2002 www. bcbscny. org
A
Health Maintenance Organization
with a point of service product
Serving: Central New York
Enrollment in this Plan is limited. You
must live or work in our geographic service area to enroll. See page 3 for
requirements.
This Plan has full accreditation from the NCQA. See the 2001 Guide for
More information on NCQA.
Enrollment codes for this Plan:
EB1 Self Only EB2 Self and Family
RI 73-461
For changes
in benefits see
page 5
An Independent Licensee of the BlueCross BlueShield Association 1
1 Page 2 3
2
2 Page
3 4
2002 HMO-CNY i Table of Contents
Table of Contents
Introduction………………………………………………………………….
...........................................................................................
1
Plain
Language………………………………………………………………...........................................................................................
1
Inspector General Advisory
.......................................................................................................................................................................
2
Section 1. Facts about this HMO plan
......................................................................................................................................................
3
How we pay providers
.............................................................................................................................................................
3
Your
Rights..............................................................................................................................................................................
3
Service
Area.............................................................................................................................................................................
4
Section 2. How we change for
2002………………………………………..............................................................................................
5
Program-wide changes
.............................................................................................................................................................
5
Changes to this
Plan.................................................................................................................................................................
5
Section 3. How you get care …………...
.................................................................................................................................................
6
Identification
cards...................................................................................................................................................................
6
Where you get covered
care.....................................................................................................................................................
6
Plan providers
....................................................................................................................................................................
6
Plan facilities
.....................................................................................................................................................................
6
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
Coinsurance
.....................................................................................................................................................................
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.................................... 20
(c) Services provided
by a hospital or other facility, and ambulance
services.................................................................. 24
(d) Emergency services/ accidents
.....................................................................................................................................
27
(e) Mental health and substance abuse benefits
................................................................................................................
29
(f) Prescription drug
benefits............................................................................................................................................
30
(g) Special features
...........................................................................................................................................................
33
(h) Dental
benefits.............................................................................................................................................................
34
Section 6. General exclusions --things we don't
cover...........................................................................................................................
35
Section 7. Filing a claim for covered services
........................................................................................................................................
36 3
3 Page 4 5
2002 HMO-CNY ii Table of Contents
Section 8.
The disputed claims
process...................................................................................................................................................
37
Section 9. Coordinating benefits with other coverage
............................................................................................................................
39
When you have…
Other health coverage
.....................................................................................................................................................
39
Original Medicare
...........................................................................................................................................................
39
Medicare managed care plan
..........................................................................................................................................
41
TRICARE/ Workers' Compensation/
Medicaid.......................................................................................................................
41
Other Government
agencies...................................................................................................................................................
42
When others are responsible for
injuries................................................................................................................................
42
Section 10. Definitions of terms we use in this
brochure........................................................................................................................
43
Section 11. FEHB
facts...........................................................................................................................................................................
45
Coverage
information...........................................................................................................................................................
45
No pre-existing condition limitation
..............................................................................................................................
45
Where you get information about enrolling in the FEHB
Program...............................................................................
45
Types of coverage available for you and your
family....................................................................................................
45
When benefits and premiums
start.................................................................................................................................
45
Your medical and claims records are confidential
.........................................................................................................
46
When you retire
............................................................................................................................................................
46
When you lose benefits
......................................................................................................................................................
46
When FEHB coverage ends
...........................................................................................................................................
46
Spouse equity
coverage.................................................................................................................................................
46
Temporary Continuation of Coverage (TCC)
...............................................................................................................
46
Converting to individual
coverage................................................................................................................................
47
Getting a Certificate of Group Health Plan
Coverage...................................................................................................
47
Long term care insurance is coming later in 2002
...................................................................................................................................
48
Index
............................................................................................................................................................................................
49
Summary of benefits
................................................................................................................................................................................
51
Rates………………………………………………………………………………………………..........................
………….. Back cover 4
4 Page
5 6
2002 HMO-CNY 1 Introduction/ Plain Language
Introduction
HMO-CNY
P. O. Box 4712, 344 South Warren Street
Syracuse, N. Y.
13221-4712
This brochure describes the benefits of HMO-CNY under our contract (CS 2318)
with the Office of Personnel Management (OPM),
as authorized by the Federal
Employees Health Benefits law. This brochure is the official statement of
benefits. No oral statement
can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family
coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits that were available before
January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and are summarized on
page 51. 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 HMO-CNY.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us"
feedback area at www. opm.
gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street,
NW Washington, DC 20415-3650. 5
5 Page 6 7
2002 HMO-CNY 2
Inspector General Advisory
Inspector General Advisory
Fraud
increases the cost of health care for everyone. If you suspect that a physician,
pharmacy, or hospital has charged you for services you did not receive,
billed you twice
for the same service, or misrepresented any information, do
the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 800/ 447-6269 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.
Stop health care fraud! 6
6 Page 7 8
2002 HMO-CNY 3 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that
contract with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to
treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments,
coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot
change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. Plan
providers accept a
negotiated payment from us, and you will be only
responsible for copayments or coinsurance.
HMO-CNY is an independent corporation organized under the Public Health Law
and Insurance Law of New York State and an
independent practice association
health plan founded in 1984. HMO-CNY operates under a license with the Blue
Cross and Blue
Shield Association (an association of independent Blue Cross
and Blue Shield Plans) which permits HMO-CNY to use the Blue Cross
and Blue
Shield service marks in a portion of New York State. HMO-CNY is solely
responsible for honoring its agreement to provide
or administer benefits for
health care.
A primary care physician selected by you from the Provider Directory will
provide or arrange your health care services. If your
selected physician is
on vacation or if you are in need of an urgent care visit, etc., appropriate
physician coverage will be available. In
addition, we have participating
physician specialists available that provide a wide range of professional
services.
