Physicians Health Services
of New York, Inc. http:// www. health. net
2002
A Health Maintenance Organization
Serving: Dutchess, Orange, Putnam, Rockland and Westchester
Counties, the five boroughs of New York City, Nassau and
Suffolk
Counties, New York
Enrollment in this Plan is limited; see page 7 for requirements.
Enrollment codes for this Plan:
PD1 Self Only
PD2 Self and Family
RI 73-531
For changes
In Benefits
See Page 8. 1
1
Page 2 3
2002 Physicians Health Services of New York, Inc. 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………........................................................................
4
Plain
Language……………………………………………………………….......................................................................
4
Inspector General
Advisory…………………………………………………………………………………………… 5
Section
1. Facts about this HMO
plan.........................................................................................................................................
6
How we pay
providers.................................................................................................................................................
6
Who provides my health care?…………………………………………………………………………….. 6
Your Rights
...................................................................................................................................................................
6
Service Area
..................................................................................................................................................................
7
Section 2. How we change for
2002……………………………………….........................................................................
8
Program-wide
changes................................................................................................................................................
8
Changes to this
Plan.....................................................................................................................................................
8
Section 3. How you get care
………….......................................................................................................................................
9
Identification cards
......................................................................................................................................................
9
Where you get covered care
.......................................................................................................................................
9
Plan providers
........................................................................................................................................................
9
Plan
facilities..........................................................................................................................................................
9
What you must do to get covered care
.....................................................................................................................
9
Primary care
.........................................................................................................................................................
10
Specialty care
.......................................................................................................................................................
10
Hospital
care.........................................................................................................................................................
11
Circumstances beyond our
control..........................................................................................................................
11
Services requiring our prior
approval.....................................................................................................................
11
Section 4. Your costs for covered
services...............................................................................................................................
12
Copayments
.........................................................................................................................................................
12
Deductible.............................................................................................................................................................
12
Coinsurance
.........................................................................................................................................................
12
Your out-of-pocket
maximum..................................................................................................................................
12
Section 5.
Benefits………………………………………………………….......................................................................
13
Overview......................................................................................................................................................................
13
(a) Medical services and supplies provided by
physicians and other health care professionals ............ 14
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ........ 23
(c)
Services provided by a hospital or other facility, and ambulance services
.......................................... 27
(d)
Emergency services/ accidents
.....................................................................................................................
30
(e) Mental health and substance abuse
benefits..............................................................................................
32
(f) Prescription drug benefits
.............................................................................................................................
34
(g) Special
features...............................................................................................................................................
38
Flexible Benefits Option 2
2 Page 3 4
2002 Physicians Health Services of New York, Inc. 3 Table of Contents
24 Hour Personal Health Advisor Line
Interactive
Provider Directory
Disease State Management Programs
Services for
Deaf and Hearing Impaired
(h) Dental
benefits.................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
........................................................................................
40
Section 6. General exclusions --things we don't
cover.........................................................................................................
41
Section 7. Filing a claim for covered services
..........................................................................................................................
42
Section 8. The disputed claims
process.....................................................................................................................................
43
Section 9. Coordinating benefits with other
coverage
............................................................................................................
45
When you have…
Other health coverage
..........................................................................................................................................
45
Original Medicare
.................................................................................................................................................
45
Medicare managed care
plan...............................................................................................................................
48
TRICARE/ Workers' Compensation/ Medicaid
......................................................................................................
49
Other Government
agencies......................................................................................................................................
49
When others are responsible for injuries
................................................................................................................
49
Section 10. Definitions of terms we use in this
brochure
.......................................................................................................
50
Section 11. FEHB facts
................................................................................................................................................................
52
Coverage
information....................................……………………………………………………………… 52
No pre-existing condition
limitation.............................................................................................................
52
Where you get information about enrolling in the FEHB
Program........................................................ 52
Types of coverage available for you and your family
...............................................................................
52
When benefits and premiums start
...............................................................................................................
52
Your medical and claims records are
confidential.....................................................................................
53
When you
retire...............................................................................................................................................
53
When you lose benefits
...........................................................................................................................................
53
When FEHB coverage
ends...........................................................................................................................
53
Spouse equity coverage
.................................................................................................................................
53
Temporary Continuation of Coverage
(TCC)............................................................................................
53
Converting to individual
coverage...............................................................................................................
53
Getting a Certificate of Group Health Plan
Coverage..............................................................................
54
Summary of benefits
......................................................................................................................................................................
58
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2002 Physicians Health Services of New York, Inc. 4
Introduction/ Plan Language/ Advisory
Introduction
Physicians Health Services of New York, Inc. One Far Mill Crossing
Shelton, CT 06484
This brochure describes the benefits of Physicians
Health Services of New York, Inc. under our contract (CS2527) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits law. This
brochure is the official statement of benefits. No oral
statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use
common words. For instance, "you" means the enrollee or family member; "we"
means Physicians Health Services of New York, Inc.
We limit acronyms to
ones you know, FEHB is the Federal Employees Health Benefits Program. OPM is the
Office of Personnel Management. If we use others, we tell you what they mean
first.
Our brochure and other FEHB plans; brochures have the same format
and similar descriptions to help you compare plans.
If you have comments or
suggestions about how to improve the structure of this brochure, let OPM know.
Visit
OPM's "Rate Us" feedback area at
www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation Division, 1900 E
Street, NW Washington, DC 20415-3650. 4
4 Page 5 6
2002 Physicians
Health Services of New York, Inc. 5 Introduction/ Plan Language/ Advisory
Inspector General Advisory
Stop health care fraud! Fraud
increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any
information, do the following:
Call the provider and ask for an
explanation. There may be an error.
If the provider does not resolve the
matter, call us at (877) 747-9585 and explain the situation.
If we do not resolve the issue, call or write THE HEALTH CARE FRAUD
HOTLINE
202/ 418-3300
The United States Office of Personnel
Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW,
Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a
claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the
Inspector General may investigate
anyone who uses an ID card if the person
tries to obtain services for someone who is not an eligible family member, or is
no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Physicians Health Services of New York, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from
non-Plan providers, you may have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available.
You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician,
hospital, or other provider will be available and/ or remain
under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or coinsurance.
Who provides my health care?
All medical care, including
hospitalization, must be provided by a Physicians Health Services of New York,
Inc. Plan
physician or provider and when appropriate, Prior Authorized by
the Physicians Health Services of New York, Inc. Medical Director.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may
get information about us, our networks, providers, and facilities. OPM's
FEHB website (www. opm. gov/ insure) lists the specific types
of
information that we must make available to you. Some of the required information
is listed below.
