PrimeHealth of Alabama, Inc http://
www. primehealth. org
2002 A Health Maintenance Organization
Serving: Southern Alabama and the Montgomery Area.
Enrollment
in this Plan is limited. You must live or work in our
Geographic service
area to enroll. See page 7 for requirements.
Enrollment codes for this Plan:
AA1 Self Only AA2 Self and Family
RI 73-280
For changes
in benefits
see page 8. 1
1 Page 2 3
2002 PrimeHealth of Alabama, Inc. Table of Contents
2
Table of Contents
Introduction………………………………………………………………........................................................................…….………
4
Plain
Language………………………………………………………….…….......................................................................................
4
Inspector General Advisory:
..............................................................................................................................................................
4-5
Section 1. Facts about this HMO plan
...................................................................................................................................................
6
How we pay providers
..........................................................................................................................................................
6
Who provides my health
care?..............................................................................................................................................
6
Your
Rights...........................................................................................................................................................................
6
Service
Area..........................................................................................................................................................................
7
Section 2. How we change for
2002………………………………………...........................................................................................
8
Program-wide changes
..........................................................................................................................................................
8
Changes to this
Plan..............................................................................................................................................................
8
Section 3. How you get care …………...
..............................................................................................................................................
9
Identification
cards................................................................................................................................................................
9
Where you get covered
care..................................................................................................................................................
9
Plan providers
.................................................................................................................................................................
9
Plan facilities
..................................................................................................................................................................
9
What you must do to get covered care
..................................................................................................................................
9
Primary
care....................................................................................................................................................................
9
Specialty
care............................................................................................................................................................
9-10
Hospital care
.................................................................................................................................................................
10
Circumstances beyond our
control......................................................................................................................................
10
Services requiring our prior
approval..................................................................................................................................
10
Section 4. Your costs for covered services
..........................................................................................................................................
11
Copayments
..................................................................................................................................................................
11
Deductible.....................................................................................................................................................................
11
Coinsurance
..................................................................................................................................................................
11
Your catastrophic protection out-of-pocket
maximum.......................................................................................................
11
Section 5. Benefits
...............................................................................................................................................................................
12
Overview………………………………….........................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals.................................. 13-20
(b) Surgical and
anesthesia services provided by physicians and other health care professionals
.............................. 21-23
(c) Services provided by a hospital or
other facility, and ambulance services
............................................................ 24-25
(d)
Emergency services/
accidents................................................................................................................................
26-27
(e) Mental health and substance abuse
benefits...........................................................................................................
28-29
(f) Prescription drug benefits
......................................................................................................................................
30-31
(g) Dental benefits
.............................................................................................................................................................
32 2
2 Page 3 4
2002 PrimeHealth of Alabama, Inc. Table of Contents
3
Section 6. General exclusions --things we don't
cover........................................................................................................................
33
Section 7. Filing a claim for covered services
.....................................................................................................................................
34
Section 8. The disputed claims
process..........................................................................................................................................
35-36
Section 9. Coordinating benefits with other coverage
...................................................................................................................
37-40
When you have…
Other health coverage
..................................................................................................................................................
37
Original Medicare
..................................................................................................................................................
37-38
Medicare managed care plan
.......................................................................................................................................
39
TRICARE/ Workers' Compensation/
Medicaid..............................................................................................................
39-40
Other Government
agencies................................................................................................................................................
40
When others are responsible for
injuries.............................................................................................................................
40
Section 10. Definitions of terms we use in this
brochure.....................................................................................................................
41
Section 11. FEHB
facts..................................................................................................................................................................
42-44
Coverage information
.........................................................................................................................................................
42
No pre-existing condition
limitation.............................................................................................................................
42
Where you get information about enrolling in the FEHB
Program..............................................................................
42
Types of coverage available for you and your
family...................................................................................................
42
When benefits and premiums
start................................................................................................................................
43
Your medical and claims records are
confidential........................................................................................................
43
When you retire
...........................................................................................................................................................
43
When you lose benefits
.......................................................................................................................................................
43
When FEHB coverage
ends..........................................................................................................................................
43
Spouse equity coverage
...............................................................................................................................................
43
Temporary Continuation of Coverage
(TCC)..............................................................................................................
43
Converting to individual
coverage...............................................................................................................................
44
Getting a Certificate of Group Health Plan Coverage
.................................................................................................
44
Long term care insurance is coming later in 2002
................................................................................................................................
45
Index
.........................................................................................................................................................................................
46
Summary of benefits
.............................................................................................................................................................................
47
Rates………………………………………………………………………………………………………….......................................
48 3
3 Page 4 5
2002 PrimeHealth of Alabama, Inc. 4
Introduction
PrimeHealth of Alabama, Inc.
