Menard,
Monroe, Montgomery, Morgan, Saline,
Sangamon, St. Clair, and Williamson.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care. We will not pay for any other health care services out of our service area
unless
the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page
8 9
2002 Group Health Plan 8
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5
Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Changes to this Plan
Your share of the non-Postal premium will
increase by 25.1% for Self Only or 21.8% for Self and Family.
We no longer
limit total blood cholesterol tests to certain age groups.
We now cover
routine screening for chlamydial infection.
We increased speech therapy
benefits by removing the requirement that services must be required to restore
functional speech.
We now cover certain intestinal transplants.
We changed the address for
sending disputed claims to OPM.
The Office visit copay for a specialist
increases to $20 per visit (Primary Care physician visits remain at $10)
Each inpatient hospital admission requires a $100 copay
Each outpatient
surgery requires a $50 copay
Each Skilled Nursing facility admission
requires a $100 copay with a 30-day maximum
Physical, occupational and
cardiac rehabilitation therapies require a 20% coinsurance
Speech therapy
requires a 20% coinsurance
Home health care requires a 20% coinsurance
Hospice care requires a 20% coinsurance
Each ambulance transport
requires a 20% coinsurance
Durable medical equipment requires a 20%
coinsurance
Orthotic and prosthetic devices require a 20% coinsurance in
addition to the specialist office visit copay
The prescription drug
copayment increases to $20 for name brand formulary and $35 for a non-formulary
drugs
The preventive dental benefit is eliminated 8
8 Page 9 10
2002 Group Health Plan 9 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it
whenever you receive services from a
Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive
your ID card, use your copy of the
Health Benefits Election Form, SF-2809,
your health benefits enrollment
confirmation (for annuitants), or your
Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-800-
755-3901.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments 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. All providers must go through our Credentialing
process. The
elements verified include state license, DEA certificate to
administer
drugs, board certification, work history, clinical privileges at
the
admitting hospital, education and training and malpractice insurance
coverage. In addition, the practitioner's history of federal or state
sanctions and malpractice claims are investigated using state and federal
sources. These are all verified by going to the original source. All
credentials are verified using the primary source.
We list Plan providers in the provider directory, which we update
periodically. There is an alphabetical index in the back of the provider
directory if you are looking for a specific provider.
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.
What you must do to get covered care It depends on the type of care
you need. First, you and each family
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. You may select an
internal medicine doctor, a
general practice doctor, or a family practice
doctor for your Primary Care
Physician. Children may designate a
Pediatrician for their Primary Care
Physician.
Primary care Your primary care physician can be a family practitioner,
general practitioner, internal medicine, doctor of osteopath (D. O.) or
pedicatrician. 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. 9
9 Page 10 11
2002 Group Health Plan 10 Section 3
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, there
are 4 circumstances in which you do not need a referral.
Women can self-refer to any participating OB/ GYN for an annual well-woman
exam.
Women can self-refer to any participating OB/ GYN for pregnancy.
Members
can self-refer to any participating Primary Eye Care provider for an annual eye
exam.
Members can self-refer to GHP's Behavioral Health Line for any Mental
Health/ Alcohol and Substance Abuse benefits.
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 work with the Plan and the
specialist to 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 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. 10
10 Page 11 12
2002 Group
Health Plan 11 Section 3
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 Precertification Department immediately at
1-800-546-4603. If you
are new to the FEHB Program, we will arrange for you
to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our 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 precertification for services such as but not limited
to:
inpatient admissions, skilled nursing or rehabilitation admissions,
transplants, outpatient surgeries, dialysis, certain outpatient diagnostics,
cardiac rehabilitation, pulmonary rehabilitation, ancillary services, pain
management, infertility services, pregnancy, self-injectable drugs, botox,
visudyne, chiropractic manipulations, speech therapy, and observation
hospital stays. 11
11 Page
12 13
2002 Group Health Plan 12
Section 4
Section 4. Your costs for covered services
You
must share the cost of some services. You are responsible for:
Copayments
A copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit. When you see a participating
specialist you pay a
copayment of $20 per office visit.
Deductible We do not have a deductible.
NOTE: If you change plans
during open season, you do not have to start
a new deductible under your old
plan between January 1 and the effective
date of your new plan. If you
change plans at another time during the
year, you must begin a new
deductible under your new plan.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our plan, you pay 20% of our allowance for durable
medical
equipment.
Your out-of-pocket maximum for copayments and coinsurance After your
copayments and/ or coinsurance total $1,000 per person or
$2,000 per family
enrollment in any calendar year, you do not have to
pay any more for covered
services except for prescription drug benefits.
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 Group Health Plan 13 Section 5
Section 5. Benefits
– OVERVIEW
(See page 8 for how our benefits changed this year and
page 55 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about
our benefits, contact
us at 1-800-755-3901 or at our website at www. ghp.
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
...............................................................................................................................
34-35
(g) Special
features....................................................................................................................................................
36
Flexible benefits option High risk pregnancies
Joint replacement program Centers of excellence for transplants
(h) Dental
benefits.....................................................................................................................................................
