Serving: Southeastern and Southcentral Pennsylvania
Enrollment in this
Plan is limited. You must live or work in our Geographic service area to enroll.
See page 5 for requirements.
Enrollment codes for this Plan:
NQ1 Self Only NQ2 Self and Family
RI 73-311
This plan has received Excellent Accreditation from
the NCQA for its
HMO and Point of Service products. See the 2002 Guide
for more information
on NCQA.
For changes in
benefits see page 6. 1
1
Page 2 3
Table of
Contents
Introduction
............................................................................................................................................................................
4
Plain
Language.........................................................................................................................................................................
4
Inspector General Advisory
.....................................................................................................................................................
4
Section 1. Facts about this HMO
plan.....................................................................................................................................
5
How we pay
providers............................................................................................................................................
5
Your Rights
............................................................................................................................................................
5
Service Area
...........................................................................................................................................................
5
Section 2. How we change for 2002
.......................................................................................................................................
6
Changes to this Plan
...............................................................................................................................................
6
Section 3. How you get care
...................................................................................................................................................
7
Identification
cards.................................................................................................................................................
7
Where you get covered care
...................................................................................................................................
7
Plan providers
.................................................................................................................................................
7
Plan
facilities...................................................................................................................................................
7
What you must do to get covered care
...................................................................................................................
7
Primary care
....................................................................................................................................................
7
Specialty care
..................................................................................................................................................
7
Hospital care
...................................................................................................................................................
8
Circumstances beyond our control
.........................................................................................................................
9
Services requiring our prior
approval.....................................................................................................................
9
Section 4. Your costs for covered
services............................................................................................................................
10
Copayments...................................................................................................................................................
10
Your out-of-pocket
maximum..............................................................................................................................
10
Section 5. Benefits
................................................................................................................................................................
11
Overview..............................................................................................................................................................
11
(a) Medical services and supplies provided by physicians and other health
care professionals...................... 12
(b) Surgical and anesthesia
services provided by physicians and other health care professionals
.................. 22
(c) Services provided by a hospital or other facility,
and ambulance services................................................ 25
(d) Emergency services/ accidents
...................................................................................................................
29
(e) Mental health and substance abuse benefits
..............................................................................................
32
(f) Prescription drug benefits
..........................................................................................................................
33
(g) Special
features..........................................................................................................................................
35
2002 HealthGuard 2 Table of Contents 2
2
Page 3 4
(h) Dental
benefits...........................................................................................................................................
36
(i) Non-FEHB benefits available to Plan members
........................................................................................
37
Section 6. General exclusions --things we don't cover
........................................................................................................
38
Section 7. Filing a claim for covered
services.......................................................................................................................
39
Section 8. The disputed claims
process.................................................................................................................................
40
Section 9. Coordinating benefits with other
coverage...........................................................................................................
42
When you have…
Other health coverage
...................................................................................................................................
42
Original Medicare
.........................................................................................................................................
42
Medicare Managed Care Plan
.......................................................................................................................
44
TRICARE/ Workers' Compensation/ Medicaid
.....................................................................................................
45
Other Government agencies
.................................................................................................................................
45
When others are responsible for injuries
..............................................................................................................
45
Section 10. Definitions of terms we use in this
brochure......................................................................................................
46
Section 11. FEHB facts
.........................................................................................................................................................
47
No pre-existing condition limitation
.............................................................................................................
47
Where you get information about enrolling in the FEHB
Program............................................................... 47
Types of coverage available for you and your
family...................................................................................
47
When benefits and premiums start
................................................................................................................
48
Your medical and claims records are confidential
........................................................................................
48
When you
retire.............................................................................................................................................
48
When you lose benefits
........................................................................................................................................
48
When FEHB coverage ends
..........................................................................................................................
48
Spouse equity
coverage.................................................................................................................................
48
Temporary Continuation of Coverage (TCC)
...............................................................................................
48
Converting to individual coverage
................................................................................................................
49
Getting a Certificate of Group Health Plan
Coverage...................................................................................
49
Long term care insurance is coming later in 2002
.................................................................................................................
50
Index
......................................................................................................................................................................................
52
Summary of benefits
..............................................................................................................................................................
53
Rates.........................................................................................................................................................................
Back cover
2002HealthGuard 3 Table of Contents 3
3
Page 4 5
Introduction HealthGuard
280 Granite Run Drive Lancaster, PA 17601
This brochure describes the benefits of HealthGuard under our contract (CS
2232) with the Office of Personnel Management (OPM), as authorized by the
Federal Employees Health Benefits law. This brochure is the official statement
of benefits. No
oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure.
If you are enrolled in this
Plan you are entitled to the benefits described in this brochure. If you are
enrolled for Self and Family coverage, each eligible family member is also
entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2002, unless those benefits are also shown in
this brochure.
OPM negotiates benefits and rates with each plan annually.
Benefit changes are effective January 1, 2002, and changes are summarized on
page 6. 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, HealthGuard.
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 other, 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, D. C. 20415-3650.
Stop health care fraud! Fraud increases the cost of health care for
everyone. If you suspect that a physician, pharmacy, or hospital has charged you
for services you did not
receive, billed you twice for the same service, or
misrepresented any information, do the following:
Call the provider and ask
for an explanation. There may be an error. If the provider does not resolve the
matter, call us at 800/ 822-0350 and
explain the situation. If we do not
resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/
418-3300
The United States Office of Personnel Management Office of the
Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC
20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who
uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain
benefits. Your agency may also take
administrative action against you.
2002 HealthGuard 4 Introduction/ Plain
Language
Inspector General Advisory 4
4 Page 5 6
Section 1 – Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any
course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan
providers, you may have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or
other provider will be available and/ or remain
under contract with us.
How we pay providers
We contract with
individual physicians, medical groups, and hospitals to provide the benefits in
this brochure. These Plan providers accept a negotiated payment from us, and you
will only be responsible for your copayments.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get
information about us, our networks, providers, and facilities. OPM's FEHB
website (www. opm. gov/ insure) lists the specific types of information
that we must make available to you. Some of the required information is
listed below.
HealthGuard has been incorporated since 1984, resulting in
17 years of operation. HealthGuard received an Excellent accreditation status
from the National Committee for Quality Assurance (NCQA).
HealthGuard consists of an extensive network of hospitals, ambulatory
surgical centers, highly qualified primary care physicians, highly qualified
specialists, and various other ancillary providers.
If you want more
information about us, call 800/ 822-0350, or write to HealthGuard, 280 Granite
Run Drive, Lancaster, PA 17601. You may also contact us by fax at 717/ 581-4580
or visit our website at www. hguard. com.
Service Area
To enroll
in this Plan, you must live or work in our Service Area. This is where our
providers practice. Our service area is: Lancaster, York, Cumberland, Dauphin,
Lebanon, and Berks counties in Pennsylvania.