1400 University
Blvd. S
Mobile, AL 36609
This brochure describes the benefits of PrimeHealth of Alabama, Inc. under
our contract (CS 2116) 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 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 PrimeHealth of
Alabama, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us"
feedback area at www. opm. gov/ insure or e-mail 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/ 544-9449 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!
Introduction/ Plain Language/ Advisory 4
4
Page 5 6
2002
PrimeHealth of Alabama, Inc. 5
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.
Introduction/ Plain Language/ Advisory 5
5
Page 6 7
2002 PrimeHealth of Alabama, Inc. 6
Section 1. Facts about this
HMO plan
This Plan is a health maintenance organization (HMO). We
require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to
treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments,
and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit
claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change plans because a provider
leaves our Plan. We cannot guarantee that any one physician, hospital, or other
provider will
be available and/ or remain under contract with us.
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. We pay our providers
negotiated payments for the services they perform. Additionally some primary
care providers are paid on a capitated basis for the
services they perform.
Who provides my health care?
PrimeHealth of Alabama, Inc. is a
Mixed Model Plan using the services of both Group and Individual Practice
Physicians. Members
are free to choose their primary care doctor from the
Plan's list of participating providers, and are not limited to specific group
practices or locations. PrimeHealth's network currently consists of over 700
physicians and 20 hospitals throughout Southern
Alabama and the Montgomery
Area.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/
insure) lists the specific types of information that we must
make available
to you. Some of the required information is listed below.
PrimeHealth of Alabama, Inc. is a Federally Qualified HMO licensed in the
state of Alabama We are the oldest HMO in the state starting in 1984
We are
a for Profit company wholly owned by the University of South Alabama Foundation.
We operate in accordance with Alabama HMO regulations as directed by the Alabama
Department of Insurance and meet all
statutory requirements of the Alabama
Departments of Insurance and Public Health.
If you want more information
about us, call 800/ 544-9449, or write to PrimeHealth of Alabama Inc., Customer
Service Dept., 1400
University Blvd. S., Mobile, AL 36609. You may also
contact us by fax at 344/ 380-3236 or visit our website at
http:// www. primehealthorg.
Section 1 6
6 Page
7 8
2002 PrimeHealth of Alabama, Inc.
7
Service Area
To enroll with us you must live in or work in
our Service Area. This is where our providers practice. Our Service Area is:
Alabama: Autauga, Baldwin, Bullock, Chilton, Clarke, Coosa, Dallas
Elmore, Escambia, Lowndes, Macon, Mobile, Montgomery,
Tallapoosa, and
Washington counties.
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.
Section 1 7
7 Page
8 9
2002 PrimeHealth of Alabama, Inc.
8
Section 2. How we change for 2002
Do not rely on these
change descriptions; this page is not an official statement of benefits. For
that, go to Section 5 Benefits. Also,
we edited and clarified language
throughout the brochure; any language change not shown here is a clarification
that does not change
benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will
increase by 23. 0% for Self Only or 49. 0% for Self and Family.
We changed
speech therapy benefits by removing the requirement that services must be
required to restore functional speech. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We no longer
limit total blood cholesterol tests to certain age groups. (Section 5( a))
Section 2 8
8 Page
9 10
2002 PrimeHealth of Alabama, Inc.
Section 3 9
Section 3. How you get care
Identification cards
We will send you an identification (ID) card when you enroll. You should
carry your ID card with you at all times. You must show it whenever you receive
services from a Plan
provider, or 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/ 544-9449.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, and/ or coinsurance, and you
will not have to file claims.
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, general practitioner, OB/ GYN where they are a PCP, or a
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,
women may see their OB/ GYN
without a referral. Covered routine eye and
dental care also do not require a referral.
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 and us to
develop a treatment plan that allows you to see your
specialist for a certain number of
visits without additional referrals. Your
primary care physician will use our criteria
when creating your treatment
plan (the physician may have to get an authorization or
approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment
you need. If he or
she decides to refer you to a specialist, ask if you can
see your current specialist. If
What you must do
to get covered care 9
9
Page 10 11
2002
PrimeHealth of Alabama, Inc. Section 3 10
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. Upon
authorization
from us 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, with authorization from
the plan.
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/ 544-9449. If you are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital
stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable
efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. For certain
prior approval services,
however, your physician must obtain approval from us. Before giving approval, we
consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
We call this review and approval process prior
authorization. Your physician must obtain
prior authorization for the
following services: hospital admissions, outpatient surgery, out
of plan
services (except in urgent cases), home health services, growth hormone therapy
(GHT), and durable medical equipment (DME). 10
10
Page 11 12
2002
PrimeHealth of Alabama, Inc. 11 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.