Physicians Health Services of New York, Inc. contracts with physicians and
other practitioners either directly or through provider organizations (IPAs and
PHOs). Most of these providers are reimbursed for each covered
service on a
fee-for-service basis with a limited percentage withheld as a reserve. The
withheld percentage is based on an estimate of overall utilization. However,
some IPAs/ PHOs may reimburse their Primary Care
Providers on the basis of a
set amount per member per month (capitated reimbursement). Depending upon the
overall utilization of members selecting Physicians Health Services of New
York, Inc. 's directly contracted or an IPAs/ PHOs Primary Care Providers, the
amount withheld by Physicians Health Services of New York, Inc. may
be returned to the providers. Physicians Health Services of New York, Inc.
also contracts with certain vendors
and suppliers (laboratory services, home
health, etc.) that are paid a capitated reimbursement. Lastly, Physicians Health
Services of New York, Inc. reimburses hospitals and facilities on the basis of a
per diem, case rate, or
some other form of negotiated fee.
If you want more information about us, call (877) 747-9585, or write to
Physicians Health Services of New York, Inc.,
One Far Mill Crossing,
Shelton, CT 06484. You may also contact us by fax at (203) 402-7056 or visit our
website at www. health. net. 6
6 Page 7 8
2002 Physicians
Health Services of New York, Inc. 7 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area.
This is where our providers practice. Our service
area is Dutchess, Orange,
Putnam, Rockland, and Westchester Counties, the five boroughs of New York City,
Nassau and Suffolk.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will pay only for emergency care
benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.
If you or a covered
family member move outside of our service area, you can enroll in another plan.
If your dependents live out of the area (for example, if your child goes to
college in another state), you should consider
enrolling in a
fee-for-service plan or an HMO that has agreements with affiliates in other
areas. If you or a family member move, you do not have to wait until Open Season
to change plans. Contact your employing or retirement
office. 7
7 Page 8 9
2002 Physicians Health Services of New York, Inc.
8 Section 2
Section 2. How we change for 2002
Do not
rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5 Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We changed speech therapy benefits by removing the requirement that
services must be required to restore functional speech. (Section 5( a))
Changes to this Plan
Your share of the non-Postal premium will
increase by 103.7% for Self Only or 80.4% for Self and Family.
We no
longer limit total blood cholesterol tests to certain age groups. (Section 5(
a))
We now cover routine screening for chlamydial infection. (Section 5(
a))
We now cover certain intestinal transplants. (Section 5( b))
We
changed the address for sending disputed claims to OPM. (Section 8)
We now
provide coverage for up to $100 for one smoking cessation program per member per
lifetime, including all related expenses such as drugs. 8
8 Page 9 10
2002 Physicians Health Services of New York, Inc. 9 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it
whenever you receive services from a
Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive
your ID card, use your copy of the Health Benefits Election Form, SF-2809, your
health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at (877)
747-9585.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
Plan providers Plan providers are physicians and other
health care professionals in our service area that we contract with to provide
covered services to our
members. We credential Plan providers according to
national standards.
We list Plan providers in the provider directory, which
we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically. The list is also on our website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for most of your health care.
You must obtain covered services from a Plan physician or provider, except in
the event of an emergency. If covered services cannot be
provided by a Plan
physician or Plan provider prior approval must be
obtained in writing from
the Physicians Health Services of New York, Inc. Medical Director before you may
receive covered services from a
Non-plan physician or provider. Physicians Health Services of New
York,
Inc. will only approve a referral to a Non-plan physician or provider if the
covered services cannot be provided by a plan physician
or provider.
To see whether a physician or provider participates in the Physicians Health
Services of New York, Inc. network, or to check the location and
phone
number of a network specialist, hospital or urgent care center you can:
Refer to the Physicians Health Services of New York, Inc. physician
and
provider directory; Call the Customer Service Department at (877) 747-9585.
The
Customer Service Department can also provide you with information
regarding professional qualifications and
credentials; Visit our website at www. health. net for the latest
information on
Plan physicians and providers; 9
9 Page 10 11
2002
Physicians Health Services of New York, Inc. 10 Section 3
Call
the Interactive Provider Directory system toll-free at (800) 686-9847 for a
personalized list of local Plan physicians and providers that can be
faxed
to you immediately or mailed to your home.
Primary care Your
primary care physician can be an internist, family or general practice
physician, an obstetrician/ gynecologist or a pediatrician for your
children.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Although you are not required to obtain a referral
from your primary care physician to see a specialist, we recommend that you
always consult your
primary care physician first.
Here are other things
you should know about specialty care:
If you need to see a specialist
frequently because of a chronic, complex, or serious medical condition, your
primary care physician
will work with your specialist to develop a treatment
plan that allows you to see your specialist. Your primary care physician will
use our
criteria when creating your treatment plan (the physician may have
to get an authorization or approval beforehand).
You may request access to a specialist to coordinate your care or access to
a specialty care center if you have a life-threatening or
degenerative and
disabling condition or disease which requires specialized medical care over a
prolonged period of time. Specialty
care may be accessed in accordance with
the terms of your Plan documents.
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see
a
specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we
can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for
other than cause; or
drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days
after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your
new plan. 10
10 Page
11 12
2002 Physicians Health Services
of New York, Inc. 11 Section 3
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 (877) 747-9585. If you
are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from
another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most services.
For certain services, however,
your physician must obtain approval from
us. Before giving approval, we
consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
We call this review and approval process prior authorization. Your physician
must obtain prior authorization for the followings services
including but
not limited to: inpatient hospitalization, elective outpatient
surgical
procedures, oxygen and related respiratory equipment, organ transplants,
rehabilitative and restorative physical, occupational, speech,
respiratory therapy and skilled nursing care.
Physicians Health Services
of New York, Inc. will provide the Plan physician or provider with an
authorization specifying the services
requested. The Plan physician or
provider will be notified prior to the initiation of the requested treatment.
Any covered services received from
a Non-Plan physician or provider must
also be prior authorized by
Physicians Health Services of New York, Inc. The
member shall be fully responsible for the cost of services to Plan providers if
prior approval for
such services has been denied by Physicians Health Services of New
York,
Inc. and the member has been notified of such determination in advance of
receiving the services. 11
11 Page 12 13
2002 Physicians
Health Services of New York, Inc. 12 Section 4
Section 4. Your
costs for covered services
You must share the cost of some services. You
are responsible for:
Copayments A copayment is a fixed amount of
money you pay to the provider, facility, pharmacy, etc. when you receive
services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit and when you go in the hospital, you
pay nothing per
admission.
Deductible We do not have a deductible
Coinsurance We do not have coinsurance.
Your catastrophic
protection After your copayments total $1,500 per person or $3,000 per
family out-of-pocket maximum enrollment in any calendar year, you do not
have to pay any more for
for copayments covered services. However, copayments for the following
services do not count toward your out-of-pocket maximum, and you must continue
to
pay copayments for these services:
Prescription Drugs
Be sure
to keep accurate records of your copayments since you are responsible for
informing us when you reach the maximum. 12
12
Page 13 14
2002 Physicians Health Services of New York, Inc. 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our
benefits changed this year and page 58 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing advice, or more
information about our benefits, contact us at (877) 747-9585or at our website at
www. health. net.
(a) Medical services and supplies provided by physicians and other health
care professionals ............................... 14-22
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care
Family planning Infertility services
Allergy care
Treatment therapies Physical and occupational therapies
Speech therapy Hearing services (testing, treatment, and
supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment
(DME)
Home health services Chiropractic
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals .................…… 23-26
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other
facility, and ambulance
services............................................................. 27-29
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
................................................................................................................................
