Health Net of
Connecticut, Inc. http:// www. health. net
2002 Formerly Physicians Health Services of Connecticut, Inc.
A Health Maintenance Organization
Serving: All of Connecticut
Enrollment in this Plan is
limited; see page 7 for requirements.
Enrollment codes for this Plan:
DP1 Self Only DP2 Self and Family
RI 73-140
For changes In Benefits
See Page 8 1
1
Page 2 3
2002 Health Net of Connecticut, Inc. 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………........................................................................
4
Plain
Language……………………………………………………………….......................................................................
4
Inspector General
Advisory…………………………………………………………………………………………… 5
Section
1. Facts about this HMO
plan.........................................................................................................................................
6
How we pay
providers.................................................................................................................................................
6
Who provides my health care?…………………………………………………………………………….. 6
Your
Rights..................................................................................................................................................................
6
Service Area
..................................................................................................................................................................
7
Section 2. How we change for
2002……………………………………….........................................................................
8
Program-wide
changes................................................................................................................................................
8
Changes to this
Plan.....................................................................................................................................................
8
Section 3. How you get care
………….……………………………………………………………………………… 9
Identification
cards………………………………………………………………………………………… 9
Where you get covered
care……………………………………………………………………………….. 9
Plan providers
........................................................................................................................................................
9
Plan
facilities..........................................................................................................................................................
9
What you must do to get covered care
.....................................................................................................................
9
Primary care
.........................................................................................................................................................
10
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
.......................................... 26
(d)
Emergency services/ accidents
.....................................................................................................................
29
(e) Mental health and substance abuse
benefits..............................................................................................
31
(f) Prescription drug benefits
.............................................................................................................................
33
(g) Special
features...............................................................................................................................................
36 2
2 Page 3 4
2002 Health Net of Connecticut, Inc. 3 Table of Contents
Flexible benefits option
24 Hour Personal Health Advisor
line
Interactive Provider Directory
Disease State Management
Programs
Services for deaf and hearing impaired
(h) Dental
benefits.................................................................................................................................................
37
(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.....................................................................................................................................
41
Section 9. Coordinating benefits with other
coverage
............................................................................................................
43
When you have…
Other health coverage
..........................................................................................................................................
43
Original Medicare
.................................................................................................................................................
43
Medicare managed care
plan...............................................................................................................................
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
................................................................................................................................................................
50
Coverage
information...............................................................................................................................................
50
No pre-existing condition
limitation.............................................................................................................
50
Where you get information about enrolling in the FEHB
Program........................................................ 50
Types of coverage available for you and your family
...............................................................................
50
When benefits and premiums start
...............................................................................................................
51
Your medical and claims records are
confidential.....................................................................................
51
When you
retire...............................................................................................................................................
51
When you lose benefits
...........................................................................................................................................
51
When FEHB coverage
ends...........................................................................................................................
51
Spouse equity coverage
.................................................................................................................................
51
Temporary Continuation of Coverage
(TCC)............................................................................................
51
Converting to individual
coverage...............................................................................................................
52
Getting a Certificate of Group Health Plan
Coverage..............................................................................
52
Long term care insurance is coming later in
2002…………………………………………………………………… 53 Index
....................................................................................................................................................................................
55
Summary of benefits
......................................................................................................................................................................
57
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2002 Health Net of Connecticut, Inc. 4 Introduction/ Plain
Language/ Advisory
Introduction
Health Net of Connecticut,
Inc. One Far Mill Crossing
Shelton, CT 06484
This brochure describes the
benefits of Health Net of Connecticut, Inc. under our contract (CS1960) with the
Office
of Personnel Management (OPM), as authorized by the Federal Employees
Health Benefits law. This brochure is the official statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are
entitled to the benefits described in this brochure. If you are enrolled for
Self and Family coverage, each eligible family member is also entitled to these
benefits. You do not have a right to
benefits that were available before
January 1, 2002, unless those benefits are also shown in this brochure.
OPM
negotiates benefits and rates with each plan annually. Benefit changes are
effective January 1, 2002, and
changes are summarized on page 8. Rates are
shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use
common words. For instance, "you" means the enrollee or family member; "we"
means Health Net of Connecticut, Inc.
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 us at fehbwebcomments@ opm. gov. You may
also
write to OPM at the Office of Personnel Management, Office of
Insurance Planning and Evaluation Division, 1900 E
Street, NW Washington, DC
20415-3650. 4
4 Page
5 6
2002 Health Net of Connecticut,
Inc. 5 Introduction/ Plain Language/ Advisory
Inspector
General Advisory
Stop health care fraud! Fraud increases the cost of
health care for everyone. If you suspect that a
physician, pharmacy, or
hospital has charged you for services you did not
receive, billed you twice
for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at (877) 747-9585 and
explain the situation.
If we do not resolve the issue, call or write THE HEALTH CARE FRAUD
HOTLINE
202/ 418-3300
The United States Office of Personnel
Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW,
Room 6400
Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a
claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the
Inspector General may investigate
anyone who uses an ID card if the person
tries to obtain services for someone who is not an eligible family member, or is
no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Health Net of Connecticut, Inc. 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
Health Care?
All medical care, including hospitalization, must be provided by a Health Net
of Connecticut, Inc. Plan physician or provider and when appropriate, Prior
Authorized by the Health Net of Connecticut, Inc. Medical Director.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You
may get information about us, our networks, providers and facilities. OPM's
FEHB website (www. opm. gov/ insure) lists the specific types
of
information that we must make available to you. Some of the required information
is listed below.