Deductible We do not have a deductible.
Note: If you change plans
during open season, you do not have to start a new
deductible under your old
plan between January 1 and the effective date of your
new plan. If you
change plans at another time during the year, you must begin a
new
deductible under your new plan.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 20% of our allowance for durable medical
equipment.
We do not have an out-of-pocket maximum. Your catastrophic protection
out-of-pocket maximum for coinsurance and
copayments 11
11 Page 12 13
2002 PrimeHealth of Alabama, Inc. 12 Section 5
Section
5. Benefits – OVERVIEW
(See page 8 for how our benefits changed
this year and page 47 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/ 544-9449
or at our website at www.
primehealth. org .
(a) Medical services and supplies provided
by physicians and other health care
professionals...................................................…. 14-21
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 .................................................... 22-24
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..................................................................................
25-26
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents
.....................................................................................................................................................
27-28
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits
................................................................................................................................
29-30
(f) Prescription drug benefits
............................................................................................................................................................
31-32
(g) Dental benefits
..................................................................................................................................................................................
33
Summary of benefits
................................................................................................................................................................................
47 12
12 Page 13
14
2002 PrimeHealth of Alabama, Inc. 13
Section 5( a)
Section 5 (a) Medical services and supplies provided
by physicians and other
health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office
medical consultations
Second surgical opinion
$10 per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Nothing
At home Nothing 13
13 Page
14 15
2002 PrimeHealth of Alabama,
Inc. 14 Section 5( a)
Lab, X-ray and other diagnostic tests
You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine
pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing
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
Prostate Specific Antigen (PSA test) – one annually
for men age 40 and older
Routine pap test
Nothing
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
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, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing if you receive these services during
your office visit;
otherwise, $10 per visit 14
14 Page 15 16
2002
PrimeHealth of Alabama, Inc. 15 Section 5( a)
Preventive care,
children You pay
Childhood immunizations recommended by the American
Academy of Pediatrics
Well-child care charges for routine examinations, immunizations and care
(through age 18)
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)
Nothing if you receive these services
during your office visit;
otherwise, $10 per
visit
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things
to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will
extend your inpatient stay if medically necessary.
We cover routine
nursery care of the newborn child during the covered portion of the mother's
maternity stay. We will
cover other care of an infant who requires non-routine
treatment only if
we cover the infant under a Self and Family
enrollment.
We pay hospitalization and surgeon services (delivery) the same
as for
illness and injury. See Hospital benefits (Section 5c)
and Surgery benefits
(Section 5b).
$10 for the 1 st office visit then nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Injectable contraceptive drugs
(such as Depo provera)
Intrauterine devices (IUDs)
Diaphrams
NOTE:
We cover oral contraceptives under the prescription drug
benefit.
$10 per office visit 15
15 Page 16 17
2002
PrimeHealth of Alabama, Inc. 16 Section 5( a)
Family planning
(continued) You pay
Not covered: reversal of voluntary
surgical sterilization, genetic
counseling,
All charges.
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination: -intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination
(IUI)
$10 per visit
Not covered:
Assisted reproductive technology (ART) procedures,
such as: -in vitro fertilization
-embryo transfer, gamete GIFT and zygote ZIFT
-Zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
Fertility
drugs
All charges.
Allergy care
Testing and treatment
Allergy injection
Nothing if you receive these services
during your
office visit; otherwise, $10 per
visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 16
16 Page 17 18
2002 PrimeHealth of Alabama, Inc. 17 Section
5( a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous
bone
marrow transplants are limited to those transplants listed
under Organ/
Tissue Transplants on page 23.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone therapy is covered
under the prescription
drug benefit.
Note: – We will only cover GHT when we preauthorize the
treatment. For
directions on how to obtain a preauthorization call
800/ 544-9449 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.
Nothing if you receive these services
during your office visit;
otherwise, $10 per
visit
Physical and occupational therapies
Up to two months per condition
for the services of each of the following:
qualified physical therapists and occupational therapists.
Note: We only cover therapy to restore bodily function when
there has
been a total or partial loss of bodily function due to
illness or injury.
Cardiac rehabilitation following a heart transplant, bypass
surgery or a
myocardial infarction, is provided for up to 36
weeks.
$10 per visit
$10 for the program
Not covered:
Long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
Up to two months per condition $10 per visit
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per visit 17
17 Page
18 19
2002 PrimeHealth of Alabama,
Inc. 18 Section 5( a)
Hearing services (testing, treatment,
and supplies)
continued
You pay
Not covered:
all other hearing testing
hearing aids, testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
We provide one
refraction once every 24 months for members age 18 and older and once every 12
months for members under
age 18.