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. HMO-USA
is a network of Blue Cross Blue Shield physicians that participate with
HealthGuard throughout the United States. Should you have an urgent, emergent
need for a
physician (non-life-threatening) which cannot wait to be treated
until you return home, you call 1-800-4-HMO-USA. For temporary living
arrangements outside of our service area, you can access HMO-USA through
HealthGuard's Member
Services 717-560-3353 or 800-822-0350. 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.
2002 HealthGuard 5 Section 1 5
5 Page 6 7
Section 2 -How we
change for 2002
Do not rely on these change descriptions; this page is
not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change
not shown here is a clarification that
does not change benefits.
Changes to this Plan
Your share of the non-Postal premium will
increase by 7. 8% for Self Only or 7. 5% for Self and Family.
You pay $10
for generic, $25 for preferred brand drugs and $40 for non-preferred drugs.
(Section 5( f))
We no longer limit total blood cholesterol tests to certain
age groups. (Section 5 (a))
We now cover routine screening for chlamydial
infection. (Section 5( a))
We changed speech therapy benefits by removing
the requirement that services must be required to restore functional speech.
(Section 5 (a)).
We now cover certain intestinal transplants. (Section 5 (b))
We changed
the address for sending disputed claims to OPM. (Section 8)
2002 HealthGuard 6 Section 2 6
6 Page 7 8
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 800-822-0350.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
Plan providers Plan providers are physicians and other health
care professionals in our service area that we contract with to provide covered
services to our members. We
credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in the
provider directory, which we update
periodically. The list is also on our website.
What you must do to get covered care It depends on the type of care
you need. First, you and each family member
must choose a primary care
physician. This decision is important since your primary care physician provides
or arranges for most of your health care. Your
first step as a HealthGuard
member will be to choose a Primary Care Physician from the HealthGuard network
of providers.
Primary care Your primary care physician can be a Family Practice
Physician, and Internist, 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 form your primary care
physician, you must return
to the primary care physician after the
consultation, unless your primary care physician authorized a certain number of
visits without additional referrals. The
primary care physician must provide
or authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a
referral. However, you may
see obstetricians and gynecologists without a referral.
2002 HealthGuard 7 Section 3 7
7 Page 8 9
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 the plan to develop
a treatment plan that allows you to see your specialist for a certain number of
visits without
additional referrals. Your primary care physician will use
our criteria when creating your treatment plan (the physician may have to get an
authorization
or approval beforehand).
If you are seeing a specialist
when you enroll in our Plan, talk to your primary care physician. Your primary
care physician will decide what
treatment you need. If he or she decides to
refer you to a specialist, ask if you can see your current specialist. If your
current specialist does not
participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see a
specialist who does not
participate with our Plan.
If you are seeing a
specialist and your specialist leaves the Plan, call your primary care
physician, who will arrange for you to see another specialist.
You may
receive services from your current specialist until we can make arrangements for
you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist
for other than cause; or -drop out of the Federal Employees Health
Benefits (FEHB) Program
and you enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan, you may
be able to continue seeing your specialist for up to 90 days after you
receive notice of the change. Contact us or, if we drop out of the Program,
contact your new plan. .
If you are in the second or third trimester of
pregnancy and you lose access to your specialist based on the above
circumstances, you can continue to see your
specialist until the end of your
postpartum care, even if it is beyond the 90 days.
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 800-822-0350. 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
2002 HealthGuard 8 Section 3 8
8 Page 9 10
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 prior approval certain services,
however, your physician must obtain approval from us. Before
giving
approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.
We call this review and approval process pre-certification. Your physician
must obtain pre-certification for the following services: Breast Reconstruction
Mammoplasty, Cardiac Rehabilitation, Chiropractic, Cosmetic Procedures,
Dental Procedures, Durable Medical Equipment, Infertility – diagnostics, drugs,
treatments, etc., Out-of-Network referrals, Sclerotherapy, Sinus Surgery,
TMJ issues, and UPPP (laser).
To obtain information on pre-authorization from HealthGuard, call the Member
Services Department at 800-822-0350 or 717-560-3353 or send an email
message
to members@ hguard. com.
2002 HealthGuard 9 Section 3 9
9 Page 10 11
Section 4 –
Your costs for covered services
You must share the cost of some
services. You are responsible for:
Copayments A co-payment is a fixed
amount of money you pay to 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.
Your catastrophic protection out-of-pocket
maximum for deductibles,
coinsurance, and copayments We do not have an out-of-pocket maximum.
2002 HealthGuard 10 Section 4 10
10
Page 11 12
Section 5 – Benefits – OVERVIEW (See page 6 for how our
benefits changed this year and page 53 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
800-822-0350 or at our website at www. hguard. com.
(a) Medical services and
supplies provided by physicians and other health care professionals
...................................... 12-21
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
................................................................ 25-28
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/
accidents....................................................................................................................................
29-31
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits....................................................................................................................
32
(f) Prescription drug benefits
..........................................................................................................................................
33-34
(g) Special features
...............................................................................................................................................................
35
Flexible Benefits Option
Centers of Excellence
Travel Benefit/
Services Overseas
(h) Dental benefits
................................................................................................................................................................
36
(i) Non-FEHB benefits available to Plan
members..............................................................................................................
37
Summary of benefits
..............................................................................................................................................................
53
2002 HealthGuard 11 Section 5 11
11
Page 12 13
Section 5( a) – Medical services and supplies provided by physicians and
other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
$10 per office visit to your primary care physician
$20 per office visit to a specialist
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
$10 per office visit to your primary care physician
$20 per office visit
to a specialist
At home $10 per visit from your primary care physician
$20 per visit from
a specialist
2002 HealthGuard 12 Section 5( a) 12
12
Page 13 14
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 if you receive these services during your office visit,
otherwise
$10 per office visit.
Preventive care, adult You pay
Routine screenings, such as:,
Total Blood Cholesterol – once every three (3) years.
Colorectal Cancer
Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening – every
three years starting at age 50 Annual physical
Chlamydial infection screening
$10 per office visit
Prostate Specific Antigen (PSA test) $10 per office visit
Routine pap
test
Note: The office visit is covered if pap test is received on the same
day; see Diagnostic and Treatment Services, above.
$10 per office visit to your primary care physician
$20 per office visit self-referred to a participating OB-Gyn office
Routine mammogram –covered for women age 35 and older, as follows:
From
age 35 through 39, one during this five year period
From age 40 through 64,
one every calendar year
At age 65 and older, one every two consecutive
calendar years
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and older and for all
adults at risk
$10 per office visit
2002 HealthGuard 13 Section 5( a) 13
13
Page 14 15
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
-Eye exams through age 17 to
determine the need for vision correction.