30-31
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
........................................................................................................
32-33
(f) Prescription drug
benefits................................................................................................................................................
34-37
(g) Special features
.......................................................................................................................................................................
38 Flexible benefits option
Personal Health Advisor Line
Interactive Provider Directory
Disease State Management Programs
(h) Dental
benefits.........................................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
................................................................................................................
40
Summary of benefits
.....................................................................................................................................................................
58 13
13 Page 14
15
2002 Physicians Health Services of New York,
Inc. 14 Section 5( a)
Section 5 (a) Medical services and
supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
$10 per office visit
Professional services of physicians
Office medical consultations
Second surgical opinion
$10 per office visit
At home
During a hospital stay
Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing 14
14 Page
15 16
2002 Physicians Health Services
of New York, Inc. 15 Section 5( a)
Preventive care, adult You
pay
Routine screenings, such as:
Total Blood Cholesterol – once
every three years
Colorectal Cancer Screening, including
Fecal occult
blood test
Sigmoidoscopy, screening – every five years starting at age 50
$10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men who are
symptomatic; whose biological father or brother have been diagnosed with
prostate cancer; and for all men age 40 and over
$10 per office visit
Routine pap test
Note: The office visit is covered if pap test is
received on the same day; see
Diagnostic and Treatment Services,
above.
$10 per office visit
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
and older , one every calendar year
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine Immunizations, limited to:
Tetanus-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
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing
Well-child care charges for routine examinations, immunizations and care (
up to age 22)
Examinations, such as:
Eye exams through age 19 to
determine the need for vision correction.
Ear exams through age 19 to determine the need for hearing correction
Examinations done on the day of immunizations (up to age 22)
Nothing 15
15 Page
16 17
2002 Physicians Health Services
of New York, Inc. 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in
mind:
You do not need to precertify your normal delivery; see page 11 for
other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and
96 hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug
benefit.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges.
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
intrauterine insemination (IUI)
Fertility drugs are covered under the Prescription Drug Benefit only
when administered in connection with the treatment of a covered
infertility service, such as IUI.
$10 per office visit 16
16 Page 17 18
2002 Physicians
Health Services of New York, Inc. 17 Section 5( a)
Infertility
services (continued) You Pay
Not covered:
Assisted reproductive technology (ART) procedures, such as: in
vitro fertilization
embryo transfer, gamete GIFT and Zygote
ZIFT
---Zygote transfer
Services and supplies related to excluded ART procedures
Fertility drugs used as part of excluded infertility treatment, such as
In vitro fertilization.
Cost of donor sperm
Cost of donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges.
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone marrow transplants
are limited to those transplants listed under
Organ/ Tissue Transplants on page 25.
Respiratory and inhalation
therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous
(IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT) is covered under the medical benefit
Lyme
disease treatment that is medically necessary and appropriate including at least
30 days of intravenous antibiotic therapy, and/ or 60
days of oral
antibiotic therapy. Coverage shall include further treatment by a board
certified rheumatiologist, infectious disease specialist or
neurologist.
Nothing 17
17 Page
18 19
2002 Physicians Health Services
of New York, Inc. 18 Section 5( a)
Physical and occupational
therapies You pay
60 visits per condition for the services of each of
the following:
-qualified physical therapists and
-occupational
therapists.
Note: We only cover therapy to restore bodily function when
there has
been a total or partial loss of bodily function due to illness or
injury.
Cardiac rehabilitation on an outpatient basis, as part of an approved
cardiac rehabilitation program for a maximum of 12 weeks following a
myocardial infarction or cardiac surgery.
$10 per office visit
Nothing per visit during covered inpatient
admission.
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
Two (2) consecutive months per condition with
approval from the Medical Director $10 per office visit
Hearing services (testing, treatment, and supplies)
First
hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 19 (see Preventive care,
children)
$10 per office visit
Not covered:
all other hearing testing
hearing
aids, testing and examinations for them
All charges. 18
18 Page 19 20
2002 Physicians
Health Services of New York, Inc. 19 Section 5( a)
Vision
services (testing, treatment, and supplies) You pay
Vision therapy
services (orthoptics and/ or pleoptic therapy) are covered to a maximum of 3
visits per member per calendar year. This is not
intended to exclude
coverage for medically necessary and appropriate
treatment for diseases of
the eye.
$10 per office visit
One routine eye examination (including refraction) per calendar year for
members to the attainment of nineteen (19) years of age; one (1) routine
eye
examination (including refraction) every two (2) calendar years for members age
nineteen (19) years of age and older (see preventive care)
$10 per office
visit
Not covered:
Eyeglasses or contact lenses and, after age 19,
examinations for them
Eye exercises
Radial keratotomy and other refractive
surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes. $10 per office
visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat
feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot (unless the
treatment is by open cutting surgery)
All charges. 19
19 Page 20 21
2002 Physicians
Health Services of New York, Inc. 20 Section 5( a)
Orthopedic
and prosthetic devices You pay
Externally worn breast prostheses and
surgical bras, including necessary replacements, following a mastectomy
External prosthetic devices, such as artificial limbs, are limited to a
maximum payment by the Plan of $5,000 for the initial appliance
and $500 per
necessary replacement prosthetic.
Internal prosthetic devices, such as
artificial joints, pacemakers, cochlear implants, and surgically implanted
breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery to insert
the device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel
cups
lumbosacral supports
corsets, trusses, elastic
stockings, support hose, and other supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
All charges.
Durable medical equipment (DME)
Durable Medical Equipment such as
wheelchairs and hospital beds, and orthopedic devices such as braces are limited
to the initial appliance or
piece of equipment.
50% of the cost of the
covered item to a maximum of $1,500 per
member per calendar year
Not covered:
Motorized wheel chairs All charges. 20
20 Page 21 22
2002 Physicians Health Services of New York, Inc.
21 Section 5( a)
Home health services You Pay
Home
health care ordered by a Plan physician and provided by a registered nurse (R.
N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include
oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the
convenience of, the patient or
the patient's family;
home care
primarily for personal assistance that does not include a medical component and
is not diagnostic, therapeutic, or
rehabilitative.
All charges.
Chiropractic
Chiropractic services as medically necessary $10 per
office visit
Alternative treatments
Acupuncture services are covered when
approved in advance up to 20 visits per member per calendar year. $20 per office
visit
Biofeedback according to approved medical criteria when medically necessary
and appropriate and prior authorized by Physicians Health
Services of New
York, Inc.
$10 per office visit 21
21 Page 22 23
2002 Physicians
Health Services of New York, Inc. 22 Section 5( a)
Alternative
treatments You Pay
Not covered:
hypnotherapy
naturopathy services
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as drugs.
Diabetes outpatient self-management training, which includes, but is not
limited to, education and medical nutrition therapy. Diabetic self-management
training shall be provided by a certified, registered or licensed health
care professional trained in the care and management
of diabetes. Therapy
visits are limited to those visits that are medically necessary and appropriate.