$10 per visit
Eye exam to determine the need for vision correction for children through age
17 (see Preventive care, children) $10 per visit
Not covered:
Eyeglasses, frames, or contact lenses( except when internally
implanted following cataract surgery)
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a
metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on
podiatric shoe
inserts.
$10 per 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. 18
18 Page 19 20
2002
PrimeHealth of Alabama, Inc. 19 Section 5( a)
Orthopedic and
prosthetic devices You pay
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, and
surgically implanted breast implant following mastectomy. Note:
See 5( b)
for coverage of the surgery to insert the device.
Corrective orthopedic
appliances for non-dental treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome.
Special braces required to correct skeletal deformities or required to
maintain the function of a disabled limb or required to support a
functionally impaired body part. We cover replacement or repair of
such
braces as deemed necessary and reasonable by a Plan
physician.
Nothing
Not covered:
orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports (except for special braces listed above)
corsets, trusses, elastic stockings, support hose, and other
supportive devices
prosthetic replacements or repairs cost of an implanted cochlear
device
cost of an implanted penile device
All charges.
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, including repair and adjustment, of
durable medical equipment
prescribed by your Plan physician, such as
oxygen and dialysis equipment.
Under this benefit, we also cover:
hospital beds;
standard wheelchairs;
crutches;
walkers;
blood
glucose monitors; and
insulin pumps
Note: Call us at 800/ 544-9449 as soon as your Plan physician
prescribes
this equipment. We will arrange with a health care provider
to rent or sell
you durable medical equipment at discounted rates and
will tell you more
about this service when you call.
20% of covered devices limited to $2,000
per covered member per calendar
year.
Not covered:
Motorized wheel chairs All charges. 19
19 Page 20 21
2002 PrimeHealth of Alabama, Inc. 20 Section
5( a)
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.
Nothing
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family;
home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges.
Chiropractic
No benefit All charges.
Alternative
treatments
Not covered:
acupuncture naturopathic
services
hypnotherapy biofeedback
All charges.
Educational classes and programs
Consults with Dietitian
Smoking Cessation
Diabetes self-management
Other classes (contact
PrimeHealth for a list of classes, times and locations)
$10 per visit
$10 per visit
Nothing 20
20
Page 21 22
2002
PrimeHealth of Alabama, Inc. 21 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 --a condition in which an individual
weighs 100 pounds or 100% over his or her normal
weight according to current
underwriting standards;
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.
Nothing
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care.
All charges. 21
21 Page 22 23
2002 PrimeHealth of Alabama, Inc. 22 Section
5( b)
Reconstructive surgery You pay
Surgery to correct a
functional defect
Surgery to correct a condition caused by injury or illness
if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes.
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: We pay for internal breast prostheses as hospital benefits.
Note:
If you need a mastectomy, you may choose to have the procedure
performed on
an inpatient basis and remain in the hospital up to 48
hours after the
procedure.
Nothing
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges.
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones; Surgical correction
of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or
their supporting structures.
Nothing
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
All charges. 22
22 Page 23 24
2002
PrimeHealth of Alabama, Inc. 23 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.
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs Transplants not listed as covered
All charges.
Anesthesia
Professional services provided in –
Hospital
(inpatient) Hospital outpatient department
Skilled nursing facility Ambulatory surgical center
Nothing
Professional services provided in –
Office $10 per visit 23
23 Page 24 25
2002 PrimeHealth of Alabama, Inc. 24 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 Section 5( a) or (b).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general nursing
care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Take-home
items Medical supplies, appliances, medical equipment, and any covered
items
billed by a hospital for use at home
Nothing
Not covered:
Custodial care Non-covered facilities, such
as nursing homes, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
Blood that is
not donated or replaced
All charges. 24
24 Page 25 26
2002
PrimeHealth of Alabama, Inc. 25 Section 5( c)
Outpatient
hospital or ambulatory surgical center You pay
Operating, recovery, and
other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do
not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/ skilled nursing care facility
benefits
Extended care benefit:
We provide a comprehensive range of benefits for up to 60 days per calendar
year when full-time skilled nursing care is necessary and confinement in a
skilled nursing facility is medically appropriate as determined by a Plan
doctor
and approved by us.
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a Plan doctor.
Nothing
Not covered: custodial care All charges.
