Health Alliance HMO http:// www.
healthalliance. org
2002
Serving: Central, East Central, Southern and Western Illinois; Western
Indiana; and Central and Eastern Iowa
Enrollment in this Plan is limited.
You must live or work in our Geographic service area to enroll. See page 6 for
requirements.
HMO and Plus Plans-East Central Illinois Service Area
This Plan has
Excellent accreditation from NCQA. See the 2002 Guide for more
information
on accreditation.
Enrollment codes for this Plan:
FX1 Self Only FX2 Self and Family
RI 73-168
For changes in benefits
see page 8.
A Health Maintenance Organization 1
1
Page 2 3
2002 Health Alliance HMO 2 Table of Contents
Table of
Contents
Introduction………………………………………………………………….
........................................................................................
4
Plain
Language.......................................................................................................................................................................................
4
Inspector General
Advisory....................................................................................................................................................................
4
Section 1. Facts about this HMO
plan...................................................................................................................................................
6
How we pay
providers..........................................................................................................................................................
6
Your Rights
..........................................................................................................................................................................
6
Service Area
.........................................................................................................................................................................
6
Section 2. How we change for
2002......................................................................................................................................................
8
Program-wide changes
.........................................................................................................................................................
8
Changes to this Plan
.............................................................................................................................................................
8
Section 3. How you get care
.................................................................................................................................................................
9
Identification cards
...............................................................................................................................................................
9
Where you get covered care
.................................................................................................................................................
9
Plan providers
................................................................................................................................................................
9
Plan
facilities..................................................................................................................................................................
9
What you must do to get covered
care..................................................................................................................................
9
Primary care
...................................................................................................................................................................
9
Specialty care
.................................................................................................................................................................
9
Hospital care
................................................................................................................................................................
10
Circumstances beyond our control
.....................................................................................................................................
10
Services requiring our prior
approval.................................................................................................................................
10
Section 4. Your costs for covered
services..........................................................................................................................................
12
Copayments..................................................................................................................................................................
12
Deductible
....................................................................................................................................................................
12
Coinsurance..................................................................................................................................................................
12
Your out-of-pocket
maximum............................................................................................................................................
12
Section 5.
Benefits...............................................................................................................................................................................
13
Overview
............................................................................................................................................................................
13
(a) Medical services and supplies provided by
physicians and other health care
professionals.................................... 14
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ................................ 23
(c) Services provided by a hospital or other facility, and
ambulance services..............................................................
27
(d) Emergency services/ accidents
.................................................................................................................................
29
(e) Mental health and substance abuse benefits
............................................................................................................
31
(f) Prescription drug benefits
........................................................................................................................................
33 2
2 Page 3 4
2002 Health Alliance HMO 3 Table of Contents
(g) Special features
.......................................................................................................................................................
36
Flexible benefits option
Services for the deaf and hearing impaired
Reciprocity Benefit
(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
........................................................................................................................................
45
TRICARE/ Workers' Compensation/ Medicaid
..................................................................................................................
46
Other Government agencies
...............................................................................................................................................
46
When others are responsible for injuries
............................................................................................................................
46
Section 10. Definitions of terms we use in this
brochure
.....................................................................................................................
47
Section 11. FEHB facts
.......................................................................................................................................................................
49
Coverage information
.......................................................................................................................................................
49
No pre-existing condition
limitation.........................................................................................................................
49
Where you get information about enrolling in the
FEHB
Program..........................................................................
49
Types of coverage available for you and your family
..............................................................................................
49
When benefits and premiums start
...........................................................................................................................
50
Your medical and claims records are
confidential....................................................................................................
50
When you retire
.......................................................................................................................................................
50
When you lose
benefits.....................................................................................................................................................
50
When FEHB coverage
ends......................................................................................................................................
50
Spouse equity coverage
...........................................................................................................................................
50
Temporary Continuation of Coverage
(TCC)..........................................................................................................
50
Converting to individual coverage
..........................................................................................................................
51
Getting a Certificate of Group Health Plan Coverage
.............................................................................................
51
Long term care insurance is coming later in
2002................................................................................................................................
52
Index.....................................................................................................................................................................................................
53
Summary of benefits
............................................................................................................................................................................
54
Rates.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Health Alliance HMO 4 Introduction/ Plain Language/ Advisory
Introduction
Health Alliance HMO 102 E Main Street
Urbana, IL 61801
This brochure describes the benefits of Health
Alliance Medical Plans, Inc., on behalf of itself and Health Alliance Midwest,
Inc., its wholly owned subsidiary, under our contract (CS 1980) 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 Alliance HMO.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions about how to
improve the structure of this brochure,
let OPM know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the
Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900
E. Street NW, Washington, DC 20415-3650.
Inspector General Advisory
Fraud increases the cost of health care
for everyone. If you suspect that a physician, pharmacy, or hospital has charged
you for services you did not receive, billed you
twice for the same service,
or misrepresented any information, do the following:
Call the provider and
ask for an explanation. There may be an error. If the provider does not resolve
the matter, call us at 800/ 851-3379 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
Stop health care fraud! 4
4 Page 5 6
2002 Health
Alliance HMO 5 Introduction/ Plain Language/ Advisory
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 Alliance HMO 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 practices when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, 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.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may
get information about us, our networks, providers, and facilities. OPM's FEHB
website (www. opm. gov/ insure) lists the specific types of information that
we must
make available to you. Some of the required information is stated
below.
Health Alliance is a unique managed care organization in that
physicians own it. Health Alliance Medical Plans, Inc., is the corporate
successor to CarleCare, Inc., a not-for-profit health maintenance organization
founded by one of the largest multi-specialty group
practices in the nation – Carle Clinic Association, P. C., in Urbana,
Illinois. CarleCare HMO enrolled its first member in March 1980 and five years
later became a federally qualified HMO. In 1989, CarleCare was reorganized as a
for-profit domestic insurance
company owned by Carle Clinic and renamed
Health Alliance Medical Plans. As such, Health Alliance can underwrite and
administer a full range of managed care products.