-Ear exams through age 17 to determine the need for hearing correction
-Examinations done on the day of immunizations (up to age 22)
$10 per visit when performed in Primary Care doctor's office
Maternity care You pay
Complete maternity (obstetrical) care, such
as:
Prenatal care
Delivery
Postnatal care
Note: Here are some
things to keep in mind:
You do not need to precertify your normal delivery;
see page 9 for other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend your inpatient
stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an
infant who requires non-routine treatment only if we cover the infant under a
Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits
(Section 5b).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
2001 HealthGuard 14 Section 5( a) 14
14 Page 15 16
Family planning You pay
A broad range of
voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine
devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the
prescription drug benefit.
$10 per office visit to your primary care physician
$20 per office visit
to a specialist
Not covered: reversal of voluntary surgical sterilization, genetic
counseling is excluded. All charges
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
-Intravaginal insemination (IVI)
-Intracervical
insemination (ICI)
-Intrauterine insemination (IUI)
Fertility
drugs, injectable
Note: We cover injectable fertility drugs under medical
benefits and oral fertility drugs under prescription drug benefit.
$10 per office visit
$20 per office visit to a specialist
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
All charges
Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit
$20 per office visit to a
specialist
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges
2002 HealthGuard 15 Section 5( a) 15
15
Page 16 17
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 24.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: – We will only cover GHT when we pre-certify the treatment. Call
800-447-0597 for pre-certification. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment; otherwise, we will
only cover GHT
services from the date you submit the information. If you do not ask or if we
determine GHT is not medically necessary, we
will not cover the GHT or
related services and supplies. See Services requiring our prior approval
in Section 3.
$10 per office visit to your primary care physician
$20 per office visit
to a specialist
Physical and occupational therapies You pay
60 visits or 60 days
whichever comes first, 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 -a graded exercise program under
continuous observation and with periodic monitoring of cardiac
response when deemed Medically Necessary for patients with a high-risk
medical condition defined by the HealthGuard Cardiac
Rehabilitation policy.
Covered Benefits are limited to eighteen (18) visits with a possibility of
eighteen (18) additional visits if a medical
reason exists for continued
monitoring.
$10 office visit copay
$10 per outpatient visit
$20 per office visit
to a specialist
Nothing per visit during covered inpatient admission
Physical and occupational therapies continued on next page.
2002
HealthGuard 16 Section 5( a) 16
16 Page 17 18
Physical and
occupational therapies (continued) You pay
Not covered:
Treatment of developmental delay, apraxic disorders and other
academic related problems, unless caused by injury or episodic
illness;
Aquatic therapy;
Equestrian therapy;
Recreation therapy;
Work hardening;
Massage
therapy;
Orthoptic therapy (visual therapy);
Music
therapy;
Infant stimulation;
Patterning therapy (except
for newborn children);
Cognitive therapy;
Multi-modality
clinics;
Other therapies not within the scope of the definition of
short-term rehabilitation therapy.
Therapy to maintain an already achieved level of function.
All charges
Speech therapy You pay
60 visits per condition Nothing
Hearing services (testing, treatment, and supplies) You pay
First
hearing aid and testing only when necessitated by accidental injury.
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit to Primary Care Physician
Not covered: all other hearing testing
hearing aids,
testing and examinations for them
All charges
.
2002 HealthGuard 17 Section 5( a) 17
17 Page 18 19
Vision services (testing, treatment, and supplies)
You pay
community vision care benefit approved by OPM, if any
One
pair of eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit
$20 per office visit to a specialist
Eye exam to determine the need for vision correction for children through age
17 (see preventive care children) $10 per office visit
$20 per office visit
to a specialist
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for them
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 office visit
$20 per office visit to a specialist
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges
2002 HealthGuard 18 Section 5( a) 18
18
Page 19 20
Orthopedic and prosthetic devices You pay
Externally worn breast
prostheses and surgical bras; including necessary replacement, following a
mastectomy;
The purchase, fitting, necessary adjustment and repairs of Medically
Necessary Orthotic Devices prescribed by a Plan PCP and
authorized in
advance by HealthGuard.
Custom molded foot Orthotics is limited to one pair
per calendar year.
A replacement of an Orthotic Device is covered only if there has been a
sufficient change in the Member's physical condition that
makes the original
device no longer functional.
The purchase, fitting, necessary adjustment,
repairs and replacements of Prosthetic Devices that replace all or part of an
absent body organ (including contiguous tissue) or replace all or part of the
function of a permanently inoperative or malfunctioning body
organ
(excluding dental appliances) as a result of Illness or Injury or congenital
defects. Such devices require a written prescription by a
Plan Provider and
must be authorized in advance by HealthGuard. Instruction and appropriate
services required for the Member to
properly use the item (such as
attachment or insertion) are covered. Expenses incurred as a result of the
misuse, negligence or loss or a
prosthetic appliance are not covered.
Non-dental treatment of temporomandibular joint (TMJ) pain dysfunction
syndrome, including orthopedic appliance.
Nothing
Not covered:
orthopedic and corrective shoes
arch
supports
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other
supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
Expenses incurred as a result of the misuse, negligence or
loss or a prosthetic appliance.
All charges
Durable medical equipment (DME) You pay
Durable Medical
Equipment shall mean equipment which is primarily and customarily used
to serve a medical purpose; can withstand
repeated use; generally is not
useful to a person in the absence of Illness or Injury; and is appropriate for
use in the home. All requirements of the
definition must be met before an
item can be considered to be Durable Medical Equipment. (Examples include:
wheelchairs and hospital beds)
Nothing
Durable medical equipment (DME) continued on next page.
2002
HealthGuard 19 Section 5( a) 19
19 Page 20 21
Durable medical
equipment (Continued) You pay
Not covered:
Motorized wheel chairs All charges
Home health services
Home health care ordered by 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.
The following services and supplies for Home Health Care are covered when
prescribed by the Plan PCP, determined to be Medically
Necessary by
HealthGuard, and provided by a Plan Home Health Care Agency. Pre-certification
must be obtained from HealthGuard.
HealthGuard shall not be required to
provide benefits for Home Health Care services when HealthGuard determines the
treatment setting is not
appropriate, or when there is a more cost effective
setting in which to provide appropriate care or member is not home bound. Home
Health
Care services include:
Professional services of a registered
nurse (R. N.) or licensed practical nurse provided that such nurse does not
ordinarily reside
in the Member's home or is not a member of the Member's immediate family.
Physical Therapy, Occupational Therapy, and Speech Therapy.
Medical and
surgical supplies provided by the Home Health Agency.
Medical social service consultation.
Dietician services.
Home medical
equipment.
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
2002 HealthGuard 20 Section 5( a) 20
20
Page 21 22
Chiropractic You pay
Chiropractic Care –for Medically Necessary
treatment of acute sciatica, back or neck pain, provided by a chiropractor who
is a Plan Provider
upon a Referral by a Plan Primary Care Physician, for up to twenty (20)
visits per calendar year.