If you have a question about selecting a personal physician from the
Directory or have a question regarding the Plan, a marketing
representative
will gladly assist you. HMO-USA guest membership benefits are available to
subscribers and their dependents if
medical care is needed outside of the
Plan's service area for an extended period of time. This benefit includes access
to primary care
doctors in the out-of-area location (i. e. an eligible
student dependent attending college outside this Plan's service area). HMO-USA
is
a network of Blue Cross and Blue Shield HMOs that can coordinate your
medical care. If you need more information, the Plan can
tell you more about
its reciprocity benefits.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may get information about your
health
plan, its 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:
HMO-CNY complies with State licensing effective May 16, 1988 through the New
York State Department of Health (NYSDOH).
HMO-CNY has a three year accreditation by the National Committee for Quality
Assurance (NCQA).
HMO-CNY has a Health Maintenance Organization certificate
of Authority to operate pursuant to Article 44 of the New York State Public
Health Law effective May 16, 1988.
HMO-CNY is a privately owned for profit corporation.
HMO-CNY meets State,
Federal, and accreditation requirements for fiscal solvency, confidentiality and
transfer of medical records.
If you want more information about us, call 800/ 447-6269, or write to
HMO-CNY, P. O. Box 4712, 344 South Warren Street,
Syracuse, N. Y.
13221-4712. You may also contact us by fax at 315/ 448-4922 or visit our website
at www. bcbscny. org . 7
7 Page 8 9
2002 HMO-CNY 4 Section 1
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: The New
York counties
of: Broome, Cayuga, Chemung, Cortland, Onondaga, Oswego, Schuyler, Steuben,
Tioga, and Tompkins and the zip
codes listed in the following counties:
Madison County (NY), 13030, 13032, 13035, 13037, 13038, 13043, 13043, 13051,
13052.
Chenango County (NY), 13730, 13733, 13830, 13778, Delaware County
(NY), 13742, 13755, 13756, 13783, 13804, 13838, 13804,
13838, 13839.
Benefits for care outside the service area are limited to emergency services
as described on page 27.
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. However, you may also contact your primary care
physician to get a referral.
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. Guest Membership is available in most parts of the
United States from HMO-USA.
Contact HMOBlue for more information regarding
Guest Membership. 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. 8
8 Page 9
10
2002 HMO-CNY 5 Section 2
Section 2.
How we change for 2002
Do not rely on these change descriptions; this
page is not an official statement of benefits. For that, go to Section 5
Benefits. Also,
we edited and clarified language throughout the brochure;
any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will decrease by -10% for Self Only or
–16.1% for Self and Family.
We added a new Section after Section 11 to
discuss the Long Term Care Insurance Program that is coming in 2002. (Section
11)
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))
You now pay
nothing for second surgical opinion, adult and child preventive care, and
routine immunizations (Section 5( a))
You now pay nothing for allergy care
treatment, treatment therapies, hearing and vision services.
You now pay
nothing for surgical procedures.
We added benefits for dental services
related to a congenital disease or anomaly, and accidental injury; you pay
nothing. (Section 5( h))
We added coverage for fertility drugs
We increased the emergency room
copay from $35 to $50
We added inpatient rehabilitation as a covered benefit
(Section 5( b) 9
9 Page
10 11
2002 HMO-CNY 6 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID
card with you at all times. You must show it whenever you receive services
from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you
receive your ID card, use
your copy of the Health Benefits Election Form,
SF-2809, your health benefits
enrollment confirmation (for annuitants), or
your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your
enrollment, or if you need replacement cards, call us at 800/ 447-6269.
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 providers include primary care, specialists, ancillary, laboratories,
and DME
suppliers.
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.
HMO-CNY contracts with all hospitals in our servicing area. The hospitals
are:
Our Lady of Lourdes Memorial Hospital, Binghamton
United Health Services
Hospitals, Binghamton
Auburn Memorial Hospital, Auburn
Arnot Ogden
Medical Center, Elmira
St Joseph's Hospital, Elmira
Cortland Memorial
Hospital, Cortland
The Hospital, Sidney
Community Memorial Hospital,
Hamilton
Community General Hospital, Syracuse
Crouse Hospital, Syracuse
St Joseph's Hospital Health Center, Syracuse
University Hospital Health
Science Center, Syracuse
A. L. Lee Memorial Hospital, Fulton 10
10 Page 11 12
2002 HMO-CNY 7 Section 3
Oswego Hospital,
Oswego
Schuyler Hospital, Montour Falls
Corning Hospital, Corning
IRA Davenport Hospital, Bath
St. James Mercy Hospital, Hornell
Barnes Kasson Hospital, Susquehanna, PA
Endless Mountains Health System,
Montrose, PA
Cayuga Medical Center at Ithaca, Ithaca
What you must do It depends on the type of care you need. First, you
and each family
to get covered care member must choose a primary care
physician. This decision is important since your
primary care physician
provides or arranges for most of your health care.
Primary care physicians are listed in our provider directory, with their
locations, phone
numbers, and whether or not the doctor is accepting new
patients. You can choose a
primary care physician from the provider
directory, or call our Member Services
Department at 315/ 448-6820.
Primary care Your primary care physician can be a general or family
practitioner, pediatrician, or internist. Your primary care physician will
provide most of your health care, or give you
a referral to see a
specialist.
If you want to change primary care physicians or if your primary care
physician leaves
the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain
number
of visits without additional referrals. The primary care physician must provide
or
authorize all follow-up care. Do not go to the specialist for return
visits unless your
primary care physician gives you a referral. However, you
may see a plan
ophthalmologist or optometrist for a routine eye exam without
a referral. Also, a woman
may see her plan gynecologist directly without a
referral from her primary care physician.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a treatment
plan with you
and your health 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). 11
11 Page 12 13
2002 HMO-CNY 8 Section 3
If you are seeing
a specialist when you enroll in our Plan, talk to your primary care physician.