$10 per office visit 22
22 Page 23 24
2002 Physicians
Health Services of New York, Inc. 23 Section 5( b)
Section 5
(b). Surgical and anesthesia services provided by physicians and other health
care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e. hospital,
surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF
SOME SURGICAL PROCEDURES. Please refer to the precertification information shown
in Section 3 to be sure
which services require precertification and identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures Treatment
of fractures, including casting
Normal pre-and post-operative care by the surgeon Correction of amblyopia
and strabismus
Endoscopy procedures Biopsy procedures
Removal of
tumors and cysts Correction of congenital anomalies (see reconstructive
surgery)
Surgical treatment of morbid obesity
Insertion of internal
prosthetic devices. See 5( a) – Orthopedic and prosthetic devices for device
coverage information.
$10 per office visit; nothing for inpatient hospital visits
Voluntary sterilization
Note: Generally, we pay for internal prostheses
(devices) according to where the procedure is done. For example, we pay Hospital
benefits for
a pacemaker and Surgery benefits for insertion of the
pacemaker.
$10 per office visit; nothing for inpatient hospital visits
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges. 23
23 Page 24 25
2002 Physicians
Health Services of New York, Inc. 24 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a
functional defect
Surgery to correct a condition caused by injury or
illness if:
the condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes.
$10 per office visit; nothing for inpatient or outpatient hospital
surgical visits
All stages of breast reconstruction surgery following a mastectomy, such
as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours
after the procedure.
See above.
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones; Surgical
correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or
their supporting structures.
TMJ surgery and other non-dental treatment.
$10 per office visit; nothing for inpatient hospital visits 24
24 Page 25 26
2002 Physicians Health Services of New York, Inc.
25 Section 5( b)
Oral and maxillofacial surgery (continued)
You pay
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.
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung:
Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach and
pancreas.
Limited Benefits -Treatment for breast cancer, multiple myeloma,
and epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those
performed for the actual donor
Implants of
artificial organs
Transplants not listed as covered
All charges 25
25 Page 26 27
2002 Physicians
Health Services of New York, Inc. 26 Section 5( b)
Anesthesia
You pay
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Nothing
Professional services provided in –
Office
$10 per office visit 26
26 Page 27 28
2002 Physicians Health Services of New York, Inc.
27 Section 5( c)
Section 5 (c). Services provided by a
hospital or other facility, and
ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care. Any
costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL
STAYS. Please
refer to Section 3 to be sure which services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general
nursing care
meals and special diets; special duty nursing when medically necessary;
and
private room when medically necessary
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 27
27 Page 28 29
2002 Physicians Health Services of New York, Inc.
28 Section 5( c)
Inpatient hospital (Continued)
You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs
and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not
donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including
nurse anesthetist services
Take-home items Medical supplies, appliances,
medical equipment, and any covered
items billed by a hospital for use at home
Nothing
Not covered:
Custodial care
Non-covered
facilities, such as nursing homes and schools
Personal comfort
items, such as telephone, television, barber
services, guest meals and beds
Private nursing care
All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals Blood and
blood plasma, if not donated or replaced
Pre-surgical testing Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
Extended care benefit: Rehabilitative and restorative physical,
occupational, speech, respiratory therapy and skilled nursing care is
limited to a combined maximum of 90 days per calendar year, when
prior approval is obtained from Physicians Health Services of New
York,
Inc. and when services are performed in a Plan inpatient facility. Up to 60 days
may be used for inpatient rehabilitation (physical,
occupational, speech, respiratory therapy)
Nothing
Not covered: custodial care All charges 28
28 Page 29 30
2002 Physicians Health Services of New York, Inc.
29 Section 5( c)
Hospice care You pay
Supportive and
palliative care for a terminally ill member is covered in the home or hospice
facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the direction
of a Plan physician who certifies that the patient is in the
terminal stages
of illness, with a life expectancy of approximately 6
months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when
medically appropriate Nothing 29
29 Page 30 31
2002 Physicians
Health Services of New York, Inc. 30 Section 5( d)
Section 5
(d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more
serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for quick
action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
physician. In extreme emergencies, if you are unable to contact your physician,
contact the
local emergency system (e. g., the 911 telephone system) or go
to the nearest hospital emergency room. Be
sure to tell the emergency room
personnel that you are a Plan member so they can notify the Plan. You or a
family member should notify the Plan within 48 hours. It is your responsibility
to ensure that the Plan
has been timely notified. If you need to be hospitalized in a Non-Plan
facility, the Plan must be notified
within 48 hours or on the first working
day following your admission, unless it was not reasonably possible to notify
the Plan within that time. If you are hospitalized in a Non-Plan facility and
Plan
physicians believe care can be better provided in a Plan hospital, you will
be transferred when medically
feasible with any ambulance charges covered in
full.
Benefits are available for care from Non-Plan providers in a medical
emergency only if delay in reaching
Plan provider wold result in death,
disability or significant jeopardy to your condition.
Plan pays reasonable charges for emergency care services to the extent the
services would have been
covered if received from Plan providers.
You pay $50 per emergency room visit, $25 per urgent care center visit or $10
copay per doctor's office
visit for emergency care services that are covered
benefits by this Plan. If the emergency results in admission to a hospital, the
emergency room copay is waived.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of an
injury or unforeseen illness. If you need to be
hospitalized, the Plan must
be notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within
that time. If you are hospitalized in Non-Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in
full. To be covered by this
Plan any follow-up care recommended by Non-Plan
providers must be approved by the Plan or Plan providers. If you are
hospitalized in Non-Plan facilities and Plan physicians believe care can be
better
provided in a Plan hospital, you will be transferred when medically feasible
with any ambulance charges
covered in full. 30
30
Page 31 32
2002
Physicians Health Services of New York, Inc. 31 Section 5( d)
To
be covered by this Plan any follow-up care recommended by Non-Plan providers
must be prior authorized by the Plan.
Plan pays reasonable charges for
emergency care services to the extent the services would have been
covered
if received by Plan providers.
You pay $50 per emergency room visit, $25 per urgent care center visit or $10
copay per doctor's office visit for emergency care services that are covered
benefits by this Plan. If the emergency results in
admission to a hospital, the emergency room copay is waived.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at
an urgent care center $25 per visit
Emergency care as an outpatient or
inpatient at a hospital,
including doctors' services, copay waived if
admitted $50 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center $25 per visit
Emergency care
as an outpatient or inpatient at a hospital,
including doctors' services,
copay waived if admitted $50 per visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing
Not covered: air ambulance All charges. 31
31 Page 32 33
2002 Physicians Health Services of New York, Inc.
32 Section 5( e)
Section 5 (e). Mental health and substance
abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for
similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAPPROVAL OF THESE SERVICES. See the instructions after
the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may
include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
Medication management
$10 per visit
Mental health and substance abuse benefits -Continued on next page 32
32 Page 33 34
2002 Physicians Health Services of New York, Inc.
33 Section 5( e)
Mental health and substance abuse benefits
(Continued) You pay
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
{plan-specific
explanation of this information}
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
follow your treatment plan and all the following authorization processes:
Your Plan physician will request prior approval from us for all necessary
services. The service must be approved before it is rendered to receive
coverage. You, or a provider acting on your behalf, may call our Prior
Approval Department at (800) 438-7886 for information. You will be
notified
of any denials.