Manipulation of the spine and extremities
Adjunctive procedures such as
ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack
application.
$10 per office visit
$20 per Specialist visit
Not covered:
Naturopathic services
Hypnotherapy
Maintenance therapy for chronic conditions
All charges
Alternative treatments
Acupuncture – by a Plan Provider up to a
maximum of thirty (30) visits per calendar year. Acupuncture will be covered for
chronic pain
syndrome when prescribed by a HealthGuard pain specialist as part of a
comprehensive pain program provided by a plan MD or DO.
Biofeedback Therapy –Medically Necessary biofeedback therapy for muscle
re-education of specific muscle groups or for treating
pathological muscle
abnormalities of spasticity, when provided by a Plan Provider. If more
conventional treatments are not successful,
treatment for incapacitating
muscle spasm or weakness is covered when part of a comprehensive pain management
program provided by a Plan
Provider.
$10 Primary Care Physician office visit copay
$20 per office visit to a
specialist
Not covered:
naturopathic services
hypnotherapy
maintenance therapy for chronic conditions
All charges
Educational classes and programs
Classes include:
Weight Management
Smoking Cessation
Diabetes Management
Childbirth
Please contact HealthGuard Member Services department at
800-822-0350 for more information.
Nothing
2002HealthGuard 21 Section 5( a) 21
21
Page 22 23
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.).
YOU 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 Normal pre-and
post-operative care by the surgeon
Correction of amblyopia and strabismus
Removal of tumors and cysts
Correction of congenital anomalies (see
reconstructive surgery) Insertion of internal prostethic devices. See 5( a) –
Orthopedic and
prosthetic devices for device coverage information. Surgical
treatment of morbid obesity --a condition in which an individual
weighs 100
pounds or 100% over his or her normal weight according to current underwriting
standards; eligible members must be age 18 or over
Nothing
Voluntary sterilization
Treatment of burns
$10 office visit co-pay
Biopsy procedures $10 PCP; $20 per office visit to a
specialist
Endoscopy procedures Treatment of fractures, including casting $20 per office
visit to a specialist
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.
Not covered: Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
All charge
2002HealthGuard 22 Section 5( b) 22
22
Page 23 24
Constructive 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.
Nothing
All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast prostheses and surgical bras and replacements (see Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in
the hospital up to 48 hours
after the procedure.
See above
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate; or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts; and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
Surgical intervention of
temporomandibular joint( TMJ)
$10 per office visit
$20 per office visit to a specialist
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
2002 HealthGuard 23 Section 5( b) 23
23
Page 24 25
Organ/ tissue transplants You pay Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single
–Double
Pancreas
Allogenetic (donor) bone marrow transplant
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 only 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 You pay
Professional services provided in:
Hospital (inpatient)
Nothing
Professional services provided in:
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
$10 per office visit
$20 per office visit to a specialist
2002 HealthGuard 24 Section 5( b) 24
24
Page 25 26
Section 5( c) -Services provided by a hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Sections 5( a) or (b).
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
All charges
2002 HealthGuard 25 Section 5( c) 25
25
Page 26 27
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 You pay
Some of HealthGuard's Plan Hospitals provide sub-acute facility care. Nothing
Skilled nursing facility (SNF): Services and supplies, including room and
board, provided during an admission at a Plan Skilled Nursing Facility are
Covered Services for 180 days only if all of the following conditions are
met: The member's Plan PCP recommends the Skilled Nursing Facility
admission; and The admission is for recovery from an Illness or Injury upon
release
from a prior Hospital stay, or the admission is in place of a
Hospital stay that would be required in the absence of these services or
supplies; and The Member is under the continuous care of his or her Plan PCP
or a
Plan Physician providing services at the direction of such Plan PCP;
and
The Member's Plan PCP certifies that he or she needs skilled nursing
care twenty-four (24) hours a day; and
The Member's admission is not for
Custodial Care or respite care; and the request for admission is pre-certified
by HealthGuard
In the event a Member elects to remain in the Skilled Nursing Facility after
the date that the Member's Plan PCP and/ or HealthGuard has
determined and
notified the Member that the Member no longer meets the criteria for continued
Inpatient confinement, the Member shall be fully
responsible for payment for
all services and supplies provided by the Skilled Nursing Facility, physicians
and/ or other Providers after such date
of notification. HealthGuard shall
not be financially responsible for any such service and supply provided after
such date of notification.
Nothing
Not covered: custodial care All charges
2002 HealthGuard 26 Section 5(
c) 26
26 Page
27 28
Hospice care
Hospice
shall mean an establishment which furnishes palliative care and supportive
services only to Members who have a medical condition
and prognosis of less than six (6) months to live and which is staffed and
equipped to:
Provide care either in the home or in a facility, or both, for persons who do
not require the full services of a Hospital or Skilled
Nursing Facility; and
Offer medial services under the direction of a physician and a continuous
twenty-four (24) hour registered nursing staff; and
Provide directly or by arrangement, social psychological or spiritual
services for the Member and his/ her family.
Covered Services.
Hospice care bereavement and pastoral counseling services for Member who has
been determined to be terminally ill by
the Member's Plan PCP are covered
only if each service or supply is furnished by a Plan Provider within six (6)
months from the date when
the terminally ill Member entered the Hospice care
program, is provided pursuant to a Referral by the Member's Plan PCP and is
pre-certified
by HealthGuard. Services may include home and Hospital visits
by nurses and social workers, pain management and symptom
control,
instruction and supervision of a family Member, Inpatient care, counseling and
emotional support; and other Home Health Care
services. Hospice care
benefits are limited to a Maximum of thirty (30) days of Inpatient care in a
Plan Hospice facility and one hundred eighty
(180) days of in-home care, per
Member per lifetime.
Nothing
Not Covered:
funeral arrangements
financial or legal
counseling
homemaker or caretaker services
any service not
solely related to the care of the Member
Sitter or companion services
for the Member or other Members of the family
Transportation
house cleaning
services and supplies
provided during periods of remission
maintenance of the house
All charges
2002 HealthGuard 27 Section 5( c) 27
27
Page 28 29
Ambulance
Covered Benefits are provided for ambulance service
providing local transportation by means of a specially designed and equipped
vehicle used only for transporting the acutely sick and Injured from a
Member's home or scene of the accident or Emergency to a
Hospital.
To be
covered, the transportation must be to the closest institution that can provide
Covered Services appropriate to the Member's
condition. If there is no Participating facility in the local area that can
provide Covered Services appropriate to the Member's
condition,, the
transportation must be to the closest facility outside the local area that can
provide the necessary service.
Covered Benefits are also available for Emergency Services actually provided
by an advanced life support unit even though the
unit does not provide
transportation.