Health Net of Connecticut, Inc. contracts with
physicians and other practitioners either directly or through
provider
organizations (IPAs and PHOs). Most of these providers are reimbursed for each
covered service on a fee-for-service basis with a limited percentage withheld as
a reserve. The withheld percentage is based on an
estimate of overall utilization. However, some IPAs/ PHOs may reimburse their
Primary Care Providers on the
basis of a set amount per member per month
(capitated reimbursement). Depending upon the overall utilization of members
selecting Health Net of Connecticut, Inc. 's directly contracted or an IPAs/
PHOs Primary Care
Providers, the amount withheld by Health Net of Connecticut, Inc. may be
returned to the providers. Health Net
of Connecticut, Inc. also contracts
with certain vendors and suppliers (laboratory services, home health, etc.) that
are paid a capitated reimbursement. Lastly, Health Net of Connecticut, Inc.
reimburses hospitals and facilities on
the basis of a per diem, case rate, or some other form of negotiated fee.
If you want more information about us, call (877) 747-9585, or write to
Health Net of Connecticut, Inc., One Far Mill Crossing, Shelton, CT 06484. You may also
contact us by fax at (203) 402-7056 or visit our website at
www. health.
net. 6
6 Page 7 8
2002 Health Net of Connecticut, Inc. 7
Section 1
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 state of Connecticut.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care benefits. 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 Health Net of Connecticut, Inc. 8 Section
2
Section 2. How we change for 2002
Do not rely on these
change descriptions; this page is not an official statement of benefits. For
that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We changed speech therapy benefits by removing the requirement that
services must be required to restore functional speech. (Section 5( a))
Changes to this Plan
Your share of the non-Postal premium will
decrease by 0. 7% for Self Only or increase by 1.6% for Self and
Family.
We now provide coverage for up to $100 for one smoking cessation program
per member per lifetime, including all related expenses such as drugs.
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover routine screening for chlamydial infection.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5(
b))
We changed the address for sending disputed claims to OPM. (Section 8)
8
8 Page 9 10
2002 Health Net of Connecticut, Inc. 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 (877)
747-9585.
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. We credential Plan providers according to
national standards.
We list Plan providers in the provider directory, which
we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we
contract with to provide covered services to our
members. We list these in the provider directory, which we update periodically.
The list is also
on our website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for most of your health care.
You must obtain covered services from a Plan physician or provider, except in
the event of an emergency. If covered services cannot be
provided by a Plan
physician or Plan provider prior approval must be
obtained in writing from
the Health Net of Connecticut, Inc. Medical Director before you may receive
covered services from a Non-Plan
physician or provider. Health Net of Connecticut, Inc. will only approve
a referral to a Non-Plan physician or provider if the covered services
cannot be provided by a plan physician or provider.
To see whether a physician or provider participates in the Health Net of
Connecticut, Inc. network, or to check the location and phone number of
a
network specialist, hospital or urgent care center you can:
Refer to the
Health Net of Connecticut, Inc. physician and provider directory;
Call the Customer Service Department at (877) 747-9585. The
Customer
Service Department can also provide you with information regarding professional qualifications and credentials;
Visit our website at www. health. net for the latest information on
Plan physicians and providers; Call the Interactive Provider Directory
system toll-free at (800) 686-
9847 for a personalized list of local Plan physicians and providers
that
can be faxed to you immediately or mailed to your home. 9
9 Page 10 11
2002 Health Net of Connecticut, Inc. 10
Section 3
Primary care Your primary care physician can be
an internist, family or general practice physician, an obstetrician/
gynecologist or a pediatrician for your
children.
If you want to change
primary care physicians or if your primary care
physician leaves the Plan,
call us. We will help you select a new one.
Specialty care Although you are not required to obtain a referral
from your primary care
physician to see a specialist, we recommend that you
always consult your primary care physician first.
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 your specialist to
develop a treatment plan that allows
you to see your specialist. Your primary care physician will use our
criteria when creating your treatment plan (the physician may have to get an
approval or approval beforehand).
You may request access to a specialist to coordinate your care or
access to a specialty care center if you have a life-threatening or
degenerative and disabling condition or disease which requires
specialized medical care over a prolonged period of time. Specialty
care
may be accessed in accordance with the terms of your Plan documents.
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 Health Net
of Connecticut, Inc. 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 customer service department immediately
at (877) 747-9585. 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 prior
approval. Your physician must obtain prior approval for the following services
including, but not
limited to: inpatient hospitalizations, elective
outpatient surgical procedures, oxygen and related respiratory equipment, organ
transplants,
rehabilitative and restorative physical, occupational, speech,
respiratory
therapy and skilled nursing care:
Health Net of Connecticut, Inc. will provide the Plan physician or
provider with an approval specifying the services requested. The Plan
physician or provider will be notified prior to the initiation of the
requested treatment. Any covered services received from a Non-Plan
physician or provider must also be prior authorized by Health Net of
Connecticut, Inc. The member shall be fully responsible for the cost of
services to Plan providers if prior approval for such services has been
denied by Health Net of Connecticut, Inc. and the member has been notified
of such determination in advance of receiving the services. 11
11 Page 12 13
2002 Health Net of Connecticut, Inc. 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 and when you go in the hospital, you
pay nothing per
admission.
Deductible We do not have a deductible.
Coinsurance
We do not have coinsurance.
Your catastrophic protection
out-of-pocket maximum After your copayments total $1,500 per person or
$3,000 per family for copayments enrollment in any calendar year, you do
not have to pay any more for
covered services. However, copayments for the following services do not count
toward your out-of-pocket maximum, and you must continue to
pay copayments
for these services:
Prescription Drugs
Be sure to keep accurate records of your copayments
since you are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 Health Net of Connecticut, Inc. 13 Section 5
Section 5. Benefits – OVERVIEW
(See page 8 for how our
benefits changed this year and page 57 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing advice, or more
information about our benefits, contact us at (877) 747-9585 or at our website
at www. health. net.