37
(i) Non-FEHB benefits available to Plan members
..................................................................................................
38
Summary of
benefits...................................................................................................................................................
55 13
13 Page 14
15
2002 Group Health Plan 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 no calendar
year deductible.
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
$10 per visit to primarycare physician
$20 per visit to specialist
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
$10 per visit to primarycare physician
$20 per visit to specialist
At home
House calls will be provided within the service area if in the
judgement
of the Plan doctor such care is necessary and appropriate.
$10 per visit to primarycare physician
$20 per visit to specialist
Not covered:
Physical examinations and immunizations that are not
necessary for
medical reasons, such as those required for obtaining or
continuing
employment or insurance, attending school or camp, or travel
All charges. 14
14 Page 15 16
2002 Group
Health Plan 15 Section 5( a)
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services
during your office visit;
otherwise,
$10 per visit to primarycare physician
$20 per visit to specialist
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – once every three years
Colorectal Cancer Screening,
including
Fecal occult blood test
$10 per visit to primarycare physician
$20 per visit to specialist
Sigmoidoscopy, screening – every five years starting at age 50
Prostate
Specific Antigen (PSA test)-one annually for men age 40 and older $10 per visit
to primarycare physician $20 per visit to specialist
Routine pap test
Note: The office visit is covered if pap test is
received on the same day;
see Diagnosis and Treatment, above.
$10 per visit to primarycare physician
or ob/ gyn
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
$10 per visit to primarycare physician
or ob/ gyn
Not covered:
Physical exams and immunizations required for obtaining
or
continuing employment or insurance, attending schools or camp, or
travel.
All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per visit to primarycare physician
$20 per visit to specialist
15
15 Page 16
17
2002 Group Health Plan 16 Section 5( a)
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics $10 per visit to primarycare
physician
Well-child care charges for routine examinations, immunizations and care
(through 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
$10 per visit to primarycare physician
Maternity care You pay
Complete maternity (obstetrical) care, such
as:
Prenatal care which includes one routine ultrasound
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; your physician should
precertify for you.
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).
$10 for initial office visit only
Not covered:
Routine sonograms to determine fetal age, size or sex
All charges
16
16 Page
17 18
2002 Group Health Plan 17
Section 5( a)
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
$10 per visit to primary care physician
$20 per visit to specialist
Not covered:
Reversal of voluntary surgical sterilization
All
charges.
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
Artificial insemination:
intravaginal
insemination (IVI)
intracervical insemination (ICI)
intrauterine
insemination (IUI)
covered for up to 6 cycles per lifetime
$10 per visit to primary care physician
$20 per visit to specialist
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization (IVF)
intracytoplasmic sperm injection
(ICSI)
embryo transfer, Gamete (GIFT) and Zygote (ZIFT)
Zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
Storage of
eggs, sperm, and embryo
Fertility Drugs
Selective
reduction
All charges.
17
17 Page
18 19
2002 Group Health Plan 18
Section 5( a)
Allergy care
Testing and treatment
Allergy injection
$10 per visit to primary care physician
$20 per visit to specialist
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 25.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Growth hormone therapy (GHT)
Note: Growth hormone is covered
under the prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment.
Call 1-800-546-4603 for preauthorization. Ask if
GHT is authorized
before you begin treatment. If we determine GHT is not
medically
necessary, we will not cover the GHT or related services and
supplies.
See Services requiring our prior approval in Section 3.
$10 per visit to primary care physician
$20 per visit to specialist
Physical and occupational therapies You pay
60 visits per
condition for the combined services of each of the following:
qualified physical therapists;
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 for up to 36 sessions
20% coinsurance for therapies done
in the office or outpatient basis
No coinsurance or copay for
therapies done during a covered
inpatient
admission.
Not covered:
Long-term rehabilitative therapy
Exercise programs
All charges.
18
18 Page
19 20
2002 Group Health Plan 19
Section 5( a)
Speech therapy
20 visits or two consecutive
months (whichever is greater)
Note: Covered in situations where it is medically necessary.
20% coinsurance for therapy done
in the office or outpatient basis
No coinsurance or copay for
therapies done during a covered
inpatient
admission.
Not covered:
Speech therapy services that are not medically
necessary
All charges.
Hearing services (testing, treatment, and supplies)
Hearing
testing $10 per visit to primary care physician $20 per visit to specialist
Not covered:
Hearing aids, testing and examinations for hearing
aids
All charges.
Vision services (testing, treatment, and supplies) You pay
Annual
eye exam
-Includes exam for refraction to get a prescription for eyeglasses
or
contacts.
$10 per visit to primary care physician
$20 per visit to specialist
Initial placement of corrective contact lenses or eyeglasses are covered for
diagnosis of pseudophakia or aphakia (surgical removal of
natural lens of
the eye).