Although you are not required to obtain a referral from your PCP to see a
specialist, we recommend that you always consult your PCP first.
In this plan, you must see Plan physicians and providers, except in the event
of a medical emergency, or when we have authorized the services to be
performed by Non-Plan providers because the service is not available from
Plan providers.
Limitation We may limit your benefits if you do not obtain a
treatment plan. 33
33 Page
34 35
2002 Physicians Health Services
of New York, Inc. 34 Section 5( f)
Section 5 (f). Prescription
drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan physician or
referral doctor must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan
pharmacy, or through the Physicians Health Services of New York, Inc. mail order
supplier.
We use a formulary. The Plan uses a formulary that
includes generic and preferred name brand drugs. The Plan's Pharmacy and
Therapeutics Committee meets on a quarterly basis to review new
medications
to be added to or deleted from the formulary.
Review for additions to the
formulary are based primarily on the following:
1. new drug therapies
introduced;
2. changes in existing drug therapies; and
3. requests
received from Plan physicians.
The criteria used are the safety and efficacy
of the drug, other similar products available, and its relative cost. Deletions
are decided by the committee based on low utilization, other types of equivalent
therapy, or negative changes in existing drug therapies. Your doctor can ask
for exceptions to the formulary. Nonformulary drugs will be covered when
prescribed by a Plan doctor.
We have an open formulary. If your physician believes a name brand product is
necessary or there is
no generic available, your physician may prescribe a
name brand drug from a formulary list. This list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower cost.
To order a prescription drug brochure, call (877) 747-9585.
Please
Note: All brand name drugs that are not listed in the preferred drug
formulary will be subject to
the highest copayment.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral physician and obtained at a Plan pharmacy will be
dispensed for up to a 34-day maximum. You pay a $10
copayment per prescription unit or refill for generic formulary drugs, $20
for preferred brand name, and $35 for all others. The cost of prescriptions
filled through the Plan's mail order supplier will be
equal to 2 copayments
for a 90-day supply.
A generic equivalent will be dispensed if it is
available, unless your physician specifically requires a name brand. If you
receive a name brand drug when a Federally-approved generic drug is available,
and your physician has not specified Dispense as Written for the name brand
drug, you have to pay the difference in cost between the name brand drug and the
generic. 34
34 Page
35 36
2002 Physicians Health Services
of New York, Inc. 35 Section 5( f)
Why use generic drugs?
To reduce your out-of-pocket expenses! A generic drug is the chemical
equivalent of a corresponding brand name drug. Generic drugs are less expensive
than brand name
drugs; therefore you may reduce your out-of-pocket costs by
choosing to use a generic drug.
When you have to file a claim. You
normally won't have to submit claims to us unless you receive emergency services
from a provider who doesn't contract with us. If you do receive a bill and need
to
file a claim, please send us all of the documents for your claim as soon as
possible. You must submit claims by December 31 of the year after the year you
received the service. Either OPM or we can
extend this deadline if you show
that circumstances beyond your control prevented you from filing on time.
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 Physicians Health Services of New York, Inc.
36 Section 5( f)
Benefit Description You pay
Covered
medications and supplies
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a Plan pharmacy 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.
Insulin with a copay charge applied to each vial
Diabetic equipment,
supplies and medication Disposable needles and syringes for the administration
of covered
prescribed medications
Intravenous fluids and medications for home use
(covered under Medical and Surgical benefits as a home health service)
Nutritional supplements for the treatment of phenylkenoturia,
branch-chained kenoturia, galactosemia and homocystinuria
Drugs for sexual
dysfunction Oral and injectable contraceptives and contraceptive devices,
including implanted contraceptive devices such as Norplant and
Depo
Provera
Fertility drugs used in connection with covered infertility
treatments, such as IUI
Immunosuppressive drugs
Note: – We will only cover GHT when we
preauthorize the treatment.
Call (877) 747-9585 for preapproval. We will ask you to submit information
that establishes that the GHT is medically necessary. Ask us
to authorize
GHT before you begin treatment; otherwise, we will only cover GHT services from
the date you submit the information. If you do
not ask or if we determine
GHT is not medically necessary, we will not
cover the GHT or related
services and supplies. See Services requiring our
prior approval in
Section 3.
Note: If there is no generic equivalent available, you will still have to pay
the brand name copay.
$10 for generic drugs.
$20 for preferred brand name
drugs
$35 for all other covered drugs 36
36 Page 37 38
2002 Physicians
Health Services of New York, Inc. 37 Section 5( f)
Covered
medications and supplies (continued) You pay
Not
covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription medicines
Drugs for which there is a
nonprescription equivalent available
Drugs obtained at a Non-Plan
pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Prescription drugs obtained for use in connection with drug addiction
Drugs to enhance athletic performance
Smoking cessation
drugs and medication including nicotine patches
Fertility drugs
used as part of excluded infertility treatments, such as In vitro fertilization.
All Charges 37
37 Page 38 39
2002 Physicians
Health Services of New York, Inc. 38 Section 5( g)
Section 5
(g). Special features
Feature Description
Flexible benefits option
Under the flexible benefits option, we determine the most effective way to
provide services.
We may identify medically appropriate alternatives to
traditional care and coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving
an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour Personal
Health Advisor line
Our free Personal Health Advisor phone line is available 24 hours a
day,
seven days a week to answer your health-related questions. If you are sick or
have been hurt, and are unsure of what to do, a
specially trained nurse can help you determine the most appropriate
course of action. The 550 nurses that staff the phones average more than 15
years of clinical experience. Together, they handle 2 million
calls every year. If you ever need help assessing an injury or illness,
call the Personal Health Advisor line, toll-free at (800) 219-5326.
Interactive Provider
Directory
Even when you do not have access to our printed directory or to the Internet,
you can still locate a Plan physician or provider. Our
Interactive Provider Directory system via touch-tone phone enables you to
have a personalized list of local physicians or providers either
faxed to
you immediately or mailed to your home. The system will
find 100 closest
Plan Providers to the zip code you supply. To access the Interactive Provider
Directory, call toll-free, (800) 686-9847.
Disease State
Management Programs
Disease State Management programs help members manage their
chronic
conditions. When you are facing the challenges of diabetes, congestive heart
disease, asthma, glaucoma, osteoporosis, kidney
disease and other chronic conditions, we can help with our education
and
care-management program. For more information, call toll-free (800) 573-2177
Services for deaf and
hearing impaired
Services for the deaf and hearing impaired can be accessed by calling
(888) 747-2424 38
38 Page
39 40
2002 Physicians Health Services
of New York, Inc. 39 Section 5( h)
Section 5 (h). Dental
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover
hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the
patient; we do not
cover the dental procedure unless it is described below.