Today, Health Alliance is the largest managed care organization based in
downstate Illinois, covering most of central and east central Illinois, as well
as numerous counties in southern Illinois and central Iowa. The corporate office
is located in Urbana, Illinois.
Health Alliance provides convenient access
to health care with a large network of quality providers. Physicians and
specialists as well as clinics, hospitals, pharmacies and other providers were
selected to be part of the Health Alliance provider network because of their
reputation for excellence.
If you want more information about us, call
800/ 851-3379, or write to Health Alliance Medical Plans, 102 East Main
Street, Urbana, IL 61801. You may also contact us by fax at 217/ 255-4699 or
visit our website at http:// www. healthalliance. org.
Service Area
To enroll in this Plan, you must live or work in one
of our service areas. A service area is a geographic region consisting of one or
more counties. The county in which you live determines your service area and
subsequently your provider network. When you enroll
in the Plan, you will be
required to select a primary care physician in your service area. This physician
will coordinate all of your medical care.
Should you require specialty or ancillary care, your primary care physician
will refer you to a provider in your service area. If you require care that is
not available within your service area, your physician will request an
out-of-network referral from a Plan medical
director. The Plan will notify
the referring physician and you in writing of the decision. Please be sure that
the out-of-network service has been approved prior to seeking out-of-network
services in order to assure coverage. The Plan's service areas are listed below.
6
6 Page 7 8
2002 Health Alliance HMO 7 Section 1
Our Illinois service areas are:
Decatur Service Area (Decatur
St. Mary's Network): Cass, Christian, Greene, Jersey, Logan, Macon, Macoupin,
Mason, Menard, Montgomery, Morgan, Sangamon, Scott
East Central Illinois Service Area: Champaign, Clark, Coles, Cumberland,
DeWitt, Douglas, Edgar, Effingham, Fayette, Ford, Iroquois, Jasper, Livingston,
McLean, Moultrie, Piatt, Shelby, Tazewell, Vermilion, Woodford
Indiana
counties included: Fountain, Vermillion, Warren
Macomb Service Area:
Hancock, Henderson, McDonough, Schuyler, Warren
Quad Cities Service Area:
Henry, Mercer, Rock Island Iowa county included: Scott
Southern Illinois Service Area: Franklin, Gallatin, Hardin, Jackson, Johnson,
Perry, Randolph, Saline, Union, Washington, Williamson
Springfield Service
Area: Cass, Christian, Greene, Jersey, Logan, Macon, Macoupin, Mason, Menard,
Montgomery, Morgan, Sangamon, Scott
Our Iowa service area is:
Central Iowa Service Area: Boone, Calhoun, Carroll, Greene, Hamilton,
Hardin, Marshall, Story, Tama, Webster, Wright
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 Alliance HMO 8 Section 2
Section 2. How we change for
2002
Do not rely on these change descriptions; this page is not an
official statement of benefits. For that, go to Section 5 Benefits. Also, we
edited and clarified language throughout the brochure; any language change not
shown here is a clarification that does not change
benefits.
Program-wide changes
We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will
increase by 14. 7% for Self Only or 12. 2% for Self and Family.
We clarified the Preventive care, adult benefits by removing the entry for
blood lead level testing for adults because it is a test more typically done for
children. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We clarified the Family planning and Infertility benefits by
providing more examples of covered and not covered benefits. (Section 5( a))
We now cover routine screening for chlamydial infection. (Section 5( a))
We changed speech therapy benefits by removing the requirement that services
must be required to restore functional speech. (Section 5( a))
We clarified Surgical procedures to show that we cover a comprehensive range
of services, such as operative procedures. (Section 5( b))
We now cover
certain intestinal transplants. (Section 5( b))
We clarified the brochure to
show why we think you should use generic drugs whenever possible. We moved other
language around within the Prescription drugs section but didn't change its
meaning. (Section 5( f))
Your Emergency Room copayment will increase from $50 to $100.
We
clarified the Medicare Primary Payer Chart to explain how we coordinate benefits
for former spouses. (Section 9)
We clarified other language about
coordinating benefits with Medicare. (Section 9)
Decatur Memorial Hospital
and the Decatur Memorial Network are no longer offered. The Decatur St. Mary's
Network, including Decatur St. Mary's Hospital, is still being offered to
members.
We added a new Section after Section 11 to discuss the Long Term Care
Insurance Program that is coming in 2002.
The Central Iowa Service Area is
now under the Enrollment Codes FX1 and FX2. 8
8
Page 9 10
2002
Health Alliance HMO 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 800/ 851-3379.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments or coinsurance, 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.
It depends on the type of
care you need. First, you and each family member must choose a primary care
physician. This decision is important since your primary care physician
provides or arranges for most of your health care.
Primary care
Your primary care physician can be a family practitioner, internist, or
pediatrician. Your primary care physician will provide most of your health care,
or give you a referral to see
a specialist.
If you want to change
primary care physicians or if your primary care physician leaves the Plan, call
us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain number of
visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may
receive optometric care
for routine eye exams and females may see a Woman's
Principal Health Care Provider without referral from a primary care physician.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will work with the specialist to
develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals. Your primary care
physician will use our criteria
when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).
What you must do to get covered care 9
9
Page 10 11
2002
Health Alliance HMO 10 Section 3
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.
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 800/ 851-3379. 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.
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.
Services requiring our prior approval 10
10
Page 11 12
2002
Health Alliance HMO 11 Section 3
We call this review and approval
process preauthorization. Your physician must obtain our approval before sending
you to a provider outside your service area or to a non-Plan
provider.