Note: a) You must be a GHP member at the time of surgery and at
the time
the initial post-surgical contact lenses or eyeglasses are
obtained.
b) See Preventive care, children for eye exams for children
Nothing
Not covered:
Corrective glasses and frames or contact lenses
(including the fitting of the lenses)
Eye exercises (orthoptics)
Radial keratotomy and other
refractive surgery such as LASIK
All charges. 19
19 Page 20 21
2002 Group
Health Plan 20 Section 5( a)
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.
$10 per visit to primary care physician
$20 per visit to specialist
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; and of any instability, imbalance or subluxation of the foot (unless the
treatment is by open
cutting surgery)
All charges.
Orthopedic and prosthetic devices You pay
Artificial limbs
(initial placement only after diagnosis is made)
External lenses following
cataract removal – initial placement only
Externally worn breast prostheses
and surgical bras, including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant following
mastectomy.
Note: We pay internal prosthetic devices as hospital
benefits; see Section 5
(c) for payment information. See 5( b) for
coverage of the surgery to insert
the device.
Corrective orthopedic appliances for treatment of temporomandibular joint
(TMJ) pain dysfunction syndrome
$10 per visit to primary care physician
$20 per visit to specialist
20% coinsurance for orthotic or
prosthetic device
Note: Office visit copay is in addition
to the 20% coinsurance for the
device,
whether billed separately or together.
Not covered:
Orthopedic, diabetic and corrective shoes
Arch supports
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings,
Jobst stockings, support hose, and other supportive devices
Prosthetic replacements
Testicular Implants
All charges. 20
20 Page 21 22
2002 Group
Health Plan 21 Section 5( a)
Durable medical equipment (DME) You
pay
Rental or purchase, at our option, including repair and adjustment,
of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
Hospital beds;
Ostomy supplies;
Wheelchairs;
Crutches;
Walkers;
Blood glucose monitors;
Insulin pumps; and
Oxygen
therapy
Note: Your physician will arrange coverage for durable medical with
GHP
and plan provider.
20% coinsurance
Not covered:
Non durable medical supplies such a c-pap masks,
foley catheters, dressings and leg bags
Repairs and Replacement of purchased equipment
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. Home Health Aide
is covered when medically necessary.
Services include intravenous therapy.
20% coinsurance
Not covered:
Nursing care requested by, or for the convenience
of, the patient or the patient's family;
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges. 21
21 Page 22 23
2002 Group
Health Plan 22 Section 5( a)
Chiropractic
Chiropractic
services for acute episode-spinal manipulations are covered when obtained by a
Plan provider and referred by PCP $10 per visit to primarycare physician $20 per
visit to specialist
Not covered:
Chiropractic services other than spinal
manipulations
All charges.
Alternative treatments
Biofeedback -when all other conservative
measures have been exhausted. $10 per visit to primarycare physician $20 per
visit to specialist
Not covered:
Naturopathic services Hypnotherapy
Acupuncture
All charges.
Educational classes and programs
Coverage is limited to:
Diabetes self-management
Living with Diabetes is an education-based
program supervised by a Certified
Diabetes Educator. The program is
coordinated through GHP's Complex Case
Management Department and is directed
at members who have diabetes. The
program includes educational materials,
quarterly newsletters, self-care
guidelines, periodic health postcard reminders (for foot exams, retinal eye
exams, cholesterol testing and long-term blood sugar tests), and referrals
to
group and individual educational programs/ support groups provided by
hospitals and home health agencies.
Healthy Basics for Healthy Babies
To help promote a healthy pregnancy,
GHP has developed a Healthy Basics for
a Healthy Baby program for its
expectant members. Healthy Basics
encourages prenatal care and a healthy
lifestyle, provides educational material,
and identifies pregnancies that
may be of greater than average risk. Healthy
Basics is a free enhancement to
the regular obstetrical care mothers receive
during pregnancy. Expectant
members are enrolled in Healthy Basics when
GHP is notified of the
pregnancy.
Nothing
Not covered:
Weight loss programs
All Charges. 22
22 Page 23 24
2002 Group Health Plan 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.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c ) for charges associated with the facility (i. e. hospital,
surgical
center, etc.)
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR 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 – when Plan criteria is met Insertion
of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic
devices for device coverage information.
$10 in primary care physician office
$20 in specialist office
$50 for
outpatient surgery
Surgical procedures continued on next page. 23
23 Page 24 25
2002 Group Health Plan 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.
$10 in primary care physician office
$20 in specialist office
$50 for
outpatient surgery
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care.
Replacement of Penile prosthesis
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; webbed
fingers; and webbed toes.
$10 in primary care physician office
$20 in specialist office
$50 for
outpatient surgery
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.
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
Scar Revision
All charges 24
24 Page 25 26
2002 Group
Health Plan 25 Section 5( b)
Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the
jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe
functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures.
Non-dental treatment of Temporomandibular (TMJ) joint pain
dysfunction syndrome
$10 in primary care physician office
$20 in specialist office
$50 for
outpatient surgery
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures
(such as root canals, extractions, periodontal membrane, gingiva,
and
alveolar bone)
Dental care involved in the treatment of TMJ
All charges.