Your primary care physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current
specialist. If
your current specialist does not participate with us, you
must receive treatment from a
specialist who does. Generally, we will not
pay for you to see a specialist who does
not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive
services from your current specialist until we can make
arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop
out of the Federal Employees Health Benefits (FEHB) Program and you enroll in
another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
You may be able to continue seeing your specialist for up to 90 days after
you receive
notice of the change. Contact us or, if we drop out of the
Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access
to your
specialist based on the above circumstances, you can continue to see
your specialist until
the end of your postpartum care, even if it is beyond
the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer
service department immediately at 800/ 447-6269. If you are new to
the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital
stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 12
12 Page 13 14
2002 HMO-CNY 9 Section 3
Circumstances
beyond our control Under certain extraordinary circumstances, such as
natural disasters, we may have to
delay your services or we may be unable to
provide them. In that case, we will make all
reasonable efforts to provide
you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. For certain
prior approval services,
however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows
generally
accepted medical practice.
We call this review and approval process prior approval. Your physician must
obtain
prior approval for the following services, such as:
Home Healthcare
Treatment of mental health conditions
Treatment of
alcoholism
Treatment of substance abuse
Physical therapy, Speech
therapy, Occupational therapy
Prosthetics
Durable medical equipment
(rental or purchase)
All out-of-plan referrals
The provider who initially treats a member must submit a treatment plan to
HMO-CNY
for continued treatment. If a treatment plan is not submitted, or if
we do not approve the
treatment plan, we will not pay for any health
services after the approval of the initial
service. 13
13 Page 14 15
2002 HMO-CNY 10 Section 4
Section 4.
Your costs for covered services
You must share the cost of some
services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician, you pay a copayment of $10
per
office visit.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 20% of our
allowance for durable medical equipment.
Your out-of-pocket maximum
We do not have an out-of-pocket maximum. 14
14
Page 15 16
2002 HMO-CNY 11 Section 5
Section 5. Benefits --OVERVIEW
(See page 5 for how our benefits changed this year and page 51 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 315/ 448-6820 or 1/ 800-447-6269 or at our
website at www. bcbscny. org .
(a) Medical services and supplies provided by physicians and other health
care professionals………...............................………. 13-20
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 Therapy
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 .................................................... 21-24
Surgical procedures
Reconstructive surgery
Oral and maxillofacial
surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided
by a hospital or other facility, and ambulance services
..................................................................................
25-27
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance
(d) Emergency services/ accidents
.....................................................................................................................................................
28-29
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits
.....................................................................................................................................
30
(f) Prescription drug benefits
............................................................................................................................................................
31-33
(g) Special
features.................................................................................................................................................................................
34
Services for deaf and hearing impaired Reciprocity benefit
Travel
benefit/ services overseas Centers of Excellence
(h) Dental benefits
..................................................................................................................................................................................
35
Summary of benefits
................................................................................................................................................................................
55 15
15 Page 16
17
2002 HMO-CNY 12 Section 5( a)
Section
5 (a) Medical services and supplies provided by physicians and other
health
care professionals
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically
necessary.
Plan physicians must provide or arrange your care.
We have
no calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Diagnostic and treatment services You pay
Professional services of physicians
In physician's office
$10
per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Second surgical opinion
Nothing
Office medical consultations $10 per office visit
Lab, X-ray and other
diagnostic tests You pay
Laboratory 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 16
16 Page 17 18
2002 HMO-CNY 13
Section 5( a)
Preventive care, adult You pay
Routine
screenings, such as:
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Nothing, Included in office copay
Sigmoidoscopy, screening – every five years starting at age 50
Prostate
Specific Antigen (PSA test) – one annually for men age 40 and older Nothing,
Included in office copay
Routine pap test
Note: The office visit is
covered if pap test is received on the same day;
see Diagnosis and
Treatment, above.
Nothing
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing, Included in office copay
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics Nothing
Examinations, such as:
Eye exams through age 17 to determine the need for
vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)
Well-child care charges for routine examinations, immunizations and care in
accordance with the prevailing clinical standards of the
American Academy of Pediatrics (through age 22)
Nothing 17
17 Page
18 19
2002 HMO-CNY 14 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care,
such as:
Prenatal care
Delivery
Postnatal care
Note: Here are
some things to keep in mind:
You do not need to precertify your normal delivery; see page 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.
Routine nursery care of the newborn child during the
covered portion of the mother's maternity stay. We will cover other care of
an infant who requires non-routine treatment only if we cover the
infant
under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning You pay
Voluntary sterilization
Injectable contraceptive drugs
Nothing
Surgically implanted contraceptives
Intrauterine devices (IUDs)
Nothing for insertion, $20 per device
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges.
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
Artificial insemination:
intravaginal
insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
$10 for the initial diagnosis;
50% of the maximum amount payable per
treatment 18
18 Page
19 20
2002 HMO-CNY 15 Section 5( a)
Infertility services (Continued) You pay
Not
covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and
zygote ZIFT
Zygote transfer
Services and supplies related
to excluded ART procedures
Cost of donor sperm
All charges.
Allergy care You pay
Testing $10 per office visit
Treatment Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges.
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 22.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Nothing
Not covered: All charges.
Rehabilitative therapies You pay
60 visits per condition for the services of each of the following:
qualified physical therapists;
occupational therapists.
Note: We
only cover therapy to restore bodily function when there
has been a total or
partial loss of bodily function due to illness or
injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or
a
myocardial infarction, is provided for up to 00 sessions
$10 per office visit 19
19 Page 20 21
2002 HMO-CNY 16
Section 5( a)
Rehabilitative therapies (Continued) You
pay
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapies You pay
Speech therapy limited to 60 visits $10
per office visit
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)
Nothing
Not covered:
all other hearing testing
hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies) You pay
One
pair of eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
Nothing
Eye exam to determine the need for vision correction for children through age
18 (see preventive care)
Annual eye refractions (which include the written
lens prescription for eyeglasses) every 2 years for members over age 18
Not covered:
Eyeglasses or contact lenses and, after age 17
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care You pay
Routine foot care when you are under active
treatment for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit 20
20 Page 21 22
2002 HMO-CNY 17
Section 5( a)
Foot care (Continued) You pay
Not covered:
Cutting, trimming or removal of corns,
calluses, or the free edge of toenails, and similar routine treatment of
conditions of the foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices You pay
Artificial limbs and
eyes;
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy.