(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 ........................... 23-25
Surgical procedures
Reconstructive
surgery
Oral and maxillofacial surgery Organ/
tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services............................................................. 26-28
Inpatient hospital Outpatient
hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
................................................................................................................................
29-30
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
........................................................................................................
31-32
(f) Prescription drug
benefits................................................................................................................................................
33-35
(g) Special features
.......................................................................................................................................................................
36
Flexible benefits option
Personal Health Advisor
Interactive Provider Directory
Disease
State Management Program
Services for deaf and hearing impaired
(h)
Dental
benefits.........................................................................................................................................................................
37
(i) Non-FEHB benefits available to Plan members
................................................................................................................
38
Summary of benefits
.....................................................................................................................................................................
57 13
13 Page 14
15
2002 Health Net of Connecticut, Inc. 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.
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 office visit
Professional services of physicians
Office medical consultations
Second surgical opinion
$10 per office visit
Professional services of physicians
At home During a hospital stay
In a skilled nursing facility
Nothing
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 14
14 Page
15 16
2002 Health Net of Connecticut,
Inc. 15 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol Once every
three years
Colorectal Cancer Screening, including
Fecal occult blood
test
Sigmoidoscopy, screening – every five years starting at age 50
$10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men who are
symptomatic; whose biological father or brother have been diagnosed with
prostate cancer; and for all men age 40 and over
$10 per office visit
Routine pap test
Note: The office visit is covered if pap test is
received on the same day; see Diagnostic and Treatment Services, above.
$10 per office visit
Routine mammogram –covered for women age 35 and older, as follows:
From
age 35 through 39, one during this five year period
From age 40 and older,
one every calendar year
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations, limited to:
Tetanus-diptheria (Td) booster –
once every 10 years, ages 19 and
over (except as provided for under
Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing
Well-child care charges for routine examinations, immunizations and
care ( up to age 22)
Examinations, such as:
Eye exams through age 19 to determine the need
for vision
correction.
Ear exams through age 19 to determine the need for hearing correction
Examinations done on the day of immunizations ( up to age 22)
$10 per office visit 15
15 Page 16 17
2002 Health Net
of Connecticut, Inc. 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in
mind:
You do not need to precertify your normal delivery; see page 11 for
other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular
delivery
and 96 hours after a cesarean delivery. We will 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).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges.
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
intrauterine insemination (IUI)
Fertility drugs are covered under the Prescription Drug Benefit only
when administered in connection with the treatment of a covered
infertility service, such as IUI
$10 per office visit 16
16 Page 17 18
2002 Health Net
of Connecticut, Inc. 17 Section 5( a)
Infertility services
(continued) You pay
Not covered:
Assisted
reproductive technology (ART) procedures, such as:
in vitro
fertilization embryo
transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures
Fertility drugs used as part of excluded infertility treatment, such as
In vitro fertilization
Cost of donor sperm
Cost of donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges.
Treatment therapies
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under Organ/ Tissue
Transplants on page 25.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Lyme disease treatment that is medically
necessary and appropriate
including at least 30 days of intravenous
antibiotic therapy, and/ or 60 days of oral antibiotic therapy. Coverage shall
include further treatment
by a board certified rheumatiologist, infectious disease specialist or
neurologist.
Nothing 17
17 Page
18 19
2002 Health Net of Connecticut,
Inc. 18 Section 5( a)
Physical and occupational therapies You
pay
60 visits per condition for the services of each of the following:
-qualified physical therapists and
-occupational therapists.
Note:
We only cover therapy to restore bodily function when there has
been a total
or partial loss of bodily function due to illness or injury.
Cardiac rehabilitation on an outpatient basis, as part of an approved
cardiac rehabilitation program for a maximum of 12 weeks following a
myocardial infarction or cardiac surgery.
$10 per office visit
Nothing per visit during covered inpatient admission
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
Two (2) consecutive months per condition with
approval from the Medical Director. $10 per office visit
Hearing services (testing, treatment, and supplies)
First
hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 19 (see Preventive care,
children)
$10 per office visit
Not covered:
all other hearing testing
hearing
aids, testing and examinations for them
All charges. 18
18 Page 19 20
2002 Health Net
of Connecticut, Inc. 19 Section 5( a)
Vision services
(testing, treatment, and supplies) You pay
Vision therapy services
(orthoptic and pleoptic therapy) are covered to a maximum of three (3) visits
per member per calendar year. This is not
intended to exclude coverage for medically necessary and appropriate
treatment for diseases of the eye.
$10 per office visit
One routine eye exam (including refraction) per calendar year to
determine the need for vision correction for children through age 19; for
members age 19 and older, one routine eye exam (including refraction)
every two calendar years. (see preventive care)
$10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 19,
examinations for
them
Eye exercises
Radial keratotomy and other refractive
surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
$10
per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat
feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot (unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices
Externally worn breast
prostheses and surgical bras, including necessary replacements, following a
mastectomy
External prosthetic devices, such as artificial limbs, are limited to a
maximum payment by the Plan of $5,000 for the initial appliance and $500 per
necessary replacement prosthetic.
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.
Corrective orthopedic appliances for non-dental
treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing 19
19 Page
20 21
2002 Health Net of Connecticut,
Inc. 20 Section 5( a)
Orthopedic and prosthetic devices
(Continued) You pay
Not covered:
orthopedic and corrective shoes
arch supports
foot
orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other
supportive devices
prosthetic replacements provided less than 3 years after the last one
we covered
All charges.
Durable medical equipment (DME)
Durable Medical Equipment such as
wheelchairs and hospital beds, and orthopedic devices such as braces are limited
to the initial appliance or
piece of equipment.
50% of the cost of the covered item to a maximum of
$1,500 per
member per calendar year.
Not covered:
Motorized wheel chairs
All charges.