Be sure to
read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth (1) resulting from accidental injury,
when services are received within 12 months of the accident; or
(2) that is necessary due to congenital disease or anomaly.
$10 per office visit; nothing for
inpatient services
Dental benefits
We have no other dental benefits. 39
39 Page 40 41
2002 Physicians Health Services of New York, Inc.
40 Section 5( i )
Section 5 (i). Non-FEHB benefits available
to Plan members
The benefits described on this page are neither offered
nor guaranteed under the contract with the FEHB Program, but are made available
to all enrollees and family members who are members of this Plan. The cost of
the benefits
described on this page is not included in the FEHB premium, and any charges
for these services do not count toward
any FEHB deductibles or out-of-pocket
maximums. These benefits are subject to the FEHB disputed claims procedure.
The Physicians Health Services of New York, Inc. "Healthy Extras" Program
Physicians Health Services of New York, Inc. AlternaCare SM : This
holistic health care program provides benefits for chiropractic and acupuncture
services, and offers discounts for massage therapy, nutritional supplements and
vitamins.
TruVision SM : Get contact lenses and related
supplies for up to a 50-percent savings. They are shipped directly to your home,
at no additional cost.
Fitness Center Discount Program: Receive 20 to 30 percent off
monthly fees at participating fitness centers through a health and fitness
network administered by WellQuest, Inc.
Well Women For Life:
Physicians Health Services of New York, Inc. leads the way in meeting the
unique health needs of women with our breast cancer screening program and
reminder mailings for mammograms and cervical
cancer screenings.
Osteoporosis and menopause education materials also are available.
Smart Start: This reminder program helps parents keep track of their
children's immunizations and provides educational material explaining the
importance of receiving these immunizations prior to age two.
WellBaby SM : This program helps members have the healthiest
possible pregnancies by complementing the advice and care of the obstetricians.
Dental Care Services – Physicians Health Services of New York, Inc.
members may enroll in Dentcare a Managed Care dental program offered by Dentcare
Delivery Systems, Inc. licensed by the New York State Insurance Department.
Dentcare's
program provides members with access to a wide range of dental
benefits with a special emphasis on preventive dentistry. Benefits are available
for preventive, basic and major care, including orthodontics. To enroll with
Dentcare, simply complete
the enclosed dental application and send it along
with an annual premium check directly to Dentcare, Delivery Systems, Inc., Attn:
Sue Merkle, 60 Charles Lindbergh Blvd., Uniondale, NY 11553. Be sure to select a
family dentist from their list since
covered services must be rendered by a
participating general dentist. The following is an example of some of the
benefits
available at participating dentists: Diagnostic and Preventive
Services Restorative Dentistry Primary And Permanent
Full mouth x-rays No Charge Silver Amalgam, one surface $10.00
Oral exam
(once every six months) No Charge Silver Amalgam, two surfaces $20.00 Flouride
treatment No Charge Silver Amalgam 3 surfaces or more $30.00
Oral Surgery Prosthetics— Crowns
Routine extractions, per tooth No
Charge Acrylic w/ metal crown $175.00 Orthodontics
Porcelain w/ metal crown $295.00 Maximum case fee— 24 month treatment
$1,950.00
Dependent children covered to age 19, or to age 23 if full-time
students.
Dentcare materials have been provided by Dentcare Delivery
Systems, Inc., for your review and consideration. Dentcare is not affiliated
with Physicians Health Services of New York, Inc. or Health Net, Inc. Dentcare
is solely responsible for
coverage, plan designs, provider network and all
other services it offers. If you have any questions about Dentcare, please
call a Dentcare representative at (800) 468-0608 extension 2269.
Physicians Health Services of New York, Inc. SmartChoice
SM Medicare+ Choice Program -Medicare beneficiaries have the
opportunity to enroll in the Physicians Health Services of New York, Inc.
SmartChoice SM
Medicare+ Choice plan. If you are an annuitant or
former spouse, you can suspend your FEHB coverage and enroll in a Medicare+
Choice plan when one is available in your area. (For details, see page 48 inside
this brochure.) Physicians
Health Services of New York, Inc. has more than a
decade of experience with Medicare-approved health plans. We are committed to
providing our members with high quality, easily accessible and affordable health
care coverage with
outstanding customer service. If you are interested in
enrolling in PHS SmartChoice SM , please call (800) 747-1823 toll-free
for more information. Medicare-approved health plans.
We are committed to providing members with high quality, easily accessible
and affordable health care coverage with
unsurpassed customer service. If
you are interested in enrolling in PHS SmartChoice SM , please call (800)
747-1823 toll-free
for more information. 40
40
Page 41 42
2002
Physicians Health Services of New York, Inc. 41 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we
will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury or condition and we agree, as discussed under
What Services Require
Our Prior Approval on page 11
We do not cover the
following:
Care by non-Plan providers except for authorized referrals or
emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility
barred from the FEHB Program. 41
41 Page 42 43
2002 Physicians
Health Services of New York, Inc. 42 Section 7
Section 7.
Filing a claim for covered services
When you see Plan physicians,
receive services at Plan hospitals and facilities, or obtain your prescription
drugs at
Plan pharmacies, you will not have to file claims. Just present
your identification card and pay your copayment, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital In most cases, providers and facilities file claims
for you. Physicians and prescription drug benefits must file on the form
HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92
form. For claims questions and assistance, call us at (877) 747-9585.
When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the
physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of
each service or supply;
The charge for each service or supply;
A
copy of the explanation of benefits, payments, or denial from any primary payer
--such as the Medicare Summary Notice
(MSN); and
Receipts, if you paid
for your services.
Submit your claims to: Health Net, Formerly PHS
Health Plans
P. O. Box 981 Bridgeport, CT 06601-0981
Attention: Claims Only
Deadline for filing your claim Send us all
of the documents for your claim as soon as possible. You must submit the claim
by December 31 of the year after the year you
received the service, unless
timely filing was prevented by administrative operations of Government or legal
incapacity, provided the claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 42
42 Page
43 44
2002 Physicians Health Services
of New York, Inc. 43 Section 8
Section 8. The disputed claims
process
Follow this Federal Employees Health Benefits Program disputed
claims process if you disagree with our decision on
your claim or request
for services, drugs, or supplies – including a request for preapproval:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Physicians Health Services of New York, Inc., One Far Mill
Crossing, Shelton, CT 06484; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports,
bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we
will send you a copy
of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, D. C. 20415-3630.
43
43 Page 44 45
2002 Physicians Health Services of New York, Inc.
44 Section 8
The Disputed Claims process (Continued)
Note: You are the only person who has a right to file a disputed
claim with OPM. Parties acting as your representative, such as medical
providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show
that you were unable to meet the deadline because of reasons beyond your
control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
(877) 747-9585 and we will
expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m. eastern time. 44
44
Page 45 46
2002
Physicians Health Services of New York, Inc. 45 Section 9
Section 9. Coordinating benefits with other coverage
When you
have other health coverage You must tell us if you are covered or a family
member is covered under another group health plan or have automobile insurance
that pays health
care expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan normally pays its
benefits in full as the primary payer and the other plan pays a reduced benefit
as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
If we pay second, we will determine what the reasonable charge for
the benefit should be. After the first plan pays, we will pay either what is
left
of the reasonable charge or our regular benefit, whichever is less. We
will not pay more than the reasonable charge. If we are the secondary payer,
we may be entitled to receive payment from your primary plan.