Note: See 5( b) for coverage of the surgery
to insert the device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing
Medical Supplies:
CPAP supplies
IV supplies
Catheters
Dressings
Elastic stockings
Stump socks
Nothing
Not covered:
Orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
All charges. 21
21 Page 22 23
2002 HMO-CNY 18
Section 5( a)
Durable medical equipment (DME) You pay
Rental
or purchase, at our option, including repair and adjustment, of
durable
medical equipment prescribed by your Plan physician, such as
oxygen and
dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
canes
walkers;
blood glucose monitors; and
insulin pumps.
20% of covered charges
Not covered: All charges.
Home health services You pay
Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen
therapy, intravenous therapy and medications.
Nothing
Not covered:
Nursing care requested by, or for the convenience
of, the patient or the patient's family;
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges.
Chiropractic You pay
Chiropractic Services – services in
connection with detection or
correction by manual or mechanical means of
structural imbalance,
distortion or subluxation in the body to remove severe
interference with
the result of or related to distortion, misalignment, or
subluxation of or
in the spine
$10 per office visit 22
22 Page 23 24
2002 HMO-CNY 19
Section 5( a)
Alternative treatments You pay
Not covered:
Naturopathic services
Hypnotherapy
Biofeedback
Acupuncture
All charges.
Educational classes and programs You pay
Coverage is limited to:
Smoking Cessation
Childbirth classes
Diabetes self-management
Nothing 23
23 Page
24 25
2002 HMO-CNY 20 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health
care professionals
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5 (c). for charges associated with the facility charge (i. e.
hospital, surgical center, etc.)
YOU MUST GET PRIOR APPROVAL FOR SOME
SURGICAL PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which services require
precertification and identify which surgeries require precertification.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Surgical procedures You pay
A
comprehensive range of services, such as:
Operative procedures
Treatment
of fractures, including casting
Normal pre-and post-operative care by the
surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of
congenital anomalies (see reconstructive surgery)
Surgical treatment of
morbid obesity --a condition in which an individual weighs 100 pounds or 100%
over his or her normal
weight according to current underwriting standards; eligible
members must
be age 18 or over
Insertion of internal prostethic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization
Treatment of burns
Note: Generally, we pay
for internal prostheses (devices) according to
where the procedure is done.
For example, we pay Hospital benefits for
a pacemaker and Surgery benefits
for insertion of the pacemaker.
Nothing
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges. 24
24 Page 25 26
2002 HMO-CNY 21
Section 5( b)
Reconstructive surgery You pay
Surgery to
correct a functional defect
Surgery to correct a condition caused by injury
or illness if:
the condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes. (This
includes dental surgery.)
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
Nothing
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery You pay
Oral surgical procedures,
limited to:
Reduction of fractures of the jaws or facial bones;
Surgical
correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve the teeth or their
supporting structures.
Nothing
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 25
25 Page 26 27
2002 HMO-CNY 22
Section 5( b)
Inpatient Rehabilitation You pay
Inpatient
physical rehabilitation is a covered service when performed in a plan approved,
free-standing or hospital-based physical
rehabilitation treatment center. Limited to 60 days.
Nothing
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single
–Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach and pancreas
National Transplant Program (NTP) – HMO-CNY utilizes
a "Centers of Excellence" Program.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges 26
26 Page 27 28
2002 HMO-CNY 23
Section 5( b)
Anesthesia You pay
Professional services
provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing 27
27 Page
28 29
2002 HMO-CNY 24 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services
I
M
P
O
R
T
A
N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically
necessary.
Plan physicians must provide or arrange your care and you must
be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated
with the professional charge (i. e., physicians, etc.) are covered in
Sections 5( a) or (b).
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Inpatient hospital You pay
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. 28
28 Page 29 30
2002 HMO-CNY 25
Section 5( c)
Outpatient hospital or ambulatory surgical center You
pay
Operating, recovery, and other treatment rooms
Prescribed drugs
and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced
Pre-surgical testing
Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment.
We do
not cover the dental procedures.
Nothing
Not covered:
blood and blood when it is available free of
charge in the area
All charges
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit:
Up to 240 days per admission when full-time
skilled nursing care is necessary;
Must be determined to be medically necessary by Plan doctor, and approved by
the Plan.
The benefit renews after 90 days (only if the member has received
no hospital care, home health care, or skilled nursing care within
that
time.
All necessary services are covered, including:
Bed, board and
general nursing care
Drugs, biologicals, supplies, and equipment ordinarily
provided or arranged by the skilled nursing facility when prescribed by a
Plan doctor.
Nothing
Not covered: custodial care All charges 29
29 Page 30 31
2002 HMO-CNY 26 Section 5( c)
Hospice
care You pay
A maximum of 210 hospice days
Supportive and palliative
care for a terminally ill member is covered in the home or hospice facility
Services include inpatient and outpatient care, and family counseling
Services are provided under the direction of a Plan doctor who certifies
that the patient is in the terminal stages of illness, with a
life
expectancy of approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges 30
30 Page 31 32
2002 HMO-CNY 27 Section 5( d)
Section 5
(d). Emergency services/ accidents
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other coverage,
including
with Medicare.
I
M
P
O
R
T
A
N
T
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or
could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are emergencies
because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are
emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we
may determine are medical emergencies – what
they all have in common is the
need for quick action.
What to do in case of emergency:
Emergencies within our service area:
In an emergency situation, call your primary care doctor
In an extreme
emergency, if you are unable to contact your doctor, contact the local emergency
system (e. g., the 911-telephone system) or go to the nearest hospital emergency
room or medical facility. Be sure to advise medical personnel
that you are a Plan member.
You or someone on your behalf must notify
your primary care physician within 2 business days, or as soon as is reasonably
possible.