Hospice care
Supportive and palliative care for a terminally ill member is covered in
the
home or a hospice facility. Services include inpatient and 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. Care
shall not exceed 180
consecutive days beyond initial approval by the Plan.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically
appropriate, and ordered by a Plan physician, and approved by the
Plan
Nothing 25
25 Page
26 27
2002 PrimeHealth of Alabama,
Inc. 26 Section 5( d)
Section 5 (d). Emergency services/
accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A
medical emergency is the sudden and unexpected onset of a condition or an injury
that you believe endangers your life or
could result in serious injury or
disability, and requires immediate medical or surgical care. Some problems are
emergencies
because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are
emergencies
because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or
sudden inability to breathe. There are many
other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
doctor. In extreme emergencies, if you are unable to contact
your doctor,
contact the local emergency system (e. g., the 911-telephone system) or go to
the nearest hospital emergency room.
Be sure to tell the emergency room
personnel that you are a Plan member so they can notify us. You or a family
member should
notify the Plan as soon as possible unless it was not
reasonably possible to do so. It is your responsibility to ensure that the Plan
has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 48 hours or on the first working day
following your
admission, unless it was not reasonable possible to notify the Plan within that
time. If you are hospitalized in
non-Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital, you will be transferred
when
medically possible with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would
result in death,
disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided
by Plan providers.
Emergencies outside our service area:
Benefits are available for
any medically necessary health service that is immediately required because of
injury or
unforeseen illness.
If you need to be hospitalized, we must be notified as soon as possible
following your admission, generally on the first
working day following
admission, unless it is not reasonably possible to notify us within that time.
If a Plan doctor believes
care can be bettered provided in a Plan hospital,
you will be transferred when medically feasible with any ambulance
charges
covered in full.
To be covered by us for any follow-up care recommended by non-plan providers,
that care must be approved by our
providers. 26
26
Page 27 28
2002
PrimeHealth of Alabama, Inc. 27 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
$10 per office visit
$25 per urgent care center visit
$25 per hospital emergency room visit. If
the emergency results in
admission to a
hospital, the emergency room copay is
waived.
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
$10 per office visit
$25 per urgent care center visit
$25 per
hospital emergency room visit. If
the emergency results in admission to a
hospital, the emergency room copay is
waived.
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance
Professional ambulance and air ambulance service when
medically
appropriate, and ordered by a Plan physician and approved by the
Plan.
See 5( c) for non-emergency service.
Nothing 27
27 Page
28 29
2002 PrimeHealth of Alabama,
Inc. 28 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
Services provided by a hospital or other
facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
(All services must be prior approved by our
Precertification department) 28
28 Page 29 30
2002
PrimeHealth of Alabama, Inc. 29 Section 5( e)
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:
Please contact our Customer Service department to obtain provider
directories and
benefit information at 800/ 544-9449. The representatives
can assist you in identifying
which procedures require a preauthorization.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 29
29 Page
30 31
2002 PrimeHealth of Alabama,
Inc. 30 Section 5( f)
Section 5 (f). Prescription drug
benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist
must write the prescription. Licensed dentists are restricted to issuing
prescriptions for antibiotics and pain medications.
Where you can obtain them. You may fill the prescription at any
participating pharmacy, or by mail through our mail-order program.
We use
a formulary. A formulary is a list of prescription drugs that we have
selected to provide effective treatment at affordable costs. When you receive a
formulary drug you pay the lowest copay. If you or your
provider select a
non-formulary drug you can still get the prescription but at a higher copay
These are the dispensing limitations. You may receive up to a 31-day
supply for one copay from your retail pharmacy. If you or your physician request
more than a 31-day supply and you attempt to have that
prescription filled at a retail pharmacy you will only receive a 31-day
supply. You may receive up to a 90-day
supply by mail order for two copays.
Certain prescription drugs may require your Plan doctor to obtain
approval
from the Plan prior to dispensing.
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 (DAW) for the name brand drug, you
have to pay the difference in cost
between the name brand drug and the
generic.
Why use generic drugs? Generic drugs contain the same active
ingredients and are equivalent in strength and dosage to the original brand name
product. Generic drugs cost you and your plan less money than a
name-brand drug.
When you have to file a claim. Should you for
some reason not be able to use a participating pharmacy you will have to submit
a claim. You can obtain a claim form by calling 800/ 544-9449.
Prescription drug benefits begin on the next page. 30
30 Page 31 32
2002 PrimeHealth of Alabama, Inc. 31 Section
5( f)
Benefit Description You pay
Covered medications and
supplies
We cover the following medications and supplies prescribed by a
Plan
physician or licensed dentist and obtained from a Plan pharmacy or
through our mail order program:
Drugs and medicines (including those administered during a non-covered
admission or in a non-covered facility) that by Federal law
of the United States require a physician's prescription for their
purchase, except those listed as Not covered.
Insulin (copay applies to each vial) Disposable needles and syringes for the
administration of covered
medications
Contraceptive drugs and devices Drugs for sexual dysfunction
are subject to dosage limits set by the
Plan. Contact the Plan for details.