Home health services
Home health care ordered by a Plan
physician and provided by a registered nurse (R. N.), licensed practical nurse
(L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include
oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the
convenience of, the patient or
the patient's family;
home care
primarily for personal assistance that does not include a medical component and
is not diagnostic, therapeutic, or
rehabilitative.
All charges. 20
20 Page 21 22
2002 Health Net
of Connecticut, Inc. 21 Section 5( a)
Chiropractic You pay
Chiropractic care on an outpatient basis will be provided for up to 2
months per condition if significant improvement can be expected within
2 months. If during the 2 month period the member has not incurred 30 visits,
the member will be entitled to the additional number of visits
needed to
reach the 30 visit limit, if significant improvement can be
expected within
these additional visits.
$10 per office visit
Alternative treatments
Acupuncture services are covered when
approved in advance up to 20 visits per member per calendar year $20 per office
visit
Naturopathy services $10 per office visit
Not covered:
hypnotherapy biofeedback
All
charges. 21
21 Page
22 23
2002 Health Net of Connecticut,
Inc. 22 Section 5( a)
Educational classes and programs You Pay
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses
such as drugs.
Diabetes outpatient self-management training, which includes, but is not
limited to, education and medical nutrition therapy. Diabetic
self-management training shall be provided by a certified,
registered or
licensed health care professional trained in the care and management of
diabetes. Therapy visits are limited to those
visits that are medically necessary and appropriate.
Diabetic training benefit shall cover:
(1) medically necessary and
appropriate training and education visits provided to a member after initial
diagnosis of diabetes for the care and
management thereof, including, but
not limited to, counseling in nutrition and the proper use of equipment and
supplies for the treatment
of diabetes, to a maximum of 10 visits;
(2) a maximum total of 4 medically necessary and appropriate training and
education visits that result from a subsequent diagnosis by a
physician or
provider marking a significant change in the member's
symptoms or condition
which requires a modification of the member's program for self-management of
diabetes; and
(3) a maximum total of 4 medically necessary and appropriate training
and
education visits as a result of the development of new techniques and treatment
for diabetes
$10 per office visit 22
22 Page 23 24
2002 Health Net
of Connecticut, Inc. 23 Section 5( b)
Section 5 (b). Surgical
and anesthesia services provided by physicians and other health care
professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e. hospital,
surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF
SOME SURGICAL PROCEDURES. Please refer to the precertification information shown
in Section 3 to be sure
which services require precertification and identify which surgeries require
precertification
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and
post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and
cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity
Insertion of internal
prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for device
coverage information.
$10 per office visit; nothing for inpatient hospital visits
Voluntary sterilization
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 per office visit; nothing for
inpatient hospital visits
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges. 23
23 Page 24 25
2002 Health Net
of Connecticut, Inc. 24 Section 5( b)
Reconstructive surgery
You pay
Surgery to correct a functional defect
Surgery to
correct a condition caused by injury or illness if:
the condition produced
a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$10 per office visit; nothing for inpatient or outpatient hospital
surgical visits
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.
See above.
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, 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.
TMJ surgery and other non-dental treatment.
$10 per office visit
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
All charges. 24
24 Page 25 26
2002 Health Net
of Connecticut, Inc. 25 Section 5( b)
Organ/ tissue
transplants You pay
Limited to:
Cornea
Heart
Heart/
lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous
bone marrow transplants (autologous stem cell and peripheral stem cell support)
for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small
intestine with the liver or small intestine with multiple organs such as the
liver,
stomach and pancreas
Limited Benefits -Treatment for breast cancer,
multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or
NIH-approved clinical trial at a Plan-designated center of excellence and if
approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as
covered
Transportation costs
All charges
Anesthesia
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Nothing
Professional services provided in –
Office
$10 per office visit 25
25 Page 26 27
2002 Health Net of Connecticut, Inc. 26
Section 5( c)
Section 5 (c). Services provided by a hospital or
other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and
exclusions in this brochure and are payable only when we determine they
are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized
in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Sections 5( a) or (b).
YOUR PHYS ICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS.
Please refer to Section 3 to be sure which services require prior
approval.
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;
meals and special diets;
special duty nursing when
medically necessary; and
private room when medically necessary
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing 26
26 Page
27 28
2002 Health Net of Connecticut,
Inc. 27 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
Nothing
Not covered:
Custodial care
Non-covered
facilities, such as nursing homes and schools
Personal comfort
items, such as telephone, television, barber services, guest meals and beds
Private nursing care
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
NOTE: – We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical impairment. We
do not cover the
dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
Extended Care Benefit:
Rehabilitative and restorative physical, occupational, speech,
respiratory therapy and skilled nursing care is limited to a combined
maximum of 90 days per calendar year, when prior approval is obtained
from Health Net of Connecticut, Inc. and when services are performed
in a
Plan inpatient facility. Up to 60 days may be used for inpatient rehabilitation
(physical, occupational, speech and respiratory therapy).
Nothing
Not covered: custodial care All charges 27
27 Page 28 29
2002 Health Net of Connecticut, Inc. 28
Section 5( c)
Hospice care You Pay
Supportive and
palliative care for a terminally ill member is covered in the home or hospice
facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the direction
of a Plan physician who certifies that the patient is in the
terminal stages
of illness, with life expectancy of approximately 6
months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when
medically appropriate Nothing 28
28 Page 29 30
2002 Health Net
of Connecticut, Inc. 29 Section 5( d)
Section 5 (d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more
serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for quick
action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
physician. In extreme emergencies, if you are unable to contact your physician,
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 should notify the Plan within 48 hours. 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 must be notified
within 48 hours or on the first working
day following your admission, unless it was not reasonably possible to notify
the Plan within that time. If you are hospitalized in a Non-Plan facility and
Plan
physicians believe care can be better provided in a Plan hospital, you will
be transferred when medically
feasible with any ambulance charges covered in
full.