You pay $50 copayment per emergency; if you are admitted to a hospital from
the emergency room, the copay is waived.
Emergencies outside our service
area:
Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness. If an emergency
situation occurs, call the local emergency system (e. g., the 911-telephone
system) or
go immediately to the nearest hospital emergency room or medical facility
You or someone on your behalf must notify your primary care physician within
2 business days, or as soon as is reasonably possible.
You pay $50 copayment per emergency; if you are admitted to a hospital from
the emergency room, the copay is waived.
Claims for care in non-life
threatening emergency medical situations which are not authorized by your
primary care physician will be denied.
To be covered by this Plan, any follow-up care must be approved by the Plan.
Contact your primary care physician if the
emergency room or medical
facility recommends additional care outside of the visit. 31
31 Page 32 33
2002 HMO-CNY 28 Section 5( d)
Benefit
Description You pay
Emergency within our service area You pay
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 per office visit
Emergency care at a doctor's office
Emergency care at an urgent care
center
$10 per office visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area You pay
Emergency care as
an outpatient or inpatient at a hospital, including doctors' services $50 per
office visit
Emergency care at a doctor's office
Emergency care at an urgent care
center
$10 per office visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
All charges.
Ambulance You pay
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing
Not covered: All charges. 32
32 Page 33 34
2002 HMO-CNY 29
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I
M
P
O
R
T
A
N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than
for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
Mental health and substance abuse benefits
You pay
All diagnostic and treatment services recommended by a Plan
provider
and contained in a treatment plan that we approve. The treatment
plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$10 per office visit
Diagnostic tests Nothing
Services provided by a hospital or other
facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
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 prior authorization from your
primary care physician.
Limitation We may limit your benefits if you do not obtain a
preauthorization. 33
33 Page
34 35
2002 HMO-CNY 30 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including
with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the
prescription – or – A plan physician or licensed dentist must write the
prescription.
Where you can obtain them. You may fill the prescription at a Plan
pharmacy, a non-network pharmacy, or by mail. We only pay a benefit when
you use a network pharmacy.
We use a formulary. A formulary is a list
of the most commonly prescribed generic and brand name drugs. If a provider
prescribes a name brand drug that is not on our formulary as a tier one or
tier two drug, you will pay
the $35 tier three drug copay.
These
are the dispensing limitations. You will be charged 1 copay for each 30 day
supply, retail or mail order. If there is no generic equivalent, you will pay
the brand for the two and three tier copay.
When you have to file a claim. If you do not use Plan pharmacies, you
will receive no benefits.
When you fill a first time prescription through
mail order. The first fill of a prescription is .limited to a maximum of a
(30) day supply. 34
34 Page
35 36
2002 HMO-CNY 31 Section 5( f)
Benefit Description You pay
Covered medications and supplies You
pay
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as excluded below.
Oral
and injectable drugs
Implanted, time release contraceptive medications, such
as Norplant
Smoking cessation drugs and medication including nicotine
patches
Enteral formulas for home use when prescribed in writing by a Plan
doctor for poor nourishment or a disorder which would cause chronic
physical disability, mental retardation, or death
Medically necessary
modified solid food products with low or modified protein for treatment of
inherited diseases of amino acids and
organic acid metabolism
Drugs for sexual dysfunction (see Prior
authorization below)
Contraceptive drugs and devices
Fertility drugs
Insulin, diabetic supplies and disposable needles and syringes needed
to
inject covered prescribed medication are available through the
Plan's
medical and surgical benefits and are subject to the doctor's
office visit
copayment
$ 5 copay per prescription unit or refill for
generic drugs per each 30
day supply
$20 copay per prescription unit or refill for
brand name drugs on our
preferred drug list
per each 30 day supply
$35 copay per prescription unit or refill for
brand name drugs not on our
preferred drug
list per each 30 day supply
Note: If there is no generic equivalent
available, you will still have to
pay the
brand name copay.
Here are some things to keep in mind about our prescription drug
program:
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.
We have an open formulary. If your physician believes a name brand product is
necessary or there is no generic available, your
physician may prescribe a
name brand drug from a formulary list.
This list of name brand drugs is a
preferred list of drugs that we
selected to meet patient needs at a lower
cost 35
35 Page 36
37
2002 HMO-CNY 32 Section 5( f)
Covered
medications and supplies (Continued) You pay
Not
covered
Drugs available without a prescription or for which there is
a nonprescription equivalent available
Vitamins and nutritional substances that can be purchased without a
prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic
performance
Implanted time-release medications other than Norplant
Drugs for weight loss
Drugs in connection with transsexual
surgery
Drugs prescribed for experiential or investigational use
Drugs for which payment is available through worker's compensation,
similar legislation, or no-fault benefits
Replacement for lost or stolen drugs.
All Charges 36
36 Page 37 38
2002 HMO-CNY 33
Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide
services.
We may identify medically appropriate alternatives to traditional care and
coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will receive approval for the same
or similar services in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Services for deaf and
hearing impaired You may communicate with us
using a TDD by calling 315/ 448-6764.
Reciprocity benefit When traveling in the U. S., BluesConnect
(formerly HMO-USA) is available to assist
members seeking medical care.
Members call 800/ 4-HMO-USA to locate the
nearest HMO provider or facility.
Centers of excellence for
transplants/ heart
surgery/ etc
HMO-CNY utilizes Centers of Excellence and has specific criteria and quality
measures in place that must be met which ensures the best care for you.
Travel benefit/ services
overseas
BlueCard Worldwide is a
service that is available to members traveling outside the
U. S. Members
call 800/ 810-BLUE (2583) for available providers. 37
37 Page 38 39
2002 HMO-CNY 34 Section 5( h)
Section 5
(h). Dental benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
We cover hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the health
of the patient; we do not cover the
dental procedure unless it is described
below.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other coverage, including with
Medicare.
I
M
P
O
R
T
A
N
T
Accidental injury benefit You pay
Treatment of sound and natural
teeth as the result of an accidental injury is a
contract benefit and care
for the member must be rendered within 12
months of the accident.