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single
–Double
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 if the donor has no other coverage for this
service.
Nothing
Organ/ Tissue Transplants continued on next page 25
25 Page 26 27
2002 Group Health Plan 26 Section 5( b)
Hair Transplants
Non human organs
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
Nothing
Not covered: All Charges
Donor screening tests and donor search
expenses, except those
performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
Not covered: All charges
Anesthesia for dental procedures 26
26 Page 27 28
2002 Group Health Plan 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
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.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
$100 per admission
Inpatient hospital continued on next page. 27
27 Page 28 29
2002 Group Health Plan 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, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Take-home
items Medical supplies, appliances, medical equipment, and any covered
items
billed by a hospital for use at home
$100 per admission
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
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration
of blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
$50 per outpatient surgery visit
Not covered:
Storage of blood donated before surgery
Designated Donor Fees All charges
Extended care benefits/ skilled nursing care facility benefits You pay
Covered for up to 30 days per calendar year when full-time skilled
nursing care is necessary and confinement in a skilled nursing
facility
is medically appropriate as determined by a Plan doctor and
approved by the
Plan.
$100 per admission
Not covered: Custodial Care All charges 28
28 Page 29 30
2002 Group Health Plan 29 Section 5( c)
Hospice care
Inpatient and Home care when authorized and
approved by Plan
20% coinsurance
Not covered:
private duty nursing homemaker services
All charges
Ambulance
Local professional ambulance service when medically
appropriate 20% coinsurance 29
29 Page 30 31
2002 Group
Health Plan 30 Section 5( d)
Section 5 (d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe
endangers your life or could result in serious
injury or disability, and requires immediate medical or
surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more
serious; examples include deep cuts and broken bones. Others are
emergencies because they are
potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability
to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
If you are in an emergency
situation, please call your primary care doctor. In medical 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 the Plan. You or a family member must notify the Plan within
48 hours unless it was not
reasonably possible to do so. It is your
responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan should be
notified by you or a family member
within 48 hours unless it is not
reasonably possible to do so. If you are hospitalized in non-Plan facilities and
Plan doctors believe care can be better provided in a Plan hospital, you
will be transferred when medically
feasible with any ambulance charges
covered in full.
The Plan or your primary care physician in conjunction with the Plan must
approve follow-up care
recommended by non-Plan providers. Normally, you will
be required to return to the Plan's service area for
follow up care.
The copayment for an Emergency Room visit is $75. The $75 copayment is waived
if you are admitted. 30
30 Page
31 32
2002 Group Health Plan 31
Section 5( d)
Benefit Description You pay
Emergency within our
service area
Emergency care at a doctor's office $10 per visit to primary care physician
$20 per visit to specialist
Emergency care at an urgent care center
Emergency care at a hospital,
including doctors' services
$75 per visit
Waived if admitted to
hospital
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office $10 per visit to primary care physician
$20 per visit to specialist
Emergency care at an urgent care center
Emergency care at a hospital,
including doctors' services
$75 per visit
Waived if admitted to
hospital
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
20% coinsurance 31
31 Page
32 33
2002 Group Health Plan 32
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
When you get 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.
We have no calendar year deductible.
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 any other
illness or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$10 per visit to primary care
physician
$20 per visit to specialist
Mental health and substance abuse benefits -Continued on next page 32
32 Page 33 34
2002 Group Health Plan 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 treatment.
$100 per admission
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the
treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one
clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all the following authorization processes:
Please call GHP's Behavioral Health Line at 1-877-227-3520 to access
mental health and substance abuse services. GHP's Behavioral Health Line
provides 24-hour access for these benefits. The Behavioral Health Line
will be able to help you identify participating providers and initiate
referral
procedures.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 33
33 Page
34 35
2002 Group Health Plan 34
Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
We have no calendar year deductible.
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 licensed Plan physician must write
the prescription.
Where you can obtain them. You may fill your
prescription at a participating retail pharmacy or by mail, or a participating
90-day pharmacy if it is maintenance medication.
We use a formulary. A drug formulary is a list of drugs available for
coverage under the Plan. The purpose of the formulary is to assist physicians in
prescribing cost effective, quality drug therapy for
members. Drugs from all
therapeutic groups are available on the drug formulary. The formulary has
a
mandatory generic policy when there is a generic medication that has been proven
by the FDA to
be the equivalent of the brand name. If a member or physician
prefers the name brand or non-formulary
drug when a generic is available,
the member will be charged the difference in cost plus
the copayment. Since
there is a copayment for non-formulary drugs, there will no longer be
exceptions to the formulary. If a doctor prescribes a non-formulary drug,
you can go back to the
doctor and ask them to prescribe something from the
formulary or pay the higher copayment.