Before giving approval, we consider if the service is medically necessary, and
if it follows generally accepted medical practice.
Preauthorization is also required for durable medical equipment, home care,
home infusion services, hospice care, infertility services, organ transplants,
pharmaceutical
recombinant biologicals, prosthetic devises, reconstructive
surgery, and spinal manipulations for assurance that the service, procedure, or
supply is medically necessary
and will be covered.
Medical necessity
determination of covered health care services under this Plan is subject to the
medical policies presently in effect and adopted or amended by Health Alliance
HMO. A copy of the medical policies and procedures relevant to a pending
coverage decision will be made available to members upon written request. 11
11 Page 12 13
2002 Health Alliance HMO 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 $100 per admission.
Deductible We do not have a deductible.
Coinsurance
Coinsurance is the percentage of our negotiated fee that you must pay for
your care.
Example: In our Plan, you pay 20% of our allowance for durable
medical equipment.
After your copayments and/ or coinsurance total $1,500
per person or $3, 000 per family enrollment in any calendar year, you do not
have to pay any more for covered services.
However, copayments or
coinsurance for the following services do not count toward your out-of-pocket
maximum, and you must continue to pay copayments or coinsurance for
these
services: Durable medical equipment
Prosthetic devices Prescription drugs
Vision care
Be sure to keep accurate records of your copayments or
coinsurance since you are responsible for informing us when you reach the
maximum.
Your catastrophic protection out-of-pocket maximum for
deductibles,
coinsurance, and copayments 12
12 Page 13 14
2002 Health Alliance HMO 13 Section 5
Section 5.
Benefits --OVERVIEW
(See page 8 for how our benefits changed this
year and page 54 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 800/ 851-3379 or visit our
website at www. healthalliance. org.
(a) Medical services and supplies
provided by physicians and other health care professionals
....................................................... 14-22
Diagnostic and
treatment services Lab, X-ray, and other diagnostic tests
Preventive care,
adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and
occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision
services (testing, treatment, and supplies) Foot care
Orthopedic and
prosthetic devices Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals................................................. 23-26
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..............................................................................
27-28
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
Services for deaf and hearing impaired Reciprocity benefit
(h) Dental benefits
..............................................................................................................................................................................
37
(i) Non-FEHB benefits available to Plan members
...........................................................................................................................
38
Summary of benefits
............................................................................................................................................................................
54 13
13 Page 14
15
2002 Health Alliance HMO 14 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
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 physician, nurse practitioner, nurse, or
physician's assistant
In physician's office
$10 per office visit
Professional services of physicians
In an urgent care center
Office
medical consultations
Second surgical opinion
$10 per office visit
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
Nothing if you are inpatient in a hospital or skilled nursing facility. You
pay only your
hospital admission copayment.
At home $20 per visit 14
14 Page 15 16
2002 Health
Alliance HMO 15 Section 5( a)
Lab, X-ray and other diagnostic
tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap
tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing. You pay only your $10 office visit copayment.
Preventive care, adult
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
Nothing. You pay only your $10 office visit copayment.
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Nothing. You pay only your $10 office visit copayment.
Routine pap test
Nothing. You pay only your $10 office visit copayment.
Routine mammogram – covered for women age 35 and older, as follows:
From
age 35 through 39, one during this five year period
From age 40 through 64,
one every calendar year
At age 65 and older, one every two consecutive
calendar years
Nothing. You pay only your $10 office visit copayment.
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-diphtheria (Td) booster –
once every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing. You pay only your $10 office visit copayment. 15
15 Page 16 17
2002 Health Alliance HMO 16 Section 5( a)
Preventive care, children
Childhood immunizations recommended
by the American Academy of Pediatrics Nothing. You pay only your $10 office
visit copayment.
Well-child care charges for routine examinations, immunizations and care
(through age 22)
Examinations, such as:
Eye exams through age 17 to
determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)
$10 per office visit
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 10 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).
$50 copayment per pregnancy. Care provided by specialists during prenatal
period is subject to the $10 office visit copayment.
Not covered: Routine sonograms to determine fetal age, size or sex All
charges. 16
16 Page
17 18
2002 Health Alliance HMO 17
Section 5( a)
Family planning
A broad range of voluntary
family planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Injectable contraceptive drugs
(such as Depo Provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE:
We cover oral contraceptives under the prescription drug benefit.
Nothing. You pay only your $10 office visit copayment.
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges.
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
intravaginal insemination (IVI) intracervical insemination
(ICI)
intrauterine insemination (IUI) Assisted reproductive technology (ART)
procedures, such as:
in vitro fertilization embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.
$10 per office visit
Not covered:
Non-medical cost of donor sperm
Non-medical cost of donor egg
Services and supplies
related to excluded ART procedures
Infertility services after
voluntary sterilization
All charges. 17
17 Page 18 19
2002 Health
Alliance HMO 18 Section 5( a)
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 You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow
transplants is limited to those transplants listed under
Organ/ Tissue Transplants on 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: – We will only cover GHT when we
preauthorize the treatment. Call 800/ 851-3379 for preauthorization. We will ask
you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will
only cover GHT
services from the date you submit the information. If you do not ask or if we
determine GHT is not medically necessary, we
will not cover the GHT or
related services and supplies. See Services requiring our prior approval
in Section 3.
$10 per office visit
Physical and occupational therapies
A combined total of 60 visits
per condition per contract year for the services of each of the following:
qualified physical therapists and occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to illness or injury.
Cardiac
rehabilitation following a heart transplant, bypass surgery or a myocardial
infarction, is provided for up to 24 sessions in 12
consecutive weeks or
less for Phase II. Phase I rehab is provided in the hospital after surgery.
$10 per office visit
$10 per outpatient visit
Nothing per visit
during covered inpatient admission.