Nothing
Not covered:
We will not cover health services related to
dental treatment of the teeth or gums, including, but not limited to: x-rays,
fillings
extractions, braces, treatments for gum disease, oral prosthetics, or
any other dental services. Dental treatment related to misalignment
of
the teeth or jaws, dysfunction of the temporomandibular joints,
and dental
TMJ disorder.
All charges
Dental benefits You pay
We have no other dental benefits. All
charges 38
38 Page
39 40
2002 HMO-CNY 35 Section 6
Section 6. General exclusions – things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it
unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury,
or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you
are not enrolled in this Plan;
Services, drugs, or supplies that are not
medically necessary;
Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice;
Experimental
or investigational procedures, treatments, drugs or devices;
Services,
drugs, or supplies related to abortions, except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is
the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program. 39
39 Page
40 41
2002 HMO-CNY 36 Section 7
Section 7. Filing a claim for covered services
When you
receive treatment from Plan physicians, receive services at Plan hospitals and
facilities, or obtain prescription drugs at Plan
pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us
directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, Hospital and Drug In most cases, providers and facilities
file claims for you. Physicians
Benefit must file on the form
HCFA-1500, Health Insurance Claim Form. Facilities will file on
the UB-92
form. For claims questions and assistance, call us at 800/ 447-6269.
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:
HMO-CNY
P. O. Box 4712, 344 S. Warren Street
Syracuse, NY 13221-4712
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the
claim by December 31 of the
year after the year you received the service, unless timely
filing was
prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing
or deny your claim if you do
not respond. 40
40 Page
41 42
2002 HMO-CNY 37 Section 8
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on your claim or
request for services, drugs, or supplies –
including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must:
(a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: HMO-CNY, P. O. Box 4712, 344
S. Warren Street, Syracuse, NY 13221-4712; and
(c) Include a statement about
why you believe our initial decision was wrong, based on specific benefit
provisions in
this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical
records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to:
(a)
Pay the claim (or, if applicable, arrange for the health care provider to give
you the care); or
(b) Write to you and maintain our denial --go to step 4;
or
(c) Ask you or your provider for more information. If we ask your
provider, we will send you a copy of our request—
go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide
within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the information was due. We
will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in
some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of
Insurance Programs, Contracts Division 2, P. O. Box 436,
Washington, D. C.
20044-0436.
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. 41
41 Page 42 43
2002 HMO-CNY 38 Section 8
Note: You are the
only person who has a right to file a disputed claim with OPM. Parties acting as
your representative, such
as medical providers, must provide a copy of your
specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons
beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our
decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against
OPM in Federal
court by December 31 of the third year after the year in which you received the
disputed services or
supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This
information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits,
and payment of
benefits. The Federal court will base its review on the record that was before
OPM when OPM decided to
uphold or overturn our decision. You may recover
only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if
not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at (315) 448-6820 or
1-800-447-6269 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division III at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 42
42
Page 43 44
2002
HMO-CNY 39 Section 9
Section 9. Coordinating benefits with other
coverage
When you have other health coverage You must tell us if you are
covered or a family member is covered under another group
health plan or
have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the
primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like
other insurers, determine which coverage is primary
according to the National
Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary
plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to
qualify for premium-free Part A insurance. (Someone who was a Federal
employee on
January 1, 1983 or since automatically qualifies.) Otherwise, if
you are age 65 or
older, you may be able to buy it. Contact 1-800-MEDICARE
for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare
managed care plan is the term used to describe the
various health plan choices available to Medicare
beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is a plan that is available (Part A or Part B) 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.
(Primary payer chart begins on next page.) 43
43 Page 44 45
2002 HMO-CNY 40 Section 9
The following
chart illustrates whether the Original Medicare Plan or this Plan should be the
primary payer for you according to your
employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered
family member has
Medicare coverage so we can administer these requirements
correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the Federal government (including when
you or
a family member are eligible for Medicare solely because of a
disability), X
2) Are an annuitant, X
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or……………………………
X
b) The position is not excluded from FEHB………………………….
(Ask your employing
office which of these applies to you.)
X
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),
X
5) Are enrolled in Part B only, regardless of your employment status, X
(for Part B
services)
X
(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,
X
(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,
X
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
X
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
X
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
X
b) Are an active employee, or X
c) Are a former spouse of an annuitant,
or X
d) Are a former spouse of an active employee X 44
44 Page 45 46
2002 HMO-CNY 41 Section 9
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 the original Medicare covers. Some
cover
extras, like prescription drugs. To learn more about enrolling in a Medicare
managed
care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in
a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care plan: You may
enroll in another
plan's Medicare Managed Care plan and also remain enrolled
in our FEHB plan. We will still
provide benefits when your Medicare Managed
Care plan is primary, even out of the managed
care plan's network and/ or
service area (if you use our Plan providers), but we will not waive
any of
our copayments and coinsurance. If you enroll in a Medicare managed care plan,
tell us. We will need to know whether you are in the Original Medicare Plan
or in a
Medicare managed care plan so we can correctly coordinate benefits
with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an
annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan is primary, eliminating your FEHB
premium. (OPM does not contribute
to your Medicare managed care plan
premium.) For information on suspending your FEHB
enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB
Program,
generally you may do so only at the next open season unless you involuntarily
lose
coverage or move out of the Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered Medicare Part A or Part B under the
FEHB Program. We will not require you to enroll in Medicare Part B and, if
you can't get premium-free Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for members, eligible
dependents of military persons.
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. 45
45 Page 46 47
2002 HMO-CNY 42 Section 9
When other
Government agencies We do not cover services and supplies when a local,
State,
are responsible for your care or Federal Government agency
directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital
for injuries care for injuries or illness
caused by another person, you must reimburse us for any expenses
we paid.
However, we will cover the cost of treatment that exceeds the amount you
received
in the settlement.