We will always provide you with the benefits described in this brochure.
Remember: even if you do not file a claim with your other plan, you
must
still tell us that you have double coverage.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65
years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay or Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who
was a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if you are age 65 or older, you may be able to buy it. Contact
1-800-
MEDICARE for more information.
Part B (Medical Insurance). Most people
pay monthly for Part B. Generally, Part B premiums are withheld from your
monthly Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices
in how you get your health care. Medicare + Choice is the term used to describe
the various health plan
choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of
Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is (Part A or Part B) available everywhere in the United
States. It is the way
everyone used to get Medicare benefits and is the way
most people get their Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital that accepts Medicare. The Original 45
45 Page 46 47
2002 Physicians Health Services of New York, Inc.
46 Section 9
Medicare Plan pays its share and you pay your share.
Some things are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this plan, you still
need to follow the rules in this brochure for us to cover your care.
Your
care must continue to be authorized by your Plan PCP, or
precertified as
required.
We will not waive any of our copayments.
(Primary payer chart begins
on next page.) 46
46 Page
47 48
2002 Physicians Health Services
of New York, Inc. 47 Section 9
The following chart illustrates
whether the Original Medicare Plan or this Plan should be the primary
payer for you according to your employment status and other factors determined
by Medicare. It is critical that you tell us if you or
a covered family
member has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you
--or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor afamilymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B
only, regardless of your employment status, (for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare
based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to
ESRD after Medicare became
primary for you under another provision,
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or …
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee 47
47 Page
48 49
2002 Physicians Health Services of New York, Inc. 48 Section 9
Claims process when you have the Original Medicare Plan --You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes
your
claim first. In most cases, your claims will be coordinated
automatically
and we will pay the balance of covered charges. You will not need to do
anything. To find out if you need to do something
about filing your claims, call us at
(877) 747-9585 or visit our website
at www. health. net
In this case we do not waive any out-of-pocket costs.
Medicare managed care plan If you are eligible for Medicare, you
may choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a
Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan.
Medicare managed care plans provide all the benefits that
Original Medicare covers. Some cover extras, like prescription drugs. To learn
more about enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments or
coinsurance for your FEHB coverage.
This Plan and another plan's
Medicare managed care plan: You
may enroll in another plan's Medicare
managed care plan and also remain enrolled in our FEHB plan. We will still
provide benefits when
your Medicare managed care plan is primary, even out of the managed
care
plan's network and/ or service area (if you use our Plan providers), but we will
not waive any of our copayments or coinsurance. If you
enroll in a Medicare managed care plan, tell us. We will need to now
whether you are in the Original Medicare Plan or in a Medicare managed care
plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care
plan:
If you are an annuitant or former spouse, you can suspend your
FEHB
coverage to enroll in a Medicare managed care plan, eliminating
your FEHB
premium. (OPM does not contribute to your Medicare managed care plan premium.)
For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to
re-enroll
in the FEHB Program, generally you may do so only at the next open
season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered Medicare Part A or Part B under the
FEHB Program. We will not require you to enroll in Medicare 48
48 Page 49 50
2002 Physicians Health Services of New York, Inc.
49 Section 9
Part B and, if you can't get premium-free Part A, we
will not ask you to enroll in it.
TRICARE TRICARE is the health care
program for eligible dependents of military persons and retirees of the
military. TRICARE includes the CHAMPUS
program. If both TRICARE and this
Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if you
have questions about
TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a
similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your
treatment, we will cover your care. You must use
our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care
for injuries for injuries or illness
that another person caused, you must reimburse us for whatever services we paid
for. 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. 49
49 Page 50 51
2002 Physicians Health Services of New York, Inc.
50 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Any service or supply that can be furnished
by someone who has no professional health care training or skills to a member:
(a) whose functional capacity has been reduced so significantly that he or
she is not able to function outside a protected, monitored or
controlled
environment (whether in an institution or in the home)
and; (b) who is not
under active and specific treatment that will increase the
Member's functional capacity to the extent necessary to enable the
member
to function outside the protected, monitored or controlled environment.
A custodial care determination is not precluded by the fact that a Member
is under the care of a supervising or attending physician and that the
services are being ordered and prescribed to support and generally
maintain the member's comfort or ensure the manageability of the
member.
Further, a custodial care determination is not precluded because the ordered and
prescribed services and supplies are being
provided or supervised by a registered nurse, a physician assistant or
physical therapist.
Experimental or
investigational services Experimental or
investigational services are those services or supplies which include, but are
not limited to, any diagnosis, treatment, procedure,
facility, equipment, drugs, drug usage, devices or supplies which are
determined, in the sole discretion of Physicians Health Services of New
York, Inc. to be Experimental or Investigational. Services are considered
to be Experimental or Investigational if any of the following applies:
The service or supply has not been formally approved by, or cannot be lawfully
marketed without the approval of the appropriate
government regulatory body or agency, including, but not limited to
the
U. S. Food and Drug Administration, and, at the time it is furnished, such
approval has not been given; or
The written informed consent form to be used by the treating facility or by
other facilities in studying substantially the same service or
supply,
refers to such service or supply as Experimental or Investigational, or as a
research project, a study, an investigation, a
test, a trial, or words of
similar effect; or
The written informed consent form and/ or the written
protocols to be utilized by the treating facility for specific services or
supplies has
not been reviewed and/ or has not been approved by the treating facility's
Institutional Review Board, or other body serving a similar
function, or if
federal law requires such review and approval; or The informed consent
documents and/ or the written protocols and/ or
published reports or peer
review articles in authoritative medical and scientific literature show that the
service or supply is the subject of a
protocol( s) or study, including Phase
I, II, or III clinical trial study, 50
50 Page 51 52
2002 Physicians
Health Services of New York, Inc. 51 Section 10
or is otherwise
under study to determine any of the following: its maximum tolerated toxicity,
its safety, its efficacy, or its overall
benefits and risks as compared with
a standard means of treatment or diagnosis.
In determining whether services or supplies are Experimental or
Investigational, Physicians Health Services of New York, Inc. will
evaluate
the services with regard to the particular Illness or disease
involved, and
will consider factors which Physicians Health Services of New York, Inc.
determines to be most relevant under the circumstances,
such as: published reports and articles in the authoritative medical,
scientific, and peer review literature; or written protocol( s) used by the
treating facility or being used by another facility studying substantially
the same drug, device, medical treatment or procedure.