Benefits are available for care from Non-Plan providers in a medical
emergency only if delay in reaching
Plan provider wold result in death,
disability or significant jeopardy to your condition.
Plan pays reasonable charges for emergency care services to the extent the
services would have been
covered if received from Plan providers.
You pay $50 per emergency room visit, $25 per urgent care center visit or $10
copay per doctor's office
visit for emergency care services that are covered
benefits by this Plan. If the emergency results in admission to a hospital, the
emergency room copay is waived.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of an
injury or unforeseen illness. If you need to be
hospitalized, the Plan must
be notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within
that time. 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. To be covered by this
Plan any follow-up care recommended by Non-Plan
providers must be approved by the Plan or Plan providers. If you are
hospitalized in Non-Plan facilities and Plan physicians believe care can be
better
provided in a Plan hospital, you will be transferred when medically feasible
with any ambulance charges
covered in full. 29
29
Page 30 31
2002
Health Net of Connecticut, Inc. 30 Section 5( d)
To be covered by
this Plan any follow-up care recommended by Non-Plan providers must be prior
authorized by the Plan.
Plan pays reasonable charges for emergency care
services to the extent the services would have been
covered if received by
Plan providers.
You pay $50 per emergency room visit, $25 per urgent care center visit or $10
copay per doctor's office visit for emergency care services that are covered
benefits by this Plan. If the emergency results in
admission to a hospital, the emergency room copay is waived.
You pay
Emergency within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center $25 per visit
Emergency care as
an outpatient or inpatient at a hospital, including doctors' services, waived if
admitted $50 per visit
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
Emergency care at an urgent care center $25 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services, waived if admitted $50 per visit
Not covered:
Elective care or non-emergency care
Emergency care
provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a 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.
Nothing
Not covered: air ambulance All charges. 30
30 Page 31 32
2002 Health Net of Connecticut, Inc. 31
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than for similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAPPROVAL OF THESE
SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive the
care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit
Diagnostic tests Nothing
Services provided by a hospital or other
facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing 31
31 Page
32 33
2002 Health Net of Connecticut,
Inc. 32 Section 5( e)
Mental health and substance abuse
benefits (Continued) You pay
Not covered: Services we
have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment plan in favor of
another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all of the following approval processes:
Your
Plan physician will request preauthorization from us for all necessary services.
The service must be approved before it is rendered to receive
coverage. You,
or a provider acting on your behalf, may call our
Preauthorization
Department at (800) 438-7886 for information. You will be notified of any
denials.
Although you are not required to obtain a referral from your PCP to see a
specialist, we recommend that you always consult your PCP first.
In this
plan, you must see Plan physicians and providers, except in the event
of a
medical emergency, or when we have authorized the services to be performed by
Non-Plan providers because the service is not available from
Plan providers.
Limitation We may limit your benefits if
you do not obtain a treatment plan. 32
32
Page 33 34
2002
Health Net of Connecticut, Inc. 33 Section 5( f)
Section 5
(f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about
how cost sharing works. Also read Section
9 about coordinating benefits with other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician or
referral doctor must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan
pharmacy, or through the Health
Net of Connecticut, Inc. mail order
supplier.
We use a formulary. The Plan uses a formulary that includes generic
and preferred name brand drugs. The Plan's Pharmacy and Therapeutics Committee
meets on a quarterly basis to review new medications
to be added to or deleted from the formulary.
Reviews for additions to
the formulary are based primarily on the following:
1. New drug therapies
introduced
2. Changes in existing drug therapies
3. Requests received
from Plan physicians
The criteria used are the safety and efficacy of the
drug, other similar products available, and its relative
cost. Deletions are
decided by the committee based on low utilization, other types of equivalent
therapy available, or negative changes in existing therapies. Your doctor can
ask for exceptions to the
formulary. Nonformulary drugs will be covered when prescribed by a Plan
doctor.
We have an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your physician may
prescribe a name brand drug from a formulary list. This list of
name brand drugs is a preferred list of drugs that we selected to meet
patient needs at a lower cost. To order a prescription drug brochure, call (877)
747-9585.
Please Note: All brand name drugs that are not listed in the preferred
drug formulary will be subject to
the highest copayment.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor and
obtained at a Plan pharmacy will be
dispensed for up to a 34-day maximum. Drugs are prescribed by Plan doctors and
dispensed in accordance with the Plan's drug formulary. You pay a $10 copayment
per prescription unit or refill for generic formulary drugs, $20 for
preferred brand name, and $35 for all
others. The cost of prescriptions
filled through the Plan's mail order supplier will be equal to 2 copayments for
a 90 days supply.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a
name brand. If you receive a name brand
drug when a Federally-approved generic drug is available, and your physician has
not specified Dispense as Written for the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic.
Why
use generic drugs? 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. 33
33 Page
34 35
2002 Health Net of Connecticut,
Inc. 34 Section 5( f)
When you have to file a claim. You
normally won't have to submit claims to us unless you receive
emergency
services from a provider who doesn't contract with us. If you do receive a bill
and need to file a claim, please send us all of the documents for your claim as
soon as possible. You must submit
claims by December 31 of the year after the year you received the service.
Either OPM or we can
extend this deadline if you show that circumstances
beyond your control prevented you from filing on time.
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
Oral contraceptive
and injectable contraceptives and contraceptive
devices including implanted
contraceptive devices, such as Norplant
Insulin
Diabetic equipment and supplies, including glucose test
tablets and
test tape, Benedict's solution or equivalent, acetone test
tablets,
insulin pumps and appurtenances, infusion devices, blood glucose
monitors, and additional diabetes equipment and supplies as listed
by the Department of Health
Disposable needles and syringes needed to
inject covered prescribed medication
Intravenous fluids and medication for home use, implantable drugs,
are
covered under Medical and Surgical benefits Growth hormones (GHT)
Fertility drugs used in connection with covered infertility
treatments,
such as IUI
Note: – We will only cover GHT when we preauthorize the treatment.