Special ground or air transportation will be covered when
deemed Medically Necessary by HealthGuard.
Nothing
Not covered:
Routine transportation between facilities and/ or
office sites. All Charges
2002 HealthGuard 28 Section 5( c) 28
28
Page 29 30
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.
2002 HealthGuard 29 Section 5( d) 29
29
Page 30 31
What
to do in case of emergency:
Availability. Covered Benefits are provided
for Emergency Services and Urgent Care twenty-four (24) hours per day, seven (7)
days per week, subject to the following conditions and limitations.
No Pre-Certification. Pre-Certification is not required for Emergency
Services.
Plan Hospital. Urgent Care must be provided at a Plan
Hospital, except in such instances where a Member's medical condition would be
jeopardized if treatment is delayed or when the Member experiences symptoms
requiring Urgent
Care while outside of the Service Area.
Emergencies within our service area:
Professional and Hospital
Services. Urgent Care and/ or Emergency Services.
Urgent Care must be
arranged by the Member's Plan PCP and authorized in accordance with
HealthGuard's policies and procedures. FAILURE TO COMPLY WITH THIS SECTION
MAY RESULT IN NON-PAYMENT
OF SERVICES PROVIDED. The Member may obtain
Emergency Services from the closest Provider. Emergency Services do not require
prior contact with the Member's Plan PCP. However, the Member or the
Provider of the Emergency Services shall use their best efforts to contact the
Member's Plan PCP and authorized care according to HealthGuard's
policies
and procedures. If care is Medically Necessary and appropriate, a Hospital
emergency room visit will be covered. An emergency
room Copayment is payable
by a Member unless the Member has been referred to an emergency room by a Plan
Primary Care Physician or by HealthGuard. Copayments will be waived if the
Member is hospitalized directly
from the emergency room. If a Member is
admitted to a Plan Hospital for Inpatient Emergency Services, the Provider of
Emergency Service
must contact the Member's Plan PCP within forty-eight (48)
hours or the next business day, whichever is later, unless it was not reasonable
possible to do so. FAILURE TO COMPLY MAY RESULT IN NON-PAYMENT
OF
SERVICES PROVIDED. If contact is not made within the designated time frame(
s), HealthGuard will only be financially responsible for
services provided
after the date of notification, provided the medical condition meets
HealthGuard's Medically Necessity review criteria.
Emergencies outside our service area:
Professional and Hospital
Services. A Member will be entitled to benefits for Urgent Care and/ or
Emergency Services received outside the Service Area provided: (1) delay in
receipt of such services until the Member could
access services at a Plan facility would jeopardize his/ her life or health,
and (2) the Member could not reasonably have been able to anticipate the need
for such services prior to having to access care or prior to leaving the Service
Area.
Urgent Care should be arranged by the Member's Plan PCP and
authorized in accordance with HealthGuard's policies and procedures. If contact
with the Member's Plan PCP cannot be made prior to receiving the Urgent
Care services, the Member must notify the Member's Plan PCP as soon as
reasonably possible following the urgent care service.
The Member may obtain Emergency Services from the closest Provider. Emergency
Services do not require prior contact with the Member's Participating PCP.
However, the Member or the Provider of the Emergency
Services shall use
their best efforts to contact the Member's Plan PCP within twenty-four (24)
hours or treatment and released, unless it was not reasonable possible to do so.
All follow-up services must be arranged by the
Member's Plan and authorized
according to HealthGuard's policies and procedures.
If care was Medically
Necessary and appropriate, a Hospital emergency room visit will be covered. An
emergency room Copayment is payable by a Member unless the Member has been
referred by a Plan Primary
Care Physician or by HealthGuard. Copayments shall be waived if the Member is
hospitalized directly from the emergency room.
2002 HealthGuard 30 Section 5( d) 30
30
Page 31 32
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
$25, waived if admitted
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area You pay
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
$25, waived if admitted
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 You pay
Covered Benefits are provided for ambulance
service providing local transportation by means of a specially
designed and equipped vehicle used only for transporting the acutely sick and
Injured from a Member's home or scene of
the accident or Emergency to a
Hospital.
To be covered, the transportation must be to the closest
institution that can provide Covered Services appropriate to
the Member's condition. If there is no Plan facility in the local area that
can provide Covered Services appropriate to the
Member's condition,, the
transportation must be to the closest facility outside the local area that can
provide the necessary
service.
Covered Benefits are also available for
Emergency Services actually provided by an advanced life support unit even
though
the unit does not provide transportation.
Special ground or air
transportation will be covered when deemed Medically Necessary by HealthGuard.
Routine
transportation between facilities and/ or office sites are not covered.
Nothing
Not covered:
Routine transportation between facilities and/ or
office sites
All Charges
2002 HealthGuard 31 Section 5( d) 31
31
Page 32 33
Section 5( e) – Mental health and substance abuse benefits
Network
Benefit
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 PREAUTHRIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
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
$20 per office visit
Diagnostic tests $20 per (visit or test)
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
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:
For access, please contact Magellan at 800-332-1024.
Limitation We may limit your benefits if you do not obtain a
treatment plan.
2002 HealthGuard 32 Section 5( e) 32
32 Page 33 34
Section 5( f) – Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the
prescription – or – A plan physician or licensed dentist must write the
prescription.
Where you can obtain them. You must fill the prescription at a plan
pharmacy, or by mail for a maintenance medication.
We use a formulary.
HealthGuard has an open formulary with a preferred list of medications. A
drug formulary is a listing of products that an organization such as a hospital
or an HMO considers the preferred medications for
patient use. HealthGuard's
formulary is for outpatient drug therapy. The products listed are considered to
be the most effective in both health outcome and cost in each therapeutic
category. The formulary is a guide for
physicians for medication use. The
Plan's drug formulary is reviewed monthly by the Medical Policy and Technology
Committee. The committee consists of the Plan's Medical Director and ten
community physicians who
have direct input into the decisions of the
committee. The committee's goal is to develop appropriate utilization of
prescription medication while maintaining cost controls. New drugs and therapies
that become available, as well as
existing drugs and therapies, are reviewed
for safety, therapeutic value and cost. Based on these factors, drugs are added
or deleted from the formulary.
These are the dispensing limitations. The retail and mail order
prescription drug benefit operates with the following quantities/ limitations:
Maximum Day Supply is 34 days; Maximum Unit Supply is 100 units; Mail
Service – Maximum Day Supply is 90 days; Mail Service – Maximum Unit Supply
is unlimited. Copayments for Generic Drugs are $10 for a 34-day supply, $25 for
Preferred Brand for a 34-day supply and $40 for Non-Preferred
Brand Name
Drugs for a 34-day supply. Prior authorizations are required for injectables
(except for imitrex, insulin, lovenex). For those medications that exceed $500
in cost your physician will need to establish
medical necessity.