If you do not seek damages, you must agree to let us try. This is called
subrogation. If you
need more information, contact us for our subrogation
procedures. 46
46 Page
47 48
2002 HMO-CNY 43 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year
begins on the effective date of their enrollment and ends on
December 31 of the same
year.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Custodial Care includes any service that can
be provided by an average individual who has
little or no medical training.
Examples of Custodial Care include: (a) assistance in meeting
activities of
daily living such as feeding, dressing, and personal hygiene, (b) administration
of
oral medications, routine changing of dressings or preparation of special
diets, (c) assistance
in walking or getting out of bed, (d) care when it is
primarily for the purpose of meeting
personal needs and could be provided by
persons without professional skills or training.
Experimental or investigational Experimental/ investigational
procedures are defined as any procedure,
services treatment, drug,
biological product or device (hereinafter referred to as
technology) that, in the sole discretion of the Plan, are determined to be
experimental or
investigational in nature.
Experimental or investigational means that the technology is determined not
to:
have final approval from the appropriate government regulatory body;
be
proven benefit for the particular diagnosis or treatment of the member's
condition;
be recognized by the medical community, as reflected in the published
peer-reviewed literature, as effective or appropriate for the particular
diagnosis or
treatment of the member's condition; or
be as beneficial as
any established alternative.
Your primary care physician will work with our
medical director and medical staff to
determine if a service is experimental
or investigational.
Medical necessity Medically Necessary Care is care which, according to
The Plan's criteria is: (a) Consistent
with the symptoms or diagnosis and
treatment of the Member's condition, disease, ailment or
injury, (b) in
accordance with standards of acceptable medical practice, (c) not solely for the
Member's convenience, or that of the Member's Doctor or other Provider, (d)
the most
appropriate supply, place of service, or level of service which can
safely be provided to the
Member, (e) provided for the diagnosis or the
direct care and treatment of the Member's
condition, illness, disease or
injury, and (f) when applied to hospitalization, the Member
requires acute
care as a bed patient due to the nature of the services rendered, or the
Member's
condition, and the Member could not have received safe or adequate
care in any other setting
(e. g. as an outpatient). 47
47 Page 48 49
2002 HMO-CNY 44 Section 10
Plan
allowance Plan allowance is the amount we use to determine our payment and
your coinsurance for
covered services. Plans determine their allowances in
different ways. We determine our
allowance as follows:
We use many different forms of Plan Allowance. Our contract with your
providers
allows us to change Plan Allowance with a 60 days notice. We
believe that by listing
Plan Allowances it would jeopardize our contracting
ability with our providers. In
addition, with our merger with the other two
BlueCross plans, we are focused on one
platform for the plan allocation at
this time we do not know how that will effect our
current Plan Allocation
with providers.
Us/ We Us and we refer to HMO-CNY
You You refers to the
enrollee and each covered family member. 48
48
Page 49 50
2002 HMO-CNY 45 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had
limitation before you enrolled in this Plan
solely because you had the condition before you enrolled.
Where you can get information See www. opm. gov/ insure . Also, your
employing or retirement office
about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB
Program Health Benefits Plans, brochures for other plans, and other
materials you need to make an
informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your
enrollment status without information from your employing
or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for
for you and your family you, your spouse,
and your unmarried dependent children under age 22, including any
foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a
disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if
you marry, give birth, or add a child to your family. You may
change your enrollment 31
days before to 60 days after that event. The Self
and Family enrollment begins on the
first day of the pay period in which the
child is born or becomes an eligible family
member. When you change to Self
and Family because you marry, the change is
effective on the first day of
the pay period that begins after your employing office
receives your
enrollment form.
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.
When benefits and The benefits in this brochure are effective on
January 1. If you joined this Plan during Open Season,
premiums start
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. 49
49 Page 50 51
2002 HMO-CNY 46 Section 11
Your medical and claims We will
keep your medical and claims information confidential. Only
records are
confidential the following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
Law enforcement officials when investigating and/ or
prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been
enrolled in the FEHB Program for the
last five years of your Federal service. If you do not meet
this
requirement, you may be eligible for other forms of coverage, such as Temporary
Continuation
of Coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not continue coverage 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 If you leave Federal service, or if
you lose coverage because you no longer qualify as a
family member, you may
be eligible for Temporary Continuation of Coverage (TCC).
For example, you
can receive TCC if you are not able to continue your FEHB enrollment
after
you retire, if you lose your job, if you are a covered dependent child and you
turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the
RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and
Former Spouse Enrollees, from your employing or
retirement office or from
www. opm. gov/
insure . It explains what you have to do to enroll. 50
50 Page 51 52
2002 HMO-CNY 47 Section 11
Converting to You may convert to
a non FEHB individual policy if: individual coverage
Your coverage
under TCC or the spouse equity law ends. If you canceled your coverage or did
not pay your premium, you cannot convert;
You decided not to receive
coverage under TCC or the spouse equity law; or
You are not eligible for
coverage under TCC or the spouse equity law.
If you leave Federal service,
your employing office will notify you of your right to
convert. You must
apply in writing to us within 31 days after you receive this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to
us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you
will not have to answer questions about your health, and we
will not impose a waiting
period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of You may be entitled to continued coverage
through the Health Insurance
Group Health Plan Coverage Portability
and Accountability Act of 1996 (HIPAA). HIPAA is a federal law that offers
limited Federal protections for health coverage availability and continuity
to people who
lose employer group coverage. If you leave the FEHB Program,
we will give you a Certificate of
Group Health Plan Coverage that indicates
how long you have been enrolled with us. You can use
this certificate when
getting health insurance or other health care coverage. Your new plan must
reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on
the information in the certificate, as long as
you enroll within 63 days of losing coverage under this
Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in
other FEHB plans, you may also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health)
refer to the "TCC and HIPAA" frequently asked questions.
These highlight
HIPAA rules, such as the requirement that Federal employees must
exhaust
any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies
you can
contact for more information. 51
51
Page 52 53
2002 HMO-CNY 48 Long Term Care Insurance
Long Term Care
Insurance Is Coming Later in 2002!