Physical and occupation therapies – continued on next page 18
18 Page 19 20
2002 Health Alliance HMO 19 Section 5( a)
Physical and occupational therapies, (continued)
Not
covered:
long-term rehabilitative therapy
exercise
programs
phase III cardiac rehabilitation
All charges.
Speech therapy
60 visits per condition per contract year $10 per
office visit
$10 per outpatient visit
Nothing per visit during covered inpatient admission.
Hearing services (testing, treatment, and supplies) You pay
First
hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered: all other hearing testing
hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit
Eye exam to determine the need for vision correction for children through age
17 (see Preventive care, children) $10 per office visit
Annual eye
refractions if you are age 18 and over $20 per office visit
Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
All charges. 19
19 Page 20 21
2002 Health
Alliance HMO 20 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per 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
Artificial limbs and eyes; stump
hose
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c)
for payment information. See 5( b)
for coverage of the surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
20% coinsurance
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 5 years after the last one we
covered, unless is irreparable and member has properly
maintained it.
All charges. 20
20 Page 21 22
2002 Health
Alliance HMO 21 Section 5( a)
Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, up to
maximum allowable benefit, such as oxygen and dialysis equipment. Under this
benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose
monitors; and
insulin pumps, lancets, and lancing devices.
Note: Call us
at 800/ 851-3379 as soon as your Plan physician prescribes this equipment. We
will arrange with a health care provider to rent or sell
you durable medical equipment at discounted rates and will tell you more
about this service when you call.
20% coinsurance
Home health services You pay
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.
$10 per office visit
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.
Chiropractic
Manipulation of the spine and extremities is covered
if referred by the Primary Care Physician and approved by a Medical Director.
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application are covered
as rehabilitative
therapy services and are subject to a limit of 60 treatments per condition per
calendar year. X-rays and other
diagnostic testing are covered under
diagnostic and treatment services and must be provided by a participating
provider.
Note: Spinal manipulations and mobilizations are covered when long-term
significant improvement can be expected from such treatment.
$10 per office visit 21
21 Page 22 23
2002 Health
Alliance HMO 22 Section 5( a)
Alternative treatments You pay
Biofeedback – under certain circumstances $10 per office visit
Not covered: naturopathic services
hypnotherapy
acupuncture
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as
prescription drugs
Diabetes self-management
$10 per office visit 22
22 Page 23 24
2002 Health
Alliance HMO 23 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (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 if
medical criteria set by plan
is met. Insertion of internal prosthetic
devices. See 5( a) – Orthopedic
and prosthetic devices for device coverage
information. Voluntary sterilization
Treatment of burns Note: Generally, we
pay for internal prostheses (devices) according to
where the procedure is
done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits
for insertion of the pacemaker.
$10 per office visit
Nothing if you are an inpatient in a hospital. You
pay only your hospital admission
copay.
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 Alliance HMO 24 Section 5( b)
Reconstructive surgery Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast; treatment
of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours
after the procedure.
$10 per office visit
Nothing if you are an inpatient in a hospital. You
pay only your hospital admission copay.
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.
$10 per office visit
Nothing if you are an inpatient in a hospital. You
pay only your hospital admission copay.
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 Alliance HMO 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.
Transportation, lodging and meals for the transplant recipient and a
companion for travel to and from a Plan designated center of excellence
is
covered. If the patient is a minor, transportation and reasonable and necessary
lodging and meal costs for two persons who travel with the
minor are
included. Expenses for meals and lodging are reimbursed at the per diem rates
established by the Internal Revenue Service.
Nothing. You pay only your hospital admission copayment and your professional
per office visit copayment.
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
Experimental organ or tissue
transplants
All charges. 25
25 Page 26 27
2002 Health
Alliance HMO 26 Section 5( b)
Anesthesia You pay
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
Nothing. You pay only your
$10 per office visit copayment. 26
26 Page 27 28
2002 Health
Alliance HMO 27 Section 5( c)
Section 5 (c). Services provided
by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by the
facility (i. e., hospital or surgical center) or ambulance service for your
surgery or care. Any costs associated with the professional charge
(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR
PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
$100 per admission
Other hospital services and supplies, such as: Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products Blood or blood plasma
Dressings, splints, casts, and sterile tray
services Medical supplies and equipment, including oxygen
Anesthetics,
including nurse anesthetist services 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, schools Personal comfort items, such as telephone,
television, barber
services, guest meals and beds Private nursing
care
All charges. 27
27 Page 28 29
2002 Health
Alliance HMO 28 Section 5( c)
Outpatient hospital or
ambulatory surgical center
Operating, recovery, and other treatment
rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma
Pre-surgical testing
Dressings, casts, and sterile tray services Medical
supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We
cover hospital services and supplies related to dental procedures when
necessitated by a non-dental physical impairment. We
do not cover the dental
procedures.
Nothing
Not covered: administrative costs related to the processing and
storage of blood from
a person you designate as a donor.
All charges.
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): up to 120 days per contract year Nothing
Not covered: custodial care All charges.
Hospice care
Supportive and palliative care for terminally ill member is covered in the
home or hospice facility. Services include inpatient or outpatient
care and
family counseling; these services are provided under the direction of a Plan
doctor who certifies that the patient is in the terminal
stages of illness,
with a life expectancy of approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically
appropriate Nothing 28
28 Page
29 30
2002 Health Alliance HMO 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 doctor.
In extreme emergencies, if you are unable to contact your doctor, consider 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. Your or a family member
should notify the Plan within 48 hours after care begins
unless it was not
reasonably possible to do so. It is your responsibility to ensure that the Plan
has been timely notified.
If you need to be hospitalized, the Plan must be
notified within 48 hours after care begins 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 the Plan
doctors believe care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges covered full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary service that is immediately required due to illness or
unforeseen injury.