These are the dispensing limitations. Participating retail pharmacies
will dispense a 30-day supply or 100-unit supply of medication (whichever is
less) for the following copayments: $8 for generic,
$20 for name brand, $35 non formulary. Prescriptions dispensed as a unit
(such as 1 box, 1 tube, 1
inhaler) will have a copayment per unit. GHP's
90-day pharmacies and mail order program will
dispense a 90-day supply (when
the prescription is written for 90-days) for 2 copayments. Some
prior
approval drugs such as Imitrex have limited dosage amounts. Please have your
doctor call for
prior approval. If a generic is available, you will pay
difference in cost, plus name brand or non-formulary
copayment. If there is
no generic equivalent available, member will pay brand name
copayment
Why use generic drugs? To reduce your out-of-pocket expenses! A
generic drug is the chemical equivalent of a corresponding brand name drug.
Generic drugs are less expensive than brand name
drugs; therefore, you may reduce your out-of-pocket costs by choosing to use
a generic drug.
When you have to file a claim. You would only have to
file a claim if you were out of our Service area and unable to use one of the
National chains participating in the Plan in an Emergency situation.
In this case, please submit an itemized bill to GHP with an explanation and
we will reimburse you
all but your copayment.
Prescription drug benefits begin on the next page. 34
34 Page 35 36
2002 Group Health Plan 35 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 for which a prescription is required by law except those listed as
Not covered
Full range of FDA-approved drugs, prescriptions, and devices for birth
control
Insulin, with a copay charge applied to each vial
Disposable
needles and syringes needed for injecting insulin and covered prescribed
medication
Blood glucose test strips for insulin dependent members
Intravenous
fluids and medication for home use are covered under Medical and Surgical
Benefits.
Growth hormone
Limited benefits: Drugs to treat sexual dysfunction
are limited. Contact the Plan for dose limits.
You pay a $20 copayment, up
to the dosage limits and all charges thereafter.
You pay $8 copayment per generic
formulary drug.
You pay $20 copayment per name
brand formulary with no generic
equivalent. For name brand drugs
with generic equivalent, you pay
$20 copay plus the difference
between the retail cost of the name
brand drug and its generic
equivalent.
You pay $35 copayment per non-formulary
drug. For non-formulary
drug
with a generic
equivalent, you pay a $35 copay
plus the difference
between the
retail cost of the brand name and
the generic equivalent.
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay.
Not covered:
Drugs available without a prescription or for which a non prescription
equivalent is available
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Vitamins and nutritional substances that can be purchased without a
prescription
Medical supplies such as dressings and antiseptics
Fertility drugs
Diabetic supplies, except for needles,
syringes, lancets and blood glucose test strips
Drugs for cosmetic purposes
Drugs to enhance athletic
performance
Smoking cessation drugs and medication, including
nicotine Patches
Drugs for weight loss
Refills for prescriptions resulting from
loss or theft
Prescription drugs for travel
Special
packaging required for drugs dispensed in nursing homes
All Charges 35
35 Page 36 37
2002 Group
Health Plan 36 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.
High risk pregnancies
To help promote a healthy pregnancy, GHP has
developed a Healthy Basics for a
Healthy Baby program for its expectant
members. Healthy Basics encourages
prenatal care and a healthy lifestyle,
provides educational material, and identifies
pregnancies that may be of
greater than average risk. Healthy Basics is a free
enhancement to the
regular obstetrical care mothers receive during pregnancy.
Expectant members
are enrolled in Healthy Basics when GHP is notified of the
pregnancy.
Joint Replacement Program
Members who are being precertified for
surgery are educated in hopes of the
following: Increase knowledge about
their surgery and postoperative care through
recovery to decrease anxiety;
Reduce length of stay for joint replacement member;
and support preoperative
teaching programs.
Centers of excellence for transplants
Group Health plan utilizes
the United Resource Network (" URN") to provide our
members with access to
nationally recognized transplant programs. These programs
are "Centers of
Excellence" offering our members quality transplant services. The
URN
network provides an opportunity for our members to have access to some of
the nation's leading transplant centers. 36
36
Page 37 38
2002
Group Health Plan 37 Section 5( h)
Section 5 (h). Dental
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year
deductible.
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
Restorative services and supplies necessary to
promptly repair (within 2
days) but not replace sound
natural teeth. The need for these services must
result
from an accidental injury.
$10 per visit to primary care physician
$20 per visit to specialist
Dental Benefits
We have no other dental benefits offered as part
of this medical plan.
. 37
37 Page 38 39
2002 Group
Health Plan 38 Section 5( i)
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.
MEDICARE PREPAID PLAN ENROLLMENT:
This Plan offers Medicare
recipients the opportunity to enroll in the Plan through Medicare without
payment of an
FEHB premium. As indicated in Section 9, certain annuitants
and former spouses who are covered by both Medicare
Parts A and B and FEHB
may elect to drop their FEHB coverage and later reenroll in FEHB. Contact your
retirement
system for information on changing your FEHB enrollment. Contact
us at 1-800-533-0362, or for the hearing impaired
1-877-231-0573, for
information on the Medicare prepaid plan and the cost of that enrollment.