Call (877) 747-9585 for preapproval. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you
do not ask or if we determine GHT is not medically necessary, we will not cover
the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.
Note: If there is no
generic equivalent available, you will still have to pay the brand name copay.
$10 for generic drugs
$20 for preferred brand name drugs
$35 for all other covered drugs 34
34 Page 35 36
2002 Health Net
of Connecticut, Inc. 35 Section 5( f)
Covered medications and
supplies (Continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and
food supplements even if a physician prescribes or administers them
Nonprescription medicines
Drugs for which there is a
nonprescription equivalent available
Drugs obtained at a non-plan
pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Prescription drugs obtained for use in connection with drug addiction
Drugs to enhance athletic performance
Smoking cessation
drugs and medications including nicotine patches
Fertility drugs used as part of excluded infertility treatment, such as
In vitro fertilization
All Charges 35
35 Page 36 37
2002 Health Net
of Connecticut, Inc. 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.
24 hour Personal Health Advisor line Our free Personal Health Advisor
phone line is available 24 hours a day, seven days a week to answer your
health-related questions. If
you are sick or have been hurt, and are unsure
of what to do, a specially trained nurse can help you determine the most
appropriate
course of action. The 550 nurses that staff the phones average more than 15
years of clinical experience. Together, they handle 2 million
calls every
year. If you ever need help assessing an injCould not acquire words on page 38
ury or illness,
call the Personal Health Advisor line, toll-free at (800)
219-5326.
Interactive Provider
Directory
Even when you do not have access to our printed directory or to the Internet,
you can still locate a Plan physician or provider. Our
Interactive Provider Directory system via touch-tone phone enables you to
have a personalized list of local physicians or providers either
faxed to
you immediately or mailed to your home. The system will
find 100 closest
Plan Providers to the zip code you supply. To access the Interactive Provider
Directory, call toll-free, (800) 686-9847.
Disease State Management
Programs
Disease State Management programs help members manage their
chronic
conditions. When you are facing the challenges of diabetes, congestive heart
disease, asthma, glaucoma, osteoporosis, kidney
disease and other chronic conditions, we can help with our education
and
care-management program. For more information, call toll-free (800) 573-2177
Services for deaf and hearing impaired Services for the deaf and
hearing impaired can be accessed by calling (800) 263-4325 36
36 Page 37 38
2002 Health Net of Connecticut, Inc. 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 cover
hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the
patient; we do
not cover the dental procedure unless it is described below.
Be sure to
read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.
Nothing
Dental benefits
When prior approval is granted by the Health Net
of Connecticut, Inc. Medical Director, coverage for medically necessary and
appropriate
general anesthesia, nursing and related hospital services for certain dental
procedures when recommended by the treating dentist or oral surgeon and
the
member's primary care physician, providing the following conditions
are met:
the member is a child under the age of 5 who is determined by their
licensed dentist and primary care physician to have a dental
condition
of significant dental complexity that it requires certain dental procedures to
be performed in the hospital; or
the member has a developmental disability, as determined by their
primary care physician that places the member at serious risk. The expense
of such anesthesia, nursing and related hospital services shall
be deemed a covered service or medical expense.
$10 for outpatient services; nothing for inpatient services. 37
37 Page 38 39
38 Page 39 40
2002 Health Net
of Connecticut, Inc. 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 11.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency
Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or
psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be
endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or incest
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program. 39
39 Page
40 41
2002 Health Net of Connecticut,
Inc. 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, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital and In most cases, providers and facilities file
claims for you. Physicians Prescription drug benefits 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 (877) 747-9585.
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: Health Net, Formerly PHS
Health Plans
P. O. Box 981
Bridgeport, CT 06601-0981 Attention: Claims
Only
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative
operations of Government or legal incapacity, provided the
claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 40
40 Page
41 42
2002 Health Net of Connecticut,
Inc. 41 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 preapproval:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Health Net of Connecticut, Inc., One Far Mill Crossing,
Shelton, CT 06484; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports,
bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we
will send you a copy
of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630.
41
41 Page 42 43
2002 Health Net of Connecticut, Inc. 42
Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you
believe our decision was wrong, based on specific benefit provisions in
this
brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval , then call us at (877) 747-9585 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. 42
42
Page 43 44
2002
Health Net of Connecticut, Inc. 43 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full
as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
If we pay second, we will determine what the reasonable charge for
the benefit should be. After the first plan pays, we will pay either what is
left
of the reasonable charge or our regular benefit, whichever is less. We
will not pay more than the reasonable charge. If we are the secondary payer,
we may be entitled to receive payment from your primary plan.
We will always provide you with the benefits described in this brochure.
Remember: even if you do not file a claim with the other plan, you must
still tell us that you have double coverage.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65
years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring
dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free Part A
insurance. (Someone who was a Federal employee on January 1, 1983 or since
automatically qualifies.) Otherwise, if you are age 65
or older, you may be able to buy it. Contact 1-800-MEDICARE for
more
information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security
check or your retirement check.
If you are eligible for Medicare, you may
have choices in how you get your health
care. Medicare + Choice is the term
used to describe the various health plan choices available to Medicare
beneficiaries. The information in the next few pages
shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is (Part A or Part B) 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 43
43 Page
44 45
2002 Health Net of Connecticut,
Inc. 44 Section 9
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 not waive any of our copayments, coinsurance, and deductibles.