A
generic equivalent will be dispensed if it is available, unless your physician
specifically requires a name brand. If you receive a name brand drug when a
Federally-approved generic drug is available, and your
physician has not specified Dispense as Written for the name brand drug, you
have to pay the difference in cost between the name brand drug and the generic.
Why use generic drugs? Generic drugs offer a safe and economic way to
meet your prescription drug needs. The generic name of a drug is its chemical
name; the name brand is the name under which the manufacturer
advertises and
sells a drug. Under federal law, generic and name brand drugs must meet the same
standards for safety, purity, strength, and effectiveness. A generic
prescription costs you – and us – less than a name-brand
drug.
2002 HealthGuard 33 Section 5( f) 33
33
Page 34 35
Here
are some things to keep in mind about our prescription drug program: You now
have a Three Tier Prescription Drug Program. The program is designed to help
members access
the medications that they need while aiding employers in
controlling the rising costs of health care. What does this three tier benefit
mean to me?
If you have prescription drug coverage, it means you will
continue to have coverage for the prescription drugs you need. However, you may
notice a difference in what you pay at the
pharmacy. With this benefit
design, your out of pocket expense will vary depending on the tier in which your
prescription drug falls. Our goal is to encourage you to choose value in your
prescriptions. This Three Tier Prescription Drug Program offers you
important advantages including:
-Coverage for a wide range of medications
-Protection for you if you need expensive medications
-Opportunity for you
to lower your out of pocket costs by using generic or preferred brand drugs
whenever possible
When you have to file a claim. Please call HealthGuard Member Services
at 800-822-0350 to request a form to be sent to AdvancePCS (HealthGuard's
Prescription Benefit Manager).
Benefit Description You pay
Covered medications and supplies
Covered medications and accessories include:
Drugs for which a
prescription is required by law
Oral and injectable contraceptive drugs;
contraceptive diaphragms
Insulin, with a copay charge applied to each vial
Disposable needles and syringes needed to inject covered prescribed
medication, including insulin
Glucose test strips for diabetics, when prescribed by a Plan doctor
Allergy serum
Intravenous fluids and medication for home use and Depo
Provera are covered under Medical and Surgical Benefits.
Ostomy bags and wafers (365 per calendar year per member)
Oral fertility
drugs
Growth hormone
$10 copayment for Preferred Generic Drugs per 34-day supply
$25 copayment
for Brand Name Drugs per 34-day supply
$40 copayment for Non-preferred
Note: If there is no generic equivalent available, you will still
have to
pay the brand name copay.
Drugs for sexual dysfunction (see Prior authorization above)
Not
covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Nonprescription medicines
All Charges
2002 HealthGuard 34 Section 5( f) 34
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Page 35 36
Section 5( g). Special features
Feature Description
Centers of
excellence for transplants/ heart
surgery/ etc
Centers of Excellence are any Hospital or facility designated by HealthGuard
at which HealthGuard will authorize payment for covered transplant services and
covered complex surgical procedures for Members.
Travel benefit/ services overseas Members who are approved by
HealthGuard to receive Transplants from a transplantation center more than 150
miles from their home will be entitled to the following travel benefits provided
if their residence is located within the
HealthGuard Service Area:
Transportation, by the most appropriate means, for the Member from his
or her home to the transplantation center at the time of transplant.
Transportation and temporary housing for the Member and one caregiver
to
accompany the Member for evaluation and pre-and post-transplantation care which
must be delivered at the transplantation center.
Lodging expense is limited to a Maximum of $100.00 per day unless approved in
advance by HealthGuard.
Food and other miscellaneous expenses are not reimbursable.
Total
lifetime reimbursement for transplantation-related travel expenses is
limited to $10,000.00.
2002 HealthGuard 35 Section 5( g) 35
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Page 36 37
Section 5( h) – Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization
for dental procedures only when a nondental physical impairment exists which
makes hospitalization necessary to safeguard the health of the patient; we do
not
cover the dental procedure unless it is described below.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage,
including with Medicare.
I M
P O
R T
A N
T
Description You Pay
Accidental injury benefit
We cover
restorative services and supplies necessary to promptly repair (but not replace)
sound natural teeth. The need for these
services must result from an
accidental injury.
$10 office visit Copay
$20 office visit to a
specialist
Dental Benefits
We have no other dental benefits.
2002 HealthGuard 36 Section 5( h) 36
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Page 37 38
Section 5( i) -Non-FEHB benefits available to Plan members
The
benefits on this page are not part of the FEHB contract or premium, and you
cannot file an FEHB disputed claim about them. Fees you pay for these
services do not count toward FEHB deductibles or out-of-pocket
maximums.
HealthGuard's Fitness Club Reimbursement Benefit.
We feel that it
is important to encourage our members, ages 18 and above, to adopt a healthy
lifestyle. Physical fitness has been shown to lower the risks of certain
diseases, such as heart disease.
We wish to encourage those who have been in a program to continue with your
program and for those who have not yet begun a program to get started. We
strongly encourage you to see your physician before beginning any exercise
program, especially if you have cardiovascular risk factors such as high
blood pressure, high cholesterol, sedentary lifestyle, tobacco use or a family
history of heart disease.
HealthGuard has designated specific Health and Fitness Clubs to participate
in the Cardiovascular Disease Reduction Fitness Program. These clubs have met
specific criteria that are essential to participate in this program.
There
are several changes in the fitness requirements as outlined in the Question
& Answer section to follow.
HOW DO I QUALIFY FOR THE NEW FITNESS
REIMBURSEMENT PROGRAM?
You must be a current HealthGuard member at the time
of joining the health and fitness club and at the time of reimbursement.
You
must be eligible under your HealthGuard plan for the fitness reimbursement
program. You must be a member of HealthGuard and a member of the HealthGuard
Designated Health and Fitness Club
for 12 consecutive months beginning in
January, to submit an application. You must participate in the fitness program
for a minimum of 104 visits.
Wellness Programs
As a Plan participant, you and all covered
family members are eligible to participate in various programs that promote
better health. The class program topics include weight management, diabetic
education, heart/ blood pressure, childbirth
classes and cholesterol management. The Plan pays the full amount for the
cost of each approved class. Member Services must be contacted in order to
register for the approved classes. For more information on the various classes
available, call Member Services at 717-560-3353 or toll-free at
800-822-0350.
2002 HealthGuard 37 Section 5( i) 37
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Page 38 39
Section 6 – General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat
your
illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you
are not enrolled in this Plan;
Services, drugs, or supplies that are not
medically necessary;
Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program.
2002 HealthGuard 38 Section 6 38
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Page 39 40
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.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, Hospital and In most cases, providers and facilities file
claims for you. Physicians must Prescription Drug Benefits 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 800-822-0350.
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:
HealthGuard, 280 Granite Run Drive, Lancaster, PA 17601
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.