VOLUNTARY DENTAL PROGRAM:
With your continued or new enrollment
with GHP for 2002, you have the opportunity to select a low-cost Voluntary
Dental program offered by CompDent. Highlights of the benefits available
with this plan are as follows:
No waiting periods No deductible
No benefit maximum No claims to file
Oral evaulations at no charge Xrays at no charge
Cleanings
– Once every 6 months at no charge Basic and major services
25%
discount for specialty services including orthodontia Additional discounted
services for pharmacy, contact lenses, glasses and hearing needs
COST PER MONTH Employee Only: $ 5.78 Employee + Family: $12.86
If you
choose to enroll in this value-added benefit, the cost for single coverage or
family coverage will be
automatically deducted from your checking account on
a monthly basis, or you may pay on an annual basis by using a
major credit
card. Participation is voluntary so you will not be automatically enrolled in
this program.
Additional information including dentist directory, benefit schedule,
enrollment application, member services phone
number and more can be found
in the CompDent packet located inside the GHP enrollment packet. 38
38 Page 39 40
2002 Group Health Plan 39 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we
will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or
treat your
illness, disease, injury, or condition and we agree, as discussed under
What Services Require Our Prior Approval
on page .
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. 39
39 Page 40 41
2002 Group
Health Plan 40 Section 7
Section 7. Filing a claim for covered
services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at
Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment or
coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 1-800-755-3901.
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: Group
Health Plan
P. O. Box 7374
London, KY 40742-7374
Prescription drugs You will not have to file claims when using
participating pharmacy providers. In emergency situations submit itemized bill.
Submit your claims to: Group Health Plan
111 Corporate Office Drive,
Suite 400
Earth City, MO 63045
Attention: Pharmacy Department
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. 40
40 Page 41 42
2002 Group Health Plan 41 Section 7
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. 41
41 Page
42 43
2002 Group Health Plan 42
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
Ask us in writing to reconsider our initial decision. Write to us at: 111
Corporate Office Drive, Suite 400, Earth City, MO 63045 You must:
(a) Write
to us within 6 months from the date of our decision; and
(b) Send your
request to us at: 111 Corporate Office Drive, Suite 400, Earth City, MO 63045;
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.
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.
You or your provider must send the information so that we receive it within
60 days of our request. We will then decide within 30 more days.
If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us --if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
1900 E Street, NW. Washington, D. C.
20415-3630. 42
42 Page
43 44
2002 Group Health Plan 43
Section 8
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.
OPM will review your disputed claim request and will use the information it
collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no
other administrative
appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If
you decide to sue, you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preuthorization/ prior approval, then call us at 1-800-
755-3901 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/ 606-0737
between 8 a. m. and 5
p. m. eastern time.
43
43 Page
44 45
2002 Group Health Plan 44
Section 9
Section 9. Coordinating benefits with other coverage
When you have other heal You must tell us if you are covered or a family
member is covered under another group health plan or have automobile insurance
that pays health care expenses
without regard to fault. This is called
"double coverage."
When you have double coverage, one plan normally pays its
benefits in full as the
primary payer and the other plan pays a reduced
benefit as the secondary payer.
We, like other insurers, determine which
coverage is primary according to the
National Association of Insurance
Commissioner's 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 (Part A or Part B) The Original Medicare
Plan (Original Medicare) is available everywhere in the
United States. It is the way everyone used to get 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 Plan PCP, or precertified as
required.
We will waive the copayments when you have Medicare part B.
(Primary
payer chart begins on next page.)
coverage th 44
44 Page 45 46
2002 Group
Health Plan 45 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 solelybecause of a disability), 9
2) Are an annuitant, 9
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or 9
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.) 9
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),
9
5) Are enrolled in Part B only, regardless of your employment status, 9 (for
Part B
services)
9
(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,
9
(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, 9
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD, 9
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision, 9
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or 9
9
b) Are an active employee, or 9
c) Are a former spouse of an annuitant,
or 9
d) Are a former spouse of an active employee 9
Please note, if
your Plan physician does not participate in Medicare, you will have to file a
claim with Medicare 45
45 Page 46 47
2002 Group Health Plan 46 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 us at 1-800-755-3901
or visit the our
website at www. ghp. com.
We waive some costs when you have the Original Medicare Plan --When
Original Medicare is the primary payer, we will waive some out-of-
pocket
costs, as follows: Specialist copayments and coinsurance.
Medical services and supplies provided by physicians and other health care
professionals. If you are enrolled in Medicare Part B, we
will waive
precertification and referral guidelines, specialist
copayments and
coinsurance.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a
Medicare managed care plan. These are health care
choices (like HMOs)
in some areas of the country. In most Medicare managed
care plans, you
can only go to doctors, specialists, or hospitals that are
part of the plan.
Medicare managed care plans provide all the benefits that
Original
Medicare covers. Some cover extras, like prescription drugs. To
learn
more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE
(1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll
in
our Medicare managed care plan and also remain enrolled in our
FEHB plan. In
this case, we do waive any of our copayments or
coinsurance for your FEHB
coverage.