(Primary payer chart begins on next page.) 44
44 Page 45 46
2002 Health Net of Connecticut, Inc. 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) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor afamilymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare
based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to
ESRD after Medicare became
primary for you under another provision,
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or …
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee 45
45 Page
46 47
2002 Health Net of Connecticut, Inc. 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 (877) 747-9585 or visit our website
at www. health. net.
In this case, we do not waive any out of pocket costs.
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 not 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
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 If you do not have one or both Parts of
Medicare, you can still be covered Medicare Part A or Part B under the
FEHB Program. We will not require you to enroll in Medicare
Part B and, if
you can't get premium-free Part A, we will not ask you to
enroll in it. 46
46 Page 47 48
2002 Health Net of Connecticut, Inc. 47
Section 9
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 When you receive money to compensate you
for medical or hospital for injuries care for injuries or illness caused
by another person, you must reimburse
us for any expenses we paid. However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation
procedures. 47
47 Page
48 49
2002 Health Net of Connecticut,
Inc. 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.
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 Any service or supply that can be furnished
by someone who has no professional health care training or skills to a member:
(a) whose functional capacity has been reduced so significantly that he or
she is not able to function outside a protected, monitored, or
controlled
environment (whether in an institution or in the home) and;
(b) who is not
under active and specific treatment that will increase the member's functional
capacity to the extent necessary to enable the
member to function outside the protected, monitored or controlled
environment. A custodial care determination is not precluded by the fact
that a member
is under the care of a supervising or attending physician and that the
services are being ordered and prescribed to support and generally maintain
the member's comfort or ensure the manageability of the
member. Further, a custodial care determination is not precluded
because
the ordered and prescribed services and supplies are being provided or
supervised by a registered nurse, a physician assistant or
physical therapist.
Experimental or investigational services are those
services or supplies which include, but are not limited to, any diagnosis,
treatment, procedure,
facility, equipment, drugs, drug usage, devices or
supplies which are determined, in the sole discretion of Health Net of
Connecticut, Inc. to be
Experimental or Investigational. Services are
considered to be
Experimental or Investigational if any of the following
applies: The service or supply has not been formally approved by, or cannot
be lawfully marketed without the approval of the appropriate
government
regulatory body or agency, including, but not limited to, the U. S. Food and
Drug Administration, and, at the time it is
furnished, such approval has not been given; or
The written informed
consent form to be used by the treating facility or by other facilities in
studying substantially the same service or
supply, refers to such service or supply as Experimental or Investigational,
or as a research project, a study, an investigation, a
test, a trial, or
words of similar effect; or
The written informed consent form and/ or the
written protocols to be utilized by the treating facility for specific services
or supplies has
not been reviewed and/ or has not been approved by the treating facility's
Institutional Review Board, or other body serving a similar
function, or if
federal law requires such review and approval; or
The informed consent
documents and/ or the written protocols and/ or published reports or peer review
articles in authoritative medical and
scientific literature show that the service or supply is the subject of a
protocol( s) or study, including Phase I, II, or III clinical trial study,
or is otherwise under study to determine any of the following: its
maximum tolerated toxicity, its safety, its efficacy, or its overall
Experimental or
investigational services 48
48 Page 49 50
2002 Health Net of Connecticut, Inc. 49
Section 10
benefits and risks as compared with a standard means of
treatment or diagnosis.
In determining whether services or supplies are
Experimental or Investigational, Health Net of Connecticut, Inc. will evaluate
the services
with regard to the particular Illness or disease involved, and
will consider
factors which Health Net of Connecticut, Inc. determines to be
most relevant under the circumstances, such as: published reports and articles
in the authoritative medical, scientific, and peer review literature; or
written protocol( s) used by the treating facility or being used by another
facility studying substantially the same drug, device, medical treatment
or procedure.
Medical necessity Health care services or supplies for prevention,
diagnosis, or treatment which are not excluded or limited by this brochure and
which are:
(a) appropriate for, and consistent with, the symptoms and proper
diagnosis or treatment of the member's illness, injury, disease, or
condition; and
(b) provided for the diagnosis or the direct care and
treatment of the member's illness, injury, disease or condition; and
(c) not primarily for the convenience, appearance, or recreation of the
member, the member's practitioner or another; and (d) within the standards
of good medical practice within the organized
medical community; and
(e) neither Experimental or Investigational; and
(f) the most appropriate supply or level of service which can safely be
provided. For Hospital stays this means the acute care as an
inpatient is
necessary due to the type of covered services a member is receiving or the
severity of the member's condition and adequate
care cannot be received as an outpatient or in a less intensive
medical
setting Not all medically necessary and appropriate services or supplies are
covered. For additional information refer to the Benefits Sections of this
brochure.
Us/ We Us and we refer to Health Net of Connecticut, Inc.
You
You refers to the enrollee and each covered family member. 49
49 Page 50 51
2002 Health Net of Connecticut, Inc. 50 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. 50
50 Page
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2002 Health Net of Connecticut,
Inc. 51 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you joined this Plan premiums start
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 Planand 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.
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. 51
51 Page
52 53
2002 Health Net of Connecticut, Inc. 52 Section 11
You may
not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse
Enrollees,
from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity
law ends (If you
canceled your coverage or did not pay your premium, you
cannot convert);
You decided not to receive coverage under TCC or the spouse equity
law;
or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days after
you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability
Group Health Plan Coverage Act of 1996 (HIPAA) is a
Federal law that offers limited Federal protections for health coverage
availability and continuity to people who
lose employer group coverage. If you leave the FEHB Program, we will give
you a Certificate of Group Health Plan Coverage that indicates how long you
have been enrolled with us. You can use this certificate when getting health
insurance or
other health care coverage. Your new plan must reduce or eliminate waiting
periods, limitations, or exclusions for health related conditions based on
the information in the certificate, as long as you enroll within 63 days of
losing
coverage under this Plan. If you have been enrolled with us for less than 12
months, but were previously enrolled in other FEHB plans, you may also
request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB
Program. See also the
FEHB web site (www. opm. gov/ insure/ health);
refer to the "TCC and
HIPPA" frequently asked questions. These highlight
HIPAA rules, such as the requirement that Federal employees must exhaust any
TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies
you can contact for more information. 52
52 Page 53 54
2002 Health Net
of Connecticut, Inc. 53 Long Term Care Insurance
Long Term
Care Insurance Is Coming Later in 2002!