2002 HealthGuard 39 Section 7 39
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Page 40 41
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: HealthGuard, 280 Granite Run
Drive, Lancaster, PA 17601; 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 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
medical 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.
2002 HealthGuard 40 Section 8 40
40
Page 41 42
The
Disputed Claims Process (Continued)
Note: You are the only person who
has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific
written consent with the review
request.
Note: The above deadlines may
be extended if you show that you were unable to meet the deadline because of
reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services drugs or supplies or from the year in which you were denied
precertification or prior approval. This is the
only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was before
OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life-threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or precertification/ prior approval, then call us at 800-447-0597 and we will
expedite our review; or
(b) We denied your initial request for care or
precertification/ prior approval, then:
-If we expedite our review
and maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
-You can call OPM's Health Benefits Contracts Division 3 at 202/
606-0737 between 8 a. m. and 5 p. m. Eastern time.
2002 HealthGuard 41 Section 8 41
41
Page 42 43
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
healthcare expenses without regard to fault. This is called "double
coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is primary according to
the National Association of Insurance
Commissioners' guidelines.
When we
are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up to our
regular benefit. We will not pay more than our allowance
What is Medicare? Medicare is a Health Insurance Program for:
-People 65 years of age and older.
-Some people with
disabilities, under 65 years of age.
-People with End-Stage Renal
Disease (permanent kidney failure requiring dialysis or a transplant).
Medicare has two parts:
-Part A (Hospital Insurance). Most people
do not have to pay for Part A. If you or your spouse worked for at least 10
years in Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was
a Federal employee on january 1, 1983 or since automatically qualifies.)
Otherwise, if
you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE for more information.
-Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security check
or
your retirement check.
If you are eligible for Medicare, you may have
choices in how you get your health care. Medicare + Choice is the term used to
describe the various health plan choices
available to Medicare
beneficiaries. The information in the next few pages shows how we coordinate
benefits with Medicare, depending on the type of Medicare
managed care plan
you have.
The Original Medicare Plan (Part A or Part B) The Original Medicare
Plan (Original Medicare) is available everywhere in the
United States. It is
the way everyone used to get Medicare benefits and is the way most people get
their Medicare Part A and Part B benefits now. You may
go to any doctor,
specialist, or hospital that accepts Medicare. The Original Medicare Plan pays
its share and you pay your share.
Some things are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care.
2002 HealthGuard 42 Section 9 42
42
Page 43 44
The
following chart illustrates whether the Original Medicare Plan or this
Plan should be the primary payer for you according to your employment status and
other factors determined by Medicare. It is critical that you tell us if you or
a
covered family member has Medicare coverage so we can administer these
requirements correctly.
Primary Payer Chart
Then the primary payer
is… A. When either you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Areanactiveemployee withthe
Federalgovernment(includingwhen youor afamilymemberare eligibleforMedicaresolely
becauseofadisability), !
2) Are an annuitant, !
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB or !
b) the position is not excluded from FEHB (Ask your employing office which of
these applies to you.) !
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge), !
5) Are enrolled in Part B only,
regardless of your employment status, ! (for Part B
services)
!
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
!
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, !
2) Have completed the 30-month ESRD
coordination period and are still eligible for Medicare due to ESRD, !
3)
Become eligible for Medicare due to ESRD after Medicare became primary for you
under another provision, !
C. When you or a covered family member have
FEHB and…
1) Are eligible for Medicare based on disability, and
a)
Are an annuitant, or !
b) Are an active employee, or !
c) Are a former spouse of an annuitant, or !
d) Are a former spouse of an
active employee … !
2002 HealthGuard 43 Section 9 43
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Page 44 45
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
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 800-822-0350.
We waive some costs when you have the Original Medicare Plan --When
Original Medicare is the primary payer, we will waive some out-of-pocket
costs, as follows:
Medical services and supplies provided by physicians
and other health
care professionals.
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:
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. If you enroll in a Medicare managed care
plan, tell us. We will need to know whether you are in the Original Medicare
Plan or in a Medicare managed care plan so we can correctly coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in a
Medicare managed care plan: If you are an annuitant or former spouse, you
can suspend your FEHB
coverage to enroll in a Medicare managed care plan,
eliminating your FEHB premium. (OPM does not contribute to your Medicare managed
care plan
premium.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB
Program,
generally you may do so only at the next open season unless you
involuntarily lose coverage or move out of the Medicare managed care plan's
service area. If you do not enroll in
Medicare Part A or Part B
If you do not have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare
Part B
and, if you can't get premium-free Part A, we will not ask you to enroll in it.
HealthGuard 2002 44 Section 9 44
44
Page 45 46
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or
State agency determines
they must provide; or
OWCP or a similar agency pays for through a third
party injury settlement or other similar proceeding that is based on a claim you
filed
under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your treatment, we will cover your care. You must use our
providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for 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.
2002 HealthGuard 45 Section 9 45
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Page 46 47
Section 10 -Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 10.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Care, including room and board, that a) does
not require the skills of technical or professional personnel on a daily basis;
b) is not furnished by
or under the supervision of such personnel or does
not otherwise meet the requirements of Skilled Nursing Facility care; or c) is
at a level such that
the Member has reached the maximum level of physical or
mental function and such person is not likely to make further significant
improvement.
Examples of Custodial Care include, but are not limited to,
assistance in walking, getting in and out of bed, bathing, dressing, feeding, or
using the
toilet; changing dressings of non-infected, post operative or
chronic conditions; preparation of special diets; supervision of medication
which
can be self-administered by the Member; general maintenance care of
colostomy or ileostomy; residential care and adult day care; protective and
supportive care including educational services, rest cures and convalescent
care.
Experimental or investigational Procedures not in accordance with
generally accepted medical services practice are not covered.
Prescription drugs and medications are not
covered unless they are
prescribed in accordance with the Food and Drug Administration guidelines.
Us/ We Us and we refer to HealthGuard
You You refers to the
enrollee and each covered family member.
2002 HealthGuard 46 Section 10 46
46
Page 47 48
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 remarry.
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.
2002 HealthGuard 47 Section 11 47
47
Page 48 49
When
benefits and Premiums start The benefits in this brochure are effective on
January 1. If you joined this Plan during
Open Season, your coverage begins
on the first day of your first pay period that starts on or after January 1.
Annuitants' coverage and premiums begin on January 1. If
you joined at any
other time during the year, your employing office will tell you the effective
date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as
other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when
coordinating benefit payments and subrogating claims;
Law
enforcement officials when investigating and/ or prosecuting alleged civil or
criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal
service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as Temporary Continuation
(TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary Continuation of
Coverage and Former Spouse Enrollees, or
other information about your coverage choices.