Retail pharmacy:
$ 7 copay per prescription unit or refill for
up to
a 31-day supply for formulary generic
drugs.
$ 12 copay per prescription unit or refill for
formulary name brand drugs
$ 30 copay per prescription unit or refill for
non-formulary generic or
name brand drug
when a generic drug is available
Mail order program:
Two (2) copays per prescription unit or
refill
for up to a 90-day supply
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Vitamins, nutrients
and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Fertility drugs
Disposable
medical supplies, such as dressings and antiseptics
Smoking cessation
drugs and medication, including nicotine patches
Weight loss product
(except when used to treat Morbid Obesity and with prior Plan approval)
All Charges. 31
31 Page 32 33
2002
PrimeHealth of Alabama, Inc 32 Section 5 (g)
Section 5 (g).
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.
We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health
of the patient; we do not cover the dental procedure unless it is
described
below.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefits You pay
We cover restorative services and supplies necessary to promptly repair or
replace sound natural teeth including the first dental prosthesis, such as a
crown or bridge. Services must be provided within three (3) months of the
date of the injury, unless the member's medical condition indicatges the
dental care must be delayed. The need for these services must result from an
accidental injury. Dental services for the treatment of injury caused
through
activities of daily living, such as eating, are not covered.
Nothing
Dental Benefits
Service You pay
Prophylaxis (cleaning) --twice a year
Annual topical application of
fluoride
Preventive dental instructions
X-rays, including bite-wings
Oral exam and treatment plan
Vitality test
Oral cancer exam
$10 copay per visit 32
32 Page 33 34
2002
PrimeHealth of Alabama, Inc. 33 Section 6
Section 6. General
exclusions --things we don't cover
The exclusions in this section apply
to all benefits. Although we may list a specific service as a benefit, we
will not cover it
unless your Plan doctor determines it is medically
necessary to prevent, diagnose, or treat your illness, disease, injury,
or
condition, and we agree, as discussed under What Services Require Our
Prior Approval on pages 10.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you
are not enrolled in this Plan;
Services, drugs, or supplies that are not
medically necessary;
Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term;
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. 33
33 Page
34 35
2002 PrimeHealth of Alabama,
Inc. 34 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/ 544-9449.
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:
PrimeHeath of Alabama, Inc.
1400 University Blvd. S.
Mobile, AL 36609.
Prescription drugs Show your card at participating pharmacies.
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. 34
34 Page
35 36
2002 PrimeHealth of Alabama,
Inc. 35 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: PrimeHealth of Alabama Inc., 1400 University Blvd. S., Mobile,
AL
36609 and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in
this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical
records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request—
go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us --if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street,
NW, Washington, D. C.
20415-3630.
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. 35
35 Page 36 37
2002
PrimeHealth of Alabama, Inc. 36 Section 8
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 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/ 544-
9449 and we will
expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 36
36
Page 37 38
2002
PrimeHealth of Alabama, Inc. 37 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
PCP, or approved as
required.
We will not waive any of our copayments or coinsurance.
(Primary payer
chart begins on next page.)
The Original Medicare Plan (Part A or Part B) 37
37 Page 38 39
2002 PrimeHealth of Alabama, Inc. 38 Section
9
The following chart illustrates whether the Original Medicare Plan
or this Plan should be the primary payer for you according to
your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered family member
has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a family member are eligible for
Medicare solely because of a disability), !
2) Are an annuitant, !
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, 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
2) 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 !
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare 38
38
Page 39 40
2002
PrimeHealth of Alabama, Inc. 39 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/ 544-9449
We do not waive any costs when you have Medicare.
Medicare managed
care plan If you are eligible for Medicare, you may choose to enroll in and
get your Medicare benefits from another type of Medicare+ Choice plan --a
Medicare managed care plan.
These are health care choices (like HMOs) in
some areas of the country. In most
Medicare managed care plans, you can only
go to doctors, specialists, or hospitals that
are part of the plan. Medicare
managed care plans provide all the benefits that Original
Medicare covers.
Some cover extras, like prescription drugs. To learn more about
enrolling in
a Medicare managed care plan, contact Medicare at 1-800-MEDICARE
(1-
800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care
plan: You may enroll in
another plan's Medicare managed care plan and
also remain enrolled in our FEHB plan.
We will still provide benefits when
your Medicare managed care plan is primary, even
out of the managed care
plan's network and/ or service area (if you use our Plan
providers), 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.
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.
If you do not enroll in Medicare Part A or Part B 39
39 Page 40 41
2002 PrimeHealth of Alabama, Inc. 40 Section
9
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will
cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for
for injuries medical or hospital care for injuries or illness
caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment
that exceeds the amount you received in the settlement.