If you need to be hospitalized, the Plan must be notified
within 48 hours after care begins or on the first working day following your
admission, unless it was not reasonable possible to notify the Plan within that
time. If a Plan doctor believes
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, follow-up care recommended by non-Plan providers
must be approved by the Plan or provided by Plan doctors. 29
29 Page 30 31
2002 Health Alliance HMO 30 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient
or inpatient at a hospital, including doctors' services
Note: If admitted, the ER copay is waived and you would pay the $100
inpatient hospital admission copay.
$10 per office visit
$10 per office visit
$100 per emergency room
visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
Note: If admitted, the ER copay is covered and you would pay the $100
inpatient hospital admission copay.
$10 per office visit
$10 per office visit
$100 per emergency room
visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing 30
30 Page 31 32
2002 Health Alliance HMO 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 PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit
Diagnostic tests Nothing
Mental health and substance abuse benefits
-continued on next page 31
31 Page 32 33
2002 Health
Alliance HMO 32 Section 5( e)
Mental health and substance
abuse benefits (continued) You pay
Services provided by a
hospital or other facility
Services in approved alternative care settings
such as partial
hospitalization, half-way house, residential treatment,
full-day hospitalization, facility based intensive outpatient treatment
$100 per admission
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order us
to pay or provide one
clinically appropriate treatment plan in favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
Except in a medical emergency or when a primary care doctor has designated
another doctor to see patients when he or she is unavailable, you must contact
your primary
care doctor for a referral before seeing any other doctor or
obtaining specialty services. Referral to a participating specialist in your
service area is given at the primary care
doctor's discretion, if
specialists or consultants are required beyond those participating in the Plan,
a Plan medical director must make the approval.
A list of participating mental health/ substance abuse providers can be found
in the Plan's provider directory for your service area or you may contact the
customer service
department at 800/ 851-3379 to see which mental health/
substance abuse providers participate with the plan in your service area.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 32
32 Page
33 34
2002 Health Alliance HMO 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 Plan physician in your service
area or a referral doctor must write the prescription.
Where you can obtain them. You must fill the prescription at a Plan
pharmacy
We use a formulary. The Plan has a tiered pharmacy copayment
structure for each 30-day supply. To keep your costs as low as possible, we ask
that you and your physician select appropriate medications from the
list.
We have an open formulary. However, the Plan recognizes the value
of using FDA-approved generic drugs whenever medically appropriate. For this
reason, you will always pay the lowest copayment for generic
drugs. If your physician believes a name brand product is necessary or there
is no generic available, your physician may prescribe a brand name drug from a
formulary list. This list of brand name drugs is a preferred
list of drugs
that we selected to meet patient needs at a lower cost. When a generic drug
doesn't exist, brand name drugs that are not on our preferred list require the
highest copayment level. To order a prescription drug
brochure, call 800/ 857-3379. Our
prescription drug formulary list is also available on our web site, www.
healthalliance. org.
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 30-day supply or manufacturer's standard package.
Manufacturer's
standard package includes, but is not limited to:
Topical cream, solution,
gel, or ointment
Otic, ophthalmic or nasal preparation, nasal or oral
inhaler
Three (10ml) vials of insulin
Antibiotic suspensions
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.
Prescriptions cannot be refilled before 75% of the previously dispensed
supply should have been consumed if taken as prescribed.
Why use generic
drugs? Generic drugs offer a safe and cost-effective way to reduce your
out-of-pocket expenses. The U. S. Food and Drug Administration sets quality
standards to ensure that these drugs have the
same active ingredients and
are equivalent in strength and dosage to the brand name drug. Generic drugs can
be expected to produce the same effect as the comparable brand name drug.
Generic drugs cost less because
companies that make them do not have to
recover the enormous costs of the research and development required to create
the original brand name drug.
When you have to file a claim. If you have to pay out-of-pocket for a
prescription because you do not have your ID card, please contact our Customer
Service Department at 800/ 851-3379 for a claim form. 33
33 Page 34 35
2002 Health Alliance HMO 34 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:
Prescription drugs prescribed by a Plan or referral doctor and obtained at a
Plan pharmacy will be dispensed for up to a 30-day
supply or manufacturer's
standard package. You pay a $7 copay per prescription unit or refill for generic
drugs, a $14 copay for brand
name drugs on the Plan's formulary and a $25
copay for brand name drugs that are not on the Plan's formulary. If the
physician
allows substitution and the member prefers a brand name drug on
the formulary instead of the generic (if available), the member pays
$7 plus
the difference in cost between the generic and the brand name drug. If the
physician does not allow substitutions, the
member will pay the $14 copay.
Drugs and medicines that by Federal law of the United States
require a
physician's prescription for their purchase except those listed as Not
covered.
Insulin Disposable needles and syringes for the administration
of covered
medications Drugs for sexual dysfunction (when the following
conditions are
met and preauthorized by the Plan) Must be medically
necessary
Member must be 18 years or older Covered quantity limited to four
(4) tablets per 30 day period
Member cannot be on nitrates No coverage for
women
Contraceptive drugs and devices Certain prescriptions drugs are
covered under the medical benefits
of this Plan and are not paid for at the
dispensing pharmacy. These include, but are not limited to: immunization agents,
antigens,
allergy and biological sera, drugs or drug products derived from
blood or blood plasma, radiologicals and pharmaceutical
recombinant
biologicals (i. e., Interferon, Erythropoieten, Human Growth Hormone, etc.)
Some prescription drugs require preauthorization from a Plan medical
director and certain criteria to be met by the member. The
member's
physician must contact the Plan in order to obtain preauthorization. To accord
with changes in medical technology,
the Plan maintains a list of
pharmaceuticals that require preauthorization. This list is available to the
member upon request.