Temporary Continuation of
Coverage (TCC) If you leave Federal service, or if you lose coverage because
you no longer
qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are
not able to continue your FEHB enrollment after you retire, if you lose your
job, if you are a covered dependent child and you turn 22 or
marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
2002 HealthGuard 48 Section 11 48
48 Page 49 50
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, from your
employing or retirement office or from www. opm. gov/ insure. It explains
what you have to do to enroll.
Converting to You may convert to
an 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 The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) of Group Health is a Federal law that
offers limited Federal protections for health coverage availability
Plan
Coverage 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.
2002 HealthGuard 49 Section 11 49
49
Page 50 51
Long
Term Care Insurance is Coming Later in 2002
The Office of Personnel
Management (OPM) will sponsor a high-quality long term care insurance program
effective in October 2002. As part of its educational effort, OPM asks you to
consider these questions:
What is long term care It's insurance to
help pay for long term care services you may need (LTC) insurance? 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, in an assisted living facility, care in
your home, adult day care,
hospice care, and more. LTC insurance can supplement care provided by family
members, reducing the burden you place on them.
I'm healthy. I won't need Welcome to the club! Long term care.
76% of Americans believe they will never need long term care, but the
Or will I? Facts are that about half of them will. And it's not just
the old folks. About 40% of people needing long term care are under age 65. They
may need chronic care due to a serious accident, a stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but
everyone should have a plan just in case. Many people now consider long term
care insurance
to be vital to their financial and retirement planning.
Is long term care expensive? Yes, it can be very expensive. A year in
a nursing home can exceed
$50,000. Home care for only three 8 – hour shifts a week can exceed $20,000 a
year. And that's before inflation!
Long term care can easily exhaust your
savings. Long term care insurance can protect your savings.
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5
(c) of your FEHB brochure. Health plans don't cover custodial care or
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.
2002 HealthGuard 50 Long Term Care Insurance
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. 50
50
Page 51 52
Long Term Care Insurance Continued
When will I get more
Employees will get more information from their agencies during
information on how to the LTC open enrollment period in the late summer/
early fall of
apply for this new coverage? 2002. Retirees will
receive information at home.
How can I find out Our toll-free teleservice center will begin in
med-2002. In the More about the meantime, you can learn more about the
program on our web site
Program NOW? at www. opm. gov/ insure/ ltc.
2002 HealthGuard 51 Long Term Care Insurance 51
51 Page 52 53
Index
Do not rely on this page; it is for
your convenience and may not show all pages where the terms appear.
Accidental injury 36 Allergy tests 15
Alternative treatment 21
Allogenetic (donor) bone
marrow transplants 24 Ambulance 25
Anesthesia
24 Autologous bone marrow
transplant 16, 24 Biopsy 22
Blood and blood plasma 25 Casts 25
Changes for 2002 6 Chemotherapy
16
Childbirth 21 Chiropractic 21
Cholesterol tests 13, 37 Claims 39
Coinsurance 5, 10 Colorectal cancer screening 13
Congenital anomalies
22, 23 Contraceptive devices and drugs 15,
34 Coordination of benefits 43
Deductible 5, 10 Definitions 46
Dental care 36 Diagnostic
services 13
Disputed claims review 40 Donor expenses (transplants) 24
Dressings 25, 26 Durable medical equipment
(DME) 19 Educational
classes and programs
21 Effective date of enrollment 46
Emergency 29
Experimental or investigational
38 Eyeglasses 18
Family planning
15
Fecal occult blood test 13 General Exclusions 38
Hearing
services 17 Home health services 20
Hospice care 27 Home nursing care 20
Hospital 23 Immunizations 13, 14
Infertility 15 Inpatient
Hospital Benefits 25
Insulin 33, 34 Laboratory and pathological
services 13 Magnetic Resonance Imagings
(MRIs) 13 Mail Order
Prescription Drugs
33 Mammograms 13
Maternity Benefits 14 Medicaid 45
Medically necessary 9, 12 Medicare 42
Members 5 Mental Conditions/
Substance
Abuse Benefits 32 Newborn care 14
Non-FEHB Benefits 37
Nurse
Licensed Practical Nurse 20 Nurse Anesthetist 25
Registered Nurse
20 Nursery charges 14
Obstetrical care 14 Occupational therapy 16
Ocular injury 18 Office visits 5
Oral and maxillofacial surgery 11
Orthopedic devices 19
Ostomy and catheter supplies 34 Out-of-pocket expenses
10
Outpatient facility care 26 Oxygen 20
Pap test 13 Physical examination 5
Physical therapy 16 Physician
12, 22
Precertification 22 Preventive care, adult 13
Preventive care,
children 14 Prescription drugs 33
Preventive services 13, 14 Prior approval
9
Prostate cancer screening 13 Prosthetic devices 19
Psychologist 32
Psychotherapy 32
Radiation therapy 16 Renal dialysis 16
Room and
board 25 Second surgical opinion 12
Skilled nursing facility care 12,
24 Smoking cessation 21
Speech therapy 17 Splints 25
Sterilization
procedures 15, 22 Subrogation 45
Substance abuse 32 Surgery 22
Anesthesia 24 Oral 23
Outpatient 24 Reconstructive 23
Syringes 34
Temporary continuation of
coverage 42 Transplants 24
Treatment
therapies 16 Vision services 18
Well child care 14 Wheelchairs
19
Workers' compensation 45 X-rays 13
2002 HealthGuard 52 Index 52
52 Page 53 54
Summary of
benefits for HealthGuard -2002
Do not rely on
this chart alone. All benefits are provided in full unless indicated and are
subject to the
definitions, limitations, and exclusions in this brochure. On
this page we summarize specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
Office visit copay: $10 primary care; $20 specialist 12
Services provided by a hospital: Inpatient
............................................................................................
Outpatient
.........................................................................................
Nothing 25
26
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$25 (waived if admitted to the hospital)….
$25 (waived if admitted to the hospital)….
31
31
Mental health and substance abuse
treatment..................................... Regular cost sharing. 32
Prescription
drugs...............................................................................
$10 Preferred Generic for 34-day supply
$25 Preferred Brand for 34-day
supply $40 Non-preferred Brand for 34-day
supply
33
Dental Care
.....................................................................................
No Benefit 37
Vision Care
.....................................................................................
No benefit 18
Special Features
..............................................................................
Wellness Programs and Fitness Club Reimbursement
38
2002HealthGuard 53 Summary of Benefits 53
53
Page 54
2002 Rate Information for
HealthGuard
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 .
Type of Enrollment Code
Non-Postal Premium
Biweekly Monthly
Gov't Your Gov't Your Share Share Share
Share
Postal Premium
Biweekly
USPS Your Share Share
Location Information
High Option Self Only
High Option Self & Family
NQ1
NQ2
$74.68 $24.89 $161.81 $53.93
$194.18 $64.72 $420.71 $140.24
$88.37 $11.20
$229.79 $29.13 54