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 or coinsurance. If you
enroll in a Medicare managed care
plan, tell us. We will need to know
whether you are in the Original Medicare
Plan or in a Medicare managed
care plan so we can correctly coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your
FEHB coverage to
enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM
does not contribute to your Medicare
managed care plan premium.) For
information on suspending your
FEHB enrollment, contact your retirement
office. If you later want to re-enroll
in the FEHB Program, generally you
may do so only at the next 46
46 Page 47 48
2002 Group
Health Plan 47 Section 9
open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not enroll in Medicare Part A or Part B If you do not have
one or both Parts of Medicare, you can still be covered
under the FEHB
Program. We will not require you to enroll in Medicare
Part B and, if you
can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or
other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
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 If you do not seek damages you must agree
to let us try. This is called for injuries subrogation. If you need more
information, contact us for our
subrogation procedures. 47
47 Page 48 49
2002 Group Health Plan 48 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 is primarily for the purpose of
helping the plan member with activities of daily living or meeting personal
needs and can be provided
safely and reasonably by people without
professional skills or training.
Examples of custodial care include rest
cures, respite care and home care.
Experimental or investigational services A drug device, treatment,
therapy, procedure, service or supply of any kind
whatsoever (a "Service")
that:
1) cannot be lawfully marketed without the approval of the Food and
Drug Administration (FDA) and such approval has not been granted
at that time of use or proposed use, or
2) is the subject of a current
investigational new drug or new device
application on file with the FDA
3) In the predominant opinion of experts, as expressed in the published
authoritative literature, that usage should be substantially confined to
research settings or that further research is needed inorder to define
safety, toxicity, efficacy or effectiveness of that Service compared
with conventional alternatives.
Group health coverage A corporation, partnership, union or other
entity that is eligible for group coverage under State or Federal laws; and
which enters into Agreement
with the Plan to offer coverage to Employees and
their eligible
dependents.
Medical necessity Services which are provided for the diagnosis or
care and treatment of medical condition; Appropriate and necessary for the
symptoms,
diagnosis or treatment of that condition; Rendered within
standards of
generally accepted medical practice; Not primarily for the
convenience of
You, Your family, or a Provider; and Perfomed in the most
appropriate
setting or manner for treating Your condition, as determined by
the
Medical Director.
Us/ We Us and we refer to Group Health Plan
You You refers
to the enrollee and each covered family member. 48
48
Page 49 50
2002 Group Health Plan 49 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. 49
49 Page
50 51
2002 Group Health Plan 50 Section 11
When benefits and
premiums start The benefits in this brochure are effective on January 1. If
you joined this Plan during Open Season,
your coverage begins on the first
day of your first pay period that starts on or after January
1. Annuitants'
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 of coverage (TCC) If you leave Federal service,
or if you lose coverage because you no longer qualify as a
family member,
you may be eligible for Temporary Continuation of Coverage (TCC).
For
example, you can receive TCC if you are not able to continue your FEHB
enrollment
after you retire, if you lose your job, if you are a covered
dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage
and Former
Spouse Enrollees, from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll. 50
50 Page 51 52
2002 Group Health Plan 51 Section 11
Converting to
You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends. If you canceled
your coverage or did not pay your premium, you cannot convert;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to
convert. You must apply in writing to us within 31 days after you receive
this notice.
However, if you are a family member who is losing coverage, the
employing or
retirement office will not notify you. You must apply in
writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you
will not have to answer questions about your health, and we
will not impose a waiting
period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996 (HIPAA), is aFederal
law that offers limited Federal protections for health coverage availability
and continuity
to people who lose employer group coverage. If you leave the
FEHB Program, we will give
you a Certificate of Group Health Plan Coverage
that indicates how long you have been enrolled with
us. You can use this
certificate when getting health insurance or other health care coverage. Your
new
plan must reduce or eliminate waiting periods, limitations, or
exclusions for health related conditions
based on the information in the
certificate, as long as you enroll within 63 days of losing coverage
under
this Plan. If you have been enrolled with us for less than 12 months, but were
previously
enrolled in other FEHB plans, you may also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC)
under the FEHB Program.. See also the FEHB web site (www. opm. gov/ insure/ health); refer
to the "TCC and HIPAA" frequently asked question. It highlights 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 haves information about Federal and State
agencies
you can contact for more information. 51
51 Page 52 53
2002 Group Health Plan 52 Long Term Care
Long Term Care
Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM)
will sponsor a high-quality long term care insurance program effective in
October 2002. As part of its educational effort, OPM asks you to consider these
questions:
It's insurance to help pay for long term care services you
may need if you can't take care of yourself because of an extended illness or
injury, or an age-related disease
such as Alzheimer's.
LTC insurance can
provide broad, flexible benefits for nursing home care, care in an assisted
living facility, care in your home, adult day care, hospice care, and more.
LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
Welcome to the club! 76% of Americans believe they will never need long term
care, but the facts are that
about half 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.
Yes, it can be very expensive. A year
in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a
week can exceed $20,000 a year. And that's
before inflation!