Failure to obtain preauthorization may result in the
dispensing pharmacy requiring personal payment from the member.
$7 per generic
$14 per brand name on formulary
$25 per brand name
non-formulary
Note: If there is no generic equivalent available, you will still have to pay
the
brand name copay.
Covered medications and supplies --continued on next page 34
34 Page 35 36
2002 Health Alliance HMO 35 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a
non-Plan pharmacy; except for out-of-area emergencies
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription medicines
Drugs for which
there is a nonprescription equivalent available
Medical supplies such
as dressings and antiseptics
All charges. 35
35 Page 36 37
2002 Health
Alliance HMO 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.
Services for deaf and hearing impaired TDD (217) 337-8137
Reciprocity benefit The Plan officers a reciprocity program for family
members living temporarily away from home in an area serviced by the Plan. Under
this program, family members living away can receive coverage for many services
normally covered
only in the home network, such as routine care and
diagnostic procedures. For additional information on this program, or to enroll
a family member, call the
Customer Service Department at 800/ 851-3379. 36
36 Page 37 38
2002 Health Alliance HMO 37 Section 5( i)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but
not replace) sound natural teeth. The need for these services must
result from an accidental injury.
Nothing
Dental benefits
We have no other dental benefits 37
37 Page 38 39
2002 Health Alliance HMO 38 Section 5( j)
Section 5 (j). Non-FEHB benefits available to Plan members
Medicare prepaid plan enrollment This Plan offers Medicare recipients
the opportunity to enroll in the Plan through Medicare. As indicated on page 45,
annuitants and former
spouses with FEHB coverage and Medicare Part B may
elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one
is available in their area. They may then re-enroll in the FEHB Program.
Most Federal annuitants have Medicare Part A. Those
without Medicare Part A
may join this Medicare prepaid plan, but will probably have to pay for hospital
coverage in addition to the Part B
premium. Before you join the plan, ask
whether the plan covers hospital benefits and, if so, what you will have to pay.
Contact your
retirement system for information on dropping your FEHB
enrollment and changing to a Medicare prepaid plan. Contact the Plan at 800/
965-4022
for information on the Medicare prepaid plan and the cost of that
enrollment.
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed claim about them. Fees you pay for
these services do not count toward FEHB deductibles or out-of-pocket
maximums. 38
38 Page
39 40
2002 Health Alliance HMO 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.
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 or physical health of the mother is in imminent
danger;
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 Alliance HMO 40
Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment or coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form. Facilities will file on the UB-92 form.
For claims
questions and assistance, call us at 800/ 851-3379.
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
Alliance Medical Plans, 102 East Main Street, Urbana, IL 61801.
Prescription drugs All Plan Pharmacies will file your claim
electronically with you only being responsible for your copayment. However, if
for any reason you had to pay for your prescription out-of-
pocket, please
call the Customer Service Department at 800/ 851-3379 for a claim form.
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 Alliance HMO 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 preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: Health Alliance Medical Plans,
102 East Main St, Urbana, IL 61801 and
(c) Include a statement about why you
believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial – go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us – if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 2, 1900 E Street, NW, Washington, DC 20415-3630. 41
41 Page 42 43
2002 Health Alliance HMO 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 800/ 851-3379 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 2 at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 42
42
Page 43 44
2002
Health Alliance HMO 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.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was
a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if
you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement
check.
If you are eligible for Medicare, you may have choices
in how you get your health care. Medicare + Choice is the term used to describe
the various health plan choices available
to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and is
the way most people
get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay
your share. Some things
are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your care
must continue to be
authorized by your Plan primary care physician and
precertified as required. We will waive copayments and coinsurance on all
services except prescription drugs if you use
plan providers and follow plan
rules (Primary payer chart begins on next page.)
The Original Medicare Plan (Part A or Part B) 43
43 Page 44 45
2002 Health Alliance HMO 44 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 …
OriginalMedicare This Plan
1) Are anactiveemployeewith
theFederalgovernment(including whenyouora familymemberare
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 44
44
Page 45 46
2002 Health Alliance HMO 45 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 800/ 851-3379.
We waive some costs when you have the Original Medicare Plan – When
Original Medicare is the primary payer, we will waive some out-of-pocket costs,
as follows:
Medical services and supplies provided by physicians and other health care
professionals. If you are enrolled in Medicare Part B, we will waive
copayments and coinsurance.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a Medicare managed care plan.
These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you can only go to doctors, specialists, or hospitals that
are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800/ 633-4227) or at www. medicare.
gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You
may enroll in our Medicare managed care plan and also remain enrolled in our
FEHB plan. In this case, we do waive
any of our copayments or coinsurance
for your FEHB coverage.
This Plan and another plan's Medicare managed
care plan: You may enroll in another plan's Medicare managed care plan and
also remain enrolled in our FEHB plan.
We will still provide benefits when
your Medicare managed care plan is primary, even out of the managed care plan's
network and/ or service area (if you use our Plan
providers), but we will
not waive any of our copayments or coinsurance. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the
Original Medicare Plan or in a Medicare managed care plan so we can
correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your Medicare managed care plan premium.) For information
on suspending your FEHB
enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next Open Season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare Part B
and, if you can't
get premium-free Part A, we will not ask you to enroll in
it.
If you do not enroll in Medicare Part A or Part B 45
45 Page 46 47
2002 Health Alliance HMO 46 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, or Federal Government are responsible for your care
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries 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. 46
46 Page
47 48
2002 Health Alliance HMO 47
Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same
year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Custodial care means services designed to help beneficiaries meet the needs
of daily living whether they are disabled or not. These services include help
in: a) walking or
getting in and out of bed; b) personal care such as
bathing, dressing, eating, preparing special diets; and/ or c) taking medication
which the beneficiary would normally be able
to take without help.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for those services. See page 12.