The Office of Personnel
Management (OPM) will sponsor a high-quality long term care insurance program
effective in October 2002. As part of its educational effort, OPM asks you to
consider these questions:
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.
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? 53
53 Page 54 55
2002 Health Net of Connecticut, Inc. 54 Long Term Care Insurance
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.
How can I
find out more about the
program NOW? 54
54
Page 55 56
2002
Health Net of Connecticut, Inc. 55 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 29
Allergy tests 17 Alternative treatment 21
Allogeneic (donor) bone marrow transplant 25
Ambulance 28 Anesthesia 25
Autologous bone marrow transplant 25
Blood and blood plasma 27 Breast
cancer screening 15
Casts 27 Changes for 2002 8
Chemotherapy 17
Childbirth 16
Chiropractic 21 Cholesterol tests 15
Claims 40 Coinsurance
12
Colorectal cancer screening 15 Congenital anomalies 23
Contraceptive
devices and drugs 34 Coordination of benefits 43
Covered services 12
Deductible 12
Definitions 48 Dental care 37
Diagnostic services
14 Disputed claims review 41
Donor expenses (transplants ) 25 Dressings 27
Durable medical equipment (DME) 20
Educational classes and
programs 22
Effective date of enrollment 48 Emergency 29
Experimental or investigational 39 Eyeglasses 19
Family planning
16 Fecal occult blood test 15
General Exclusions 39
Hearing services 18
Home health
services 20 Hospice care 28
Home nursing care 20 Hospital 11
Immunizations 15
Infertility
16 Inpatient Hospital Benefits 26
Insulin 34 Laboratory and pathological
services 14 Magnetic
Resonance Imagings
(MRIs) 14 Mail Order Prescription Drugs 33
Mammograms
15 Maternity Benefits 16
Medicaid 47 Medically necessary 49
Medicare 43
Mental Conditions/ Substance
Abuse Benefits 31 Newborn care 16
Non-FEHB
Benefits 38 Nurse
Licensed Practical Nurse 20 Nurse Anesthetist 27
Registered Nurse 20 Nursery charges 16
Obstetrical care 16
Occupational therapy 18
Office visits 14 Oral and maxillofacial surgery 24
Orthopedic devices 19 Out-of-pocket expenses 12
Outpatient facility care
27 Oxygen 17
Pap test 15
Physical examination 15 Physical therapy
18
Plan facilities 9 Plan providers 9
Preventive care, adult 15 Preventive
care, children 15
Prescription drugs 33 Preventive services 15
Primary
care 10 Prior approval 11
Prostate cancer screening 15 Prosthetic devices 19
Psychologist 31 Radiation therapy 17
Room and board 26 Second
surgical opinion 14
Skilled nursing facility care 27 Speech therapy 18
Specialty care 10 Splints 27
Sterilization procedures 16 Subrogation 47
Substance abuse 31 Surgery 23
Anesthesia 25 Oral 24
Outpatient
23 Reconstructive 24
Syringes 34 Temporary continuation of
coverage 51 Transplants 25
Treatment therapies 17
Vision
services 19
Well child care 15 Wheelchairs 20
Workers' compensation 47 X-rays 14 55
55
Page 56 57
2002
Health Net of Connecticut, Inc. 56
NOTES: 56
56 Page 57 58
2002 Health Net of Connecticut, Inc. 57
Summary of benefits for Health Net of Connecticut, Inc. – 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 14
Services provided by a hospital:
Inpatient.......................................................................................................
Outpatient....................................................................................................
Nothing
Nothing
26
27
Emergency benefits:
In-area
.........................................................................................................
Out-of-area
.................................................................................................
$10 per office visit; $25 per visit
to urgent care center; $50 per visit
to hospital emergency room
$10 per office visit; $25 per visit
to urgent care center; $50 per visit
to hospital emergency room
30
30
Mental health and substance abuse treatment
.......................................... Regular cost sharing. 31
Prescription
drugs...........................................................................................
$10 for generic formulary drugs; $20 for preferred brand name
drugs; $35 for
all other drugs
33
Dental Care-(as described in section 5(
h))............................................ Nothing 37
Vision
Care...................................................................................................
$10 per visit 19
Special features: Personal Health Advisor Interactive
Provider Directory
Disease State Management Programs
Services for Deaf
and Hearing Impaired
36
Protection against catastrophic costs (your out-of-pocket maximum)
................................................................ Nothing
after $1,500/ Self Only or $3,000/ Family enrollment per year
Some costs do
not count toward this protection
12 57
57
Page 58
2002 Health Net of
Connecticut, Inc. 58
2002 Rate Information for
Health Net of
Connecticut, Inc.
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 and Tool & Die employees (see RI 70-2B);
and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal
employees, postal retirees, or associate members of any postal employee
organization. Refer to the applicable FEHB Guide.
Type of
Enrollment Code
Non-Postal Premium
Biweekly Monthly
Gov't Your
Gov't Your Share Share Share Share
Postal Premium
Biweekly
USPS
Your
Share Share
All of Connecticut
High Option Self Only
High Option
Self & Family
DP1
DP2
$97.86 $50.76 $212.03 $109.98
$223.41 $191.90 $484.06
$415.78
$115.52 $33.10
$263.75 $151.56 58