The Office of Personnel
Management (OPM) will sponsor a high-quality long term care insurance program
effective in October
2002. As part of its educational effort, OPM asks you
to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease such as
Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice care, and more. LTC
insurance can supplement care provided by family members, reducing the burden
you
place on them.
Welcome to the club! 76% of Americans believe they will never need long term
care, but the facts are that
about half of them will. And it's not just the
old folks. About 40% of people needing
long term care are under age 65. They
may need chronic care due to a serious accident, a
stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their financial
and retirement planing.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before
inflation!
Long term care can easily exhaust your savings.
Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c)
of your FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted living facility or
a continuing need for a home health aide to help
you get in and out of bed and with other
activities of daily living. Limited
stays in skilled nursing facilities can be covered in
some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100
day limit.
Medicaid covers long term care for those who meet their
state's poverty guidelines, but has restrictions on covered services and where
they can be received. Long term care
insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in
mid-2002. In the meantime, you can learn more about the program on our web site
at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 52
52 Page 53 54
2002 HMO-CNY 49 Index
Index
Do
not rely on this page; it is for your convenience and may not show all pages
where the terms appear
Accidental injury 34
Allergy tests 15
Alternative treatment 19
Ambulance 28
Anesthesia 23
Autologous
bone marrow transplant 22
Birthing centers 14
Blood and blood plasma 24
Breast cancer screening 13
Casts 24
Catastrophic protection 54
Changes for 2002 5
Chemotherapy 15
Childbirth 14
Chiropractic 18
Cholesterol tests 13
Claims 34
Coinsurance 10
Colorectal cancer
screening 13
Congenital anomalies 20
Contraceptive devices and drugs 31
Coordination of benefits 40
Covered providers 6
Crutches 18
Definitions 43
Dental care 34
Diagnostic services 12
Disputed
claims review 37
Donor expenses (transplants) 22
Dressings 17
Durable medical equipment (DME) 18
Educational classes and
programs 19
Effective date of enrollment 6
Emergency 27
Experimental
or investigational 43
Eyeglasses 16
Family planning 14
Fecal
occult blood test 13
General Exclusions 35
Hearing services 16
Home health services 18
Hospice care 26
Home nursing care 16
Hospital 24
Immunizations 13
Infertility 14
Inhospital physician care 24
Inpatient Hospital
Benefits 24
Insulin 31
Laboratory and pathological
services
12
Machine diagnostic tests 12
Magnetic Resonance Imagings
(MRIs) 12
Mail Order Prescription Drugs 31
Mammograms 13
Maternity Benefits 14
Medicaid 41
Medically necessary 13
Medicare 39
Members 3
Mental Conditions/ Substance
Abuse
Benefits 29
Newborn care 14
Nurse
Licensed Practical Nurse 18
Nurse Practitioner 18
Registered Nurse 18
Nursery charges 14
Obstetrical care 14
Occupational therapy 15
Ocular injury 16
Office visits 3
Oral and maxillofacial surgery 21
Orthopedic devices
17
Ostomy and catheter supplies 17
Out-of-pocket expenses 10
Outpatient facility care 25
Oxygen 18
Pap test 13
Physical examination 13
Physical
therapy 15
Physician 7
Pre-admission testing 9
Preventive care,
adult 13
Preventive care, children 13
Prescription drugs 30
Preventive services 13
Prior approval 9
Prostate cancer screening 13
Prosthetic devices 17
Psychologist 29
Radiation therapy 15
Renal dialysis 15
Room and board 24
Second surgical opinion
12
Skilled nursing facility care 25
Smoking cessation 19
Speech
therapy 16
Splints 24
Sterilization procedures 14
Subrogation 41
Substance abuse 29
Surgery
Anesthesia 23 Oral 21
Outpatient 25 Reconstructive 21
Syringes 31
Temporary
continuation of coverage
46
Transplants 22
Vision
services 16
Well child care 13
Wheelchairs 18
Workers'
compensation 41
X-rays 12 53
53 Page 54 55
2002 HMO-CNY 50
NOTES: 54
54 Page 55 56
2002 HMO-CNY 51
Summary
Summary of benefits for HMO-CNY 2002
Do not rely
on this chart alone. All benefits are provided in full unless indicated and
are subject to the definitions,
limitations, and exclusions in this
brochure. On this page, we summarize specific expenses we cover; for more
detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover
on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by
physicians:
Diagnostic and treatment services provided in the
office................. Office visit copay: $10 primary
care; $10 specialist
20
Services provided by a hospital:
Inpatient
...........................................................................................
Outpatient.........................................................................................
Nothing
24
24
Emergency benefits:
In-area
.............................................................................................
Out-of-area
......................................................................................
$50 per incident
$50 per incident 27
27
Mental health and
substance abuse treatment....................................... Regular cost
sharing. 29
Prescription drugs
.................................................................................
Drugs prescribed by a Plan doctor and obtained at a Plan
pharmacy.
Mail order maintenance drugs.
You pay a $5 copay for generic
drugs, a $20 copay for preferred
brand name drugs or a $35
copay for non-preferred brand
name drugs
per prescription unit
or refill
You pay a $15 copay for generic
drugs, a $60 copay for preferred
brand drugs or a $105 copay for
non-preferred brand name drug
per
prescription unit or refill.
30
Dental
Care.......................................................................................
Accidental injury benefit; you pay
nothing.
34
Vision
Care.......................................................................................
One refraction every two years.
You pay nothing.
16
Protection against catastrophic costs
(your out-of-pocket maximum)
........................................................
No Maximum
10 55
55 Page
56
2002 HMO-CNY 52 Premium Page
2002 Rate
Information for
HMO-CNY
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. Refer to the
applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share
Self Only EB1 97.86 33.84 212.03 73.32 115.52 16.18
Self and Family
EB2 223.41 125.86 484.06 272.69 263.75 85.52 56