The Plan considers factors which it 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 protocols used
by the treating facility or being used by another facility studying
substantially the same drug, device, or medical
treatment. This Plan also
considers federal and other government agency approval as essential to the
treatment of an injury or illness by but not limited to the following:
American Medical Association, U. S. Surgeon General, U. S. Department of
Public Health, the Food and Drug Administration, or the National Institutes of
Health.
Group health coverage Any group arrangement that provides a member
with hospital, medical, surgical, or dental benefits and that consists of
employer-sponsored group insurance, association
sponsored group prepayment
coverage, coverage under labor-management trusteed plans, employer organization
plans, or employee benefit organizations.
Medical necessity A service or supply which is required to identify or
treat a member's condition and is: appropriate and necessary for, and consistent
with the symptom or diagnosis and
treatment or distinct improvement of an
illness or injury; and adequate and essential for the evaluation or treatment of
a disease, condition or
illness; and can reasonably be expected to improve
the member's condition or level of
functioning; and conforms with standards
of good medical practice, uniformly recognized and
professionally endorsed
by the general medical community at the time it is provided; and
not mainly
for the convenience of the member, a physician or other provider; and the most
appropriate medical service, supply or level of care, which can safely be
provided. When applied to inpatient care, it further means that the member's
medical symptoms or condition require that the services cannot be safely
provided to the
member as an outpatient.
Experimental or investigational services 47
47 Page 48 49
2002 Health Alliance HMO 48 Section 10
Plan allowance Plan allowance is the amount we use to determine
our payment and your coinsurance for covered services. Plans determine their
allowances in different ways. We determine our
allowance as follows: plan
allowance is based on the reasonable and customary charge. Preferred providers
accept the Plan allowance as payment in full.
Us/ We Us and we refer to Health Alliance Medical Plans.
You
You refers to the enrollee and each covered family member. 48
48 Page 49 50
2002 Health Alliance HMO 49 Long Term Care Insurance
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had before you enrolled
limitation 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 can answer your
about enrolling in the questions, and give you a Guide to Federal
Employees Health Benefits Plans, brochures
FEHB Program 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 you, your spouse, for you and your family and
your unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes coverage for.
Under certain circumstances, you may also continue coverage for a disabled child
22 years of age or
older who is incapable of self-support.
If you have a
Self Only enrollment, you may change to a Self and Family enrollment if you
marry, give birth, or add a child to your family. You may change your enrollment
31
days before to 60 days after that event. The Self and Family enrollment
begins on the first day of the pay period in which the child is born or becomes
an eligible family
member. When you change to Self and Family because you
marry, the change is effective on the first day of the pay period that begins
after your employing office receives your
enrollment form; benefits will not
be available to your spouse until you marry.
Your employing or retirement
office will not notify you when a family member is no longer eligible to
receive health benefits, nor will we. Please tell us immediately when
you
add or remove family members from your coverage for any reason, including
divorce, or when your child under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another FEHB
plan. 49
49 Page
50 51
2002 Health Alliance HMO 50 Long Term Care Insurance
Temporary continuation of
coverage (TCC)
When benefits and The benefits in this brochure are effective on
January 1. If you joined this plan during premiums start 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 the following records are confidential
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
Law enforcement officials when investigating and/ or
prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse
equity If you are divorced from a Federal employee or annuitant, you may not
continue to get coverage benefits under your former spouse's enrollment.
But, you may be eligible for your own
FEHB coverage under the spouse equity law. If you are recently divorced or
are anticipating a divorce, contact your ex-spouse's employing or retirement
office to get RI
70-5, the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage
choices.
If you leave Federal
service, or if you lose coverage because you no longer qualify as a family
member, you may be eligible for Temporary Continuation of Coverage (TCC).
For example, you can receive TCC if you are not able to continue your FEHB
enrollment after you retire, if you lose your job, if you are a covered
dependent child and you turn 22
or marry, etc.
You may not elect TCC if
you are fired from your Federal job due to gross misconduct.
Enrolling in
TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees,
from your employing or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll. 50
50
Page 51 52
2002 Health Alliance HMO 51 Long Term Care Insurance
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity law
ends (If you canceled your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days after you receive
this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us
within 31 days
after you are no longer eligible for coverage.
Your
benefits and rates will differ from those under the FEHB Program; however, you
will not have to answer questions about your health, and we will not impose a
waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a Federal Group Health Plan Coverage
law that offers limited Federal protections for health coverage availability
and continuity
to people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have
been enrolled with us. You can use this
certificate when getting health insurance or other health care coverage. Your
new plan must reduce or eliminate waiting periods,
limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you
have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB
Program. See also the FEHB web site
(www. opm. gov/ insure/ health);
refer to the "TCC and HIPAA" frequently asked questions. These highlight
HIPAA rules, such as the requirement that Federal employees
must exhaust
any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies
you can contact for more information. 51
51
Page 52 53
2002 Health Alliance HMO 52 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:
What is long term care (LTC)
insurance? It's insurance to help pay for long term care services you may
need if you can't take care of yourself because of an extended
illness or
injury, or an age-related disease such as Alzheimer's. LTC insurance can provide
broad, flexible benefits for care in a nursing home, in an assisted living
facility, in your home, adult
day care, hospice care, and more. LTC
insurance can supplement care provided by family members, reducing the burden
you place on them.
I'm healthy. I won't need long term care. Or, will I? 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 you should have a plan just in case. LTC
insurance may be vital to your financial and retirement planning.
Is long term care expensive? Yes. A year in a nursing home can exceed
$50,000 and only three 8-hour shifts a week can exceed $20,000 a year, and
that's
before inflation! LTC can easily exhaust your savings but LTC
insurance can protect it.