If you do not
seek damages you must agree to let us try. This is called subrogation. If
you need more information, contact us for our subrogation procedures. 40
40 Page 41 42
2002 PrimeHealth of Alabama, Inc. 41 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 11.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Covered services Care we
provide benefits for, as described in this brochure.
Experimental or
We review requests from our providers to consider providing benefits for
Investigational services new technology and/ or new application of
existing technology. Examples include drugs, biologicals, diagnostics, devices,
therapeutics, and procedures. The technology must be
approved by the appropriate government regulatory body and scientific
evidence must be
published in a peer reviewed journal. The technology or
procedure must demonstrate that
it improves heath outcomes, outweighing any
harmful effects.
Medical necessity Means services or supplies which, under the
provisions of this brochure, are: (1) necessary for the symptoms, diagnosis or
treatment of the condition; (2) provided for
diagnosis or direct care and
treatment of the condition; (3) not primarily for the
convenience of the
member or the member's physician or any other provider; and (4) the
most
appropriate supply or level of services which can safely be provided in
accordance
with the provisions of this brochure. For inpatient stays, this
means that acute care as an
inpatient is necessary due to the acuity of
services the member is receiving and the
severity of the member's condition
and that safe and adequate care cannot be received as
an outpatient or in a
less intensified setting. Medically necessary services shall be
determined
by the Medical Director.
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 by reviewing
various sources such as Medicare, other plan payments and
negotiated fees.
Based on that analysis we establish amounts that we will pay for any
given
service. All our providers accept 100% of the plan allowance as payment in full.
Us/ We Us and we refer to PrimeHealth of Alabama, Inc.
You
You refers to the enrollee and each covered family member. 41
41 Page 42 43
2002 PrimeHealth of Alabama, Inc. 42 Section
11
Section 11. FEHB facts
No pre-existing condition We will
not refuse to cover the treatment of a condition that you had
limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office
about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your
enrollment status without information from your employing
or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for
for you and your family you, your spouse,
and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a
disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if
you marry, give birth, or add a child to your family. You may
change your enrollment 31
days before to 60 days after that event. The Self
and Family enrollment begins on the
first day of the pay period in which the
child is born or becomes an eligible family
member. When you change to Self
and Family because you marry, the change is effective
on the first day of
the pay period that begins after your employing office receives your
enrollment form, benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no
longer eligible to receive health benefits, nor will we. Please
tell us immediately when
you add or remove family members from your coverage
for any reason, including
divorce, or when your child under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not
be enrolled in or covered as a family member by another FEHB
plan. 42
42 Page
43 44
2002 PrimeHealth of Alabama,
Inc. 43 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you joined this Plan
premiums
start during Open Season, your coverage begins on the first day of your
first pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on January 1. If
you joined at any other time during the year, your employing office will tell
you the
effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only
records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This 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 coverage If you are divorced from a Federal employee or
annuitant, you may not continue to get benefits under your former spouse's
enrollment. But, you may be eligible for your own
FEHB coverage under the spouse equity law. If you are recently divorced or
are
anticipating a divorce, contact your ex-spouse's employing or retirement
office to get RI
70-5, the Guide to Federal Employees Health Benefits
Plans for Temporary Continuation
of Coverage and Former Spouse Enrollees,
or other information about your coverage
choices.
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no longer qualify as of Coverage (TCC) 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. 43
43
Page 44 45
2002 PrimeHealth of Alabama, Inc. 44 Section 11
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity law
ends (If you canceled your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to
convert. You must apply in writing to us within 31 days after you receive
this notice.
However, if you are a family member who is losing coverage, the
employing or
retirement office will not notify you. You must apply in
writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you
will not have to answer questions about your health, and we
will not impose a waiting
period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of 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. 44
44
Page 45 46
2002 PrimeHealth of Alabama, Inc. 45 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office
of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in
October 2002. As part of its educational
effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease
such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice care, and more.
LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
Welcome to the club! 76% of Americans believe they will never need long term
care, but the facts are that
about half of them will. And it's not just the
old folks. About 40% of people
needing long term care are under age 65. They
may need chronic care due to a
serious accident, a stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital
to their
financial and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's
before inflation!
Long term care can easily exhaust your savings.
Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c)
of your FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted
living facility or a continuing need for a home health aide to help
you get in and out
of bed and with other activities of daily living. Limited
stays in skilled nursing
facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the meantime, you
can learn more about the program on our web site at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 45
45 Page 46 47
2002 PrimeHealth of Alabama, Inc. 46 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 32
Allergy tests 16
Alternative treatment 20
Allogenetic (donor) bone marrow
transplant 23
Ambulance 27
Anesthesia 23
Autologous bone marrow transplant
23
Biopsies
21
Blood and blood plasma 25
Breast cancer screening 14
Changes for 2002 8
Chemotherapy 17
Childbirth 15
Chiropractic 20
Cholesterol tests 14
Claims 35
Coinsurance 11
Colorectal cancer
screening 14
Congenital anomalies 21
Contraceptive devices and drugs 15
Coordination of benefits 38
Covered charges 40
Covered providers 9
Crutches 19
Definitions 42
Dental care 32
Diagnostic services 14
Dialysis 17
Disputed claims review 36
Donor expenses (transplants) 23
Dressings
24
Durable medical equipment
(DME) 19
Educational classes and
programs 20
Effective date of enrollment 4
Emergency 26-27
Experimental or investigational 34
Eyeglasses 18
Family planning 15-16 Fecal occult blood test 14
General Exclusions 34
Hearing services 17-18 Home health
services 20
Hospice care 25
Home nursing care 20
Hospital 10
Immunizations
14-15
Infertility 16
Inhospital physician care 24
Inpatient
Hospital Benefits 24
Insulin 31
Laboratory and pathological
services 14
Machine diagnostic tests 14 Magnetic Resonance
Imagings
(MRIs) 14
Mail Order Prescription Drugs 31
Mammograms 14
Maternity Benefits 15
Medicaid 41
Medically necessary 42
Medicare 38
Members 6
Mental Conditions/ Substance
Abuse
Benefits 28
Newborn care 15
Nursery charges 15
Obstetrical
care 15 Occupational therapy 17
Ocular injury 18 Office visits 11
Oral and maxillofacial surgery 22
Orthopedic devices 19
Out-of-pocket expenses 11 Outpatient facility care 25
Oxygen 20
Pap test 14 Physical examination 14
Physical therapy 17 Physician
9
Pre-admission testing 10 Preventive care, adult 14
Preventive care,
children 15 Prescription drugs 31
Preventive services 14-15 Prior approval
10
Prostate cancer screening 14 Prosthetic devices 22
Psychologist 28
Psychotherapy 28
Radiation therapy 17 Room and board 24
Skilled nursing facility care 25 Smoking cessation 20
Speech
therapy 17 Splints 24
Sterilization procedures 15 Subrogation 41
Substance abuse 28 Surgery 21
Anesthesia 23 Oral 22
Outpatient 21
Reconstructive 22
Syringes 31 Temporary continuation of
coverage
44 Transplants 23
Treatment therapies 17 Vision services 18
Well child care 16 Wheelchairs 19
Workers' compensation 40
X-rays 14 46
46 Page
47 48
2002 PrimeHealth of Alabama,
Inc. 47 Summary
Summary of benefits for PrimeHealth of
Alabama, Inc. – 2002
Do not rely on this chart alone. All
benefits are provided in full unless indicated and are subject to the
definitions,
limitations, and exclusions in this brochure. On this page we
summarize specific expenses we cover; for more detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover on
your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $10 primary care; $10 specialist 13
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing
Nothing
24
25
Emergency benefits:
In-area..............................................................................................
Out-of-area
......................................................................................
$25 per emergency room visit
$25 per emergency room visit
27
27
Mental health and substance abuse treatment
....................................... Regular cost sharing. 28
Prescription drugs
.................................................................................
For up to a 31-day supply per prescription unit or refill at a Retail
pharmacy
For up to a 90-day supply per prescription unit or refill through Mail
order
Retail pharmacy: $7 copay for formulary
generic drugs; $12 copay for
formulary name
brand drugs; and $30 copay for non-formulary
drugs.
Mail order: Two (2) copays
31
Dental Care:
Accidental injury benefit
...........................................................
Preventive
dental care ...............................................................
Nothing
$10 copay per visit
32
Vision Care:
One refraction every 24 months for members 18 and older
......
One refraction every 12 months for members under 18 ............
$10 copay per visit
$10 copay per visit
18
Protection against catastrophic costs
(your out-of-pocket
maximum).........................................................
We do not have an out-of-pocket maximum
11 47
47 Page 48
2002
PrimeHealth of Alabama, Inc. Rates 48
2002 Rate Information for
PRIMEHEALTH OF ALABAMA, INC.
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment
category, refer to the FEHB Guide for that category or
contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the
FEHB Guide for United States Postal Service Employees,
RI 70-2. Different postal rates apply
and special FEHB guides are published
for Postal Service Nurses, RI 70-2B; and for Postal
Service Inspectors and
Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of
any postal employee organization who are not career
postal employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share
Self Only AA1 $94.69 $31.56 $205.16 $68.38 $112.05 $14.20
Self and
Family AA2 $223.41 $100.05 $484.06 $216.77 $263.75 $59.71 48