Long term care can easily exhaust your savings. Long
term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c)
of your FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted
living facility or a continuing need for a home health aide to help
you get in and out
of bed and with other activities of daily living. Limited
stays in skilled nursing
facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in
mid-2002. In the meantime, you can learn
more about the program on our web site at www. opm. gov/ insure/ ltc.
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.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 52
52 Page 53 54
2002 Group Health Plan 53 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury 37 Allergy tests 18
Alternative treatment 22
Allogenetic (donor) bone marrow
transplant 25 Ambulance 31
Anesthesia 26
Autologous bone marrow
transplant 25 Biopsies 23
Breast cancer screening 15 Changes for 2002 8
Chemotherapy 18
Childbirth 16
Chiropractic 22 Cholesterol tests 15
Claims 40 Coinsurance
12
Colorectal cancer screening 15 Congenital anomalies 24
Contraceptive
devices and drugs 17 Coordination of benefits 44
Covered charges 13 Covered
providers 9
Crutches 21
Deductible 12 Definitions 48
Dental care 37 Diagnostic services 14
Disputed claims review 42 Donor
expenses (transplants) 25
Durable medical equipment (DME) 21
Educational classes and programs 22 Effective date of enrollment 50
Emergency 30 Family planning 17
Fecal occult blood test 15
General Exclusions 39
Hearing services 19 Home health services
21
Hospice care 29 Home nursing care 21
Hospital 27 Identification
Card 9
Immunizations 15 Infertility 17
Inhospital physician care 14
Inpatient Hospital Benefits 27
Insulin 35 Laboratory and
pathological services 15 Machine diagnostic tests 15
Mail Order
Prescription Drugs 34 Mammograms 15
Maternity Benefits 16 Medicaid 47
Medicare 44 Mental Conditions/ Substance
Abuse Benefits 32 Newborn care
16
Non-FEHB Benefits 38 Nursery charges 16
Obstetrical care 16
Occupational therapy 18
Office visits 14 Oral and maxillofacial surgery 25
Orthopedic devices 20 Ostomy supplies 21
Out-of-pocket expenses 12
Outpatient facility care 28 Pap test 15
Physical examination 15
Physical therapy 18
Precertification 11 Preventive care, adult 15
Preventive care, children 16 Prescription drugs 34
Prior approval 11
Prostate cancer screening 15
Prosthetic devices 20 Psychologist 32,33
Psychotherapy 32,33 Radiation therapy 18
Skilled nursing facility
care 28 Speech therapy 19
Sterilization procedures 17, 24
Substance
abuse 32, 33 Surgery 23
Anesthesia 26 Oral 25
Outpatient 23
Reconstructive 24
Syringes 35 Temporary continuation of
coverage
50 Transplants 25
Vision services 19 Well child care 16
Wheelchairs 21 Workers' compensation 47
X-rays 15 53
53 Page 54 55
2001 Group Health Plan 54
NOTES 54
54 Page 55 56
2002 Group Health Plan 55 Summary
Summary of benefits for the Group Health Plan -2002
Do not
rely on this chart alone. All benefits are provided in full unless indicated
and are subject to
the definitions, limitations, and exclusions in this
brochure. On this page we summarize specific
expenses we cover; for more
detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code
from the cover on your enrollment form.
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: $10 primary care; $20 specialist 14
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
$100 per admission copay
$50 per outpatient surgery
27
28
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$75 per emergency room visit,
waived if admitted to hospital.
$75 per emergency room visit,
waived if admitted to hospital.
31
31
Mental health and substance abuse
treatment..................................... Regular cost sharing. 32
Prescription drugs
................................................................................
$8 generic
$20 name brand
$35 non formulary
Copayment is per 30-day
supply
and applies to each unit (i. e. box,
tube, vial, inhaler).
34
Dental Care
.......................................................................................
No dental benefit 37
Vision Care
.......................................................................................
Annual Eye exam is covered for
$10 primary care; $20 specialist 19
Special features
Flex Benefits option, High risk pregnancies, Joint
replacement
program, Centers of excellence for transplants
36
Protection against catastrophic costs
(your out-of-pocket
maximum)......................................................... Nothing after
$1, 000/ Self Only or
$2000/ Family enrollment per year
Some costs do not count toward
this protection
12 55
55 Page
56
2002 Group Health Plan 56 Rates
2002
Rate Information for GROUP HEALTH PLAN
Non-Postal rates apply to
most non-Postal enrollees. If you are in a special enrollment category, refer to
the FEHB Guide for that category or contact the agency that maintains
your
health benefits enrollment.
Postal rates apply to career Postal
Service employees. Most employees should refer to the FEHB Guide for United
States Postal Service Employees, RI 70-2. Different postal
rates apply and
special FEHB guides are published for Postal Service Nurses, 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
High Option
Self Only MM1 $97.86 $51.26 $212.03 $111.06 $115. 52
$33.60
High Option
Self and Family MM2 $223.41 $98.68 $484.06 $213.80 $263.
75 $58.34 56