But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look under "Not covered" in sections 5( a) and 5( c) of
your FEHB brochure. Custodial care, assisted living, or
continuing home
health care for activities of daily living are not covered. Limited stays in
skilled nursing facilities can be covered in some circumstances.
Medicare
only covers skilled nursing home care after a hospitalization with a 100 day
limit. Medicaid covers LTC for those who meet their state's guidelines, but
restricts covered services and where they can be received.
LTC insurance can
provide choices of care and preserve your independence.
When will I get
more information? Employees will get more information from their agencies
during the late summer/ early fall of 2002.
Retirees will receive
information at home.
How can I find out more about the program NOW?
A toll-free telephone number will begin in mid-2002. You can learn more
about the program now at www. opm. gov/
insure/ ltc.
Many FEHB enrollees think their health plan and/ or Medicare covers long-term
care. Unfortunately, they are WRONG! How are YOU planning to pay for the
future custodial or chronic care you may need? Consider buying long term care
insurance. 52
52 Page
53 54
2002 Health Alliance HMO 53
Index
Index
Do not rely on this page; it is for your
convenience and may not show all pages where the terms appear.
Accidental
injury 29 Allergy tests 18
Alternative treatment 22 Allogenetic (donor)
bone marrow transplant 25
Ambulance 28 Anesthesia 26
Autologous bone
marrow transplant 28 Biopsies 23
Blood and blood plasma 27 Breast
cancer screening 15
Casts 23 Catastrophic protection 12
Changes for 2002
8 Chemotherapy 18
Childbirth 16 Chiropractic 21
Cholesterol tests 15
Claims 40
Coinsurance 12 Colorectal cancer screening 15
Congenital
anomalies 24 Contraceptive devices and drugs 33
Coordination of benefits 43
Covered charges 13
Covered providers 9 Crutches 21
Deductible 12
Definitions 47
Dental care 37 Diagnostic services 15
Disputed claims
review 41 Donor expenses (transplants) 25
Dressings 27 Durable medical
equipment (DME) 21
Educational classes and programs 22 Effective date
of enrollment 50
Emergency 29 Experimental or investigational 39
Eyeglasses 19 Family planning 17
Fecal occult blood test 15
General Exclusions 39 Hearing services 19
Home health
services 21 Hospice care 28
Home nursing care 21 Hospital 27
Immunizations 15, 16 Infertility 17
Inhospital physician care 14
Inpatient Hospital Benefits 27
Insulin 33 Laboratory and pathological
services 15 Machine diagnostic tests 15
Magnetic Resonance
Imagings (MRIs) 15
Mammograms 15 Maternity Benefits 16
Medicaid 46
Medically necessary 47
Medicare 43 Mental Conditions/ Substance
Abuse
Benefits 31 Newborn care 16
Non-FEHB Benefits 38 Nurse
Licensed
Practical Nurse 21 Nurse Anesthetist 27
Nurse Practitioner 14 Registered
Nurse 21
Nursery charges 16 Obstetrical care 16
Occupational
therapy 18 Ocular injury 19
Office visits 14 Oral and maxillofacial surgery
24
Orthopedic devices 20 Ostomy and catheter supplies 21
Out-of-pocket
expenses 12 Outpatient facility care 28
Oxygen 21
Pap test 15 Physical examination 14
Physical therapy 18 Physician
14
Pre-admission testing 28 Precertification 10
Preventive care, adult
15 Preventive care, children 16
Prescription drugs 33 Preventive services
15, 16
Prior approval 10 Prostate cancer screening 15
Prosthetic devices
20 Psychologist 31
Psychotherapy 31 Radiation therapy 18
Renal
dialysis 18 Room and board 27
Second surgical opinion 14 Skilled
nursing facility care 28
Smoking cessation 22 Speech therapy 19
Splints
27 Sterilization procedures 17
Subrogation 46 Substance abuse 31
Surgery
23 Anesthesia 26
Oral 24 Outpatient 28
Reconstructive 24 Syringes 34
Temporary continuation of coverage 50
Transplants 25 Treatment
therapies 18
Vision services 19 Well child care 16
Wheelchairs 21 Workers' compensation 46
X-rays 15 53
53 Page 54 55
2002 Health Alliance HMO 54 Summary
Summary of benefits for the Health Alliance HMO – 2002
Do
not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the definitions,
limitations, and exclusions in
this brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover on
your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
Office visit copay: $10 primary care; $10 specialist 14
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient..........................................................................................
$100 per admission copay
Nothing
27
28
Emergency benefits:
In-area
.............................................................................................
Out-of-area......................................................................................
$10 physician office/$ 100 hospital
$10 physician office/$ 100 hospital
30
30
Mental health and substance abuse
treatment..................................... Regular cost sharing. 31
Prescription
drugs.................................................................................
$7/$ 14/$ 25 33
Dental
Care........................................................................................
No benefit. 37
Vision
Care........................................................................................
No benefit. 19
Special features:
Flexible benefits
option..............................................................................................................................................
Services for deaf and hearing
impaired......................................................................................................................
Reciprocity benefits
...................................................................................................................................................
36
36
36
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 54
54
Page 55
2002 Health Alliance HMO
2002 Rate Information for Health Alliance HMO
Non-Postal rates
apply to most non-Postal enrollees. If you are in a special enrollment
category, refer to the FEHB Guide for that category or contact the agency that
maintains your
health benefits enrollment.
Postal rates apply to
career Postal Service employees. Most employees should refer to the FEHB Guide
for United States Postal Service Employees, RI 70-2. Different postal rates
apply
and special FEHB guides are published for Postal Service Nurses, RI
70-2B; and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Standard Option
Self Only FX 97.86 40.39 212.03 87.51 115.52 22.73
Standard Option
Self and Family FX 223.41 99.27 484.06 215.08 263.75
58.93 55