Medical necessity Health care services or supplies for prevention,
diagnosis, or treatment which are not excluded or limited by this Certificate of
Coverage and
which are: a. appropriate for, and consistent with, the
symptoms and proper
diagnosis or treatment of the Member's Illness, injury,
disease, or
condition; and b. provided for the diagnosis or the direct care
and treatment of the
Member's Illness, injury, disease, or condition; and
c. not primarily for
the convenience, appearance, or recreation of the Member, the Member's
practitioner or another; and
d. within the standards of good medical practice within the organized
medical community; and e. neither Experimental or Investigational; and
f. the most appropriate supply or Level of Care which can safely be
provided. For Hospital stays this means the acute care as an Inpatient is
necessary due to the type of Covered Services a Member
is receiving or the severity of the Member's condition and adequate
care
cannot be received as an outpatient or in a less intensive medical setting.
Not all Medically Necessary services or supplies are covered.
Us/ We Us and we refer to Physicians Health Services of New York, Inc.
You You refers to the enrollee and each covered family member. 51
51 Page 52 53
2002 Physicians Health Services of New York, Inc. 52 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www.
opm. gov/ insure. Also, your employing or retirement office about
enrolling in the can answer your questions, and give you a Guide to
Federal Employees
FEHB Program Health Benefits Plans,
brochures for other plans, and other materials you need to make an informed
decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22, including any
foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31
days before to 60 days after that event. The Self
and Family enrollment begins on the
first day of the pay period in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your
enrollment form; benefits will not be available to your spouse
until you marry.
Your employing or retirement office will not notify you when a family
member is no
longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your coverage for
any reason, including
divorce, or when your child under age 22 marries or turns 22.
If you or
one of your family members is enrolled in one FEHB plan, that person may not be
enrolled in or covered as a family member by another FEHB plan.
When benefits and The benefits in this brochure are effective on
January 1. If you joined this Plan premiums start during Open Season,
your coverage begins on the first day of your first pay period that starts on or
after January 1. Annuitants' coverage and premiums begin on January 1. If
you joined at any other time during the year, your employing office will tell
you the effective date of coverage. 52
52 Page 53 54
2002 Physicians Health Services of New York, Inc. 53 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 coverage continue to get benefits under your
former spouse's enrollment. But, you may be eligible
for your own FEHB coverage under the spouse equity law. If you are recently
divorced
or are anticipating a divorce, contact your ex-spouse's employing
or retirement office to get RI 70-5, the
Guide to Federal Employees
Health Benefits Plans for Temporary
Continuation of Coverage and Former
Spouse Enrollees, or other information about your
coverage choices.
Temporary continuation of coverage (TCC) If you leave Federal
service, or if you lose coverage because you no longer qualify as a
family
member, you may be eligible for Temporary Continuation of Coverage (TCC). For
example, you can receive TCC if you are not able to continue your FEHB
enrollment
after you retire , if you lose your job, if you are a covered
dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide
to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage
and
Former Spouse Enrollees, from your employing or retirement office or
from
www. opm. gov/ insure. It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity
law ends (If you canceled your
coverage or did not pay your premium, you
cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
53
53 Page 54 55
2002 Physicians Health Services of New York, Inc. 54 Section 11
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us
within 31 days
after you are no longer eligible for coverage.
Your
benefits and rates will differ from those under the FEHB Program; however, you
will not have to answer questions about your health, and we will not impose a
waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA)
Group Health Plan Coverage 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. 54
54 Page
55 56
2002 Physicians Health Services of New York, Inc. 55 Long Term Care
Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality
long term care insurance program effective in October
2002. As part of its
educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease such as Alzheimer's.
LTC insurance can provide broad,
flexible benefits for nursing home care, care in an assisted living facility,
care in your home, adult day care, hospice care, and more. LTC insurance can
supplement care provided by family members, reducing the burden you place on
them.
Welcome to the club! 76% of Americans believe they will never need long
term care, but the facts are that about half of
them will. And it's not just
the old folks. About 40% of people needing long term care are under
age 65.
They may need chronic care due to a serious accident, a stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their financial and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before inflation!
Long term care can easily exhaust your savings.
Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a stay in
an assisted living facility or a continuing need
for a home health aide to
help you get in and out of bed and with other activities of daily living.
Limited stays in skilled nursing facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest
level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It also has a 100 day
limit.
Medicaid
covers long term care for those who meet their state's poverty guidelines, but
has restrictions on covered services and where they can be received.
Long
term care insurance can
provide choices of care and preserve your
independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in mid-2002. In the
meantime, you can learn more about the program on our web site at www. opm. gov/
insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need?
You should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more
information on how to
apply for this new
insurance
coverage?
How can I find out more
about the program
NOW? 55
55 Page 56 57
2002 Physicians Health Services of New York, Inc.
56 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 30
Allergy tests 17 Alternative treatment 21
Allogeneic (donor) bone marrow transplant 25
Ambulance 29 Anesthesia 26
Autologous bone marrow transplant 25
Blood and blood plasma 28 Breast
cancer screening 15
Casts 28 Changes for 2002 8
Chemotherapy 17
Childbirth 16
Chiropractic 21 Cholesterol tests 15
Claims 42 Coinsurance
12
Colorectal cancer screening 15 Congenital anomalies 23
Contraceptive
devices and drugs 36 Coordination of benefits 45
Covered services 12
Deductible 12
Definitions 50 Dental care 39
Diagnostic services
14 Disputed claims review 43
Donor expenses (transplants ) 25 Dressings 28
Durable medical equipment (DME) 20
Educational classes and
programs 22
Effective date of enrollment 50 Emergency 30
Experimental or investigational 50 Eyeglasses 19
Family planning
16
Fecal occult blood test 15
General Exclusions 41
Hearing services 18 Home health
services 21
Hospice care 29 Home nursing care 21
Hospital 11 Immunizations 15
Infertility 16 Inpatient Hospital Benefits 27
Insulin 36 Laboratory
and pathological
services 14 Magnetic Resonance Imagings
(MRIs) 14
Mail Order Prescription Drugs 34
Mammograms 15 Maternity Benefits 16
Medicaid 49 Medically necessary 51
Medicare 45 Mental Conditions/
Substance
Abuse Benefits 32 Newborn care 16
Non-FEHB Benefits 40 Nurse
Licensed Practical Nurse 21 Nurse Anesthetist 28
Registered Nurse 21
Nursery charges 16
Obstetrical care 16
Occupational therapy 18
Office visits 14
Oral and maxillofacial surgery 24 Orthopedic devices 20
Out-of-pocket
expenses 12 Outpatient facility care 28
Oxygen 17 Pap test 15
Physical examination 15 Physical therapy 18
Plan facilities 9 Plan provider 9
Preventive care, adult 15 Preventive
care, children 15
Prescription drugs 34 Preventive services 15
Primary
care 10 Prior approval 11
Prostate cancer screening 15 Prosthetic devices 20
Psychologist 32 Radiation therapy 17
Room and board 27 Second
surgical opinion 14
Skilled nursing facility care 28 Specialty care 10
Speech therapy 18 Splints 28
Sterilization procedures 16 Subrogation 49
Substance abuse 32 Surgery 23
Anesthesia 26 Oral 24
Outpatient
23 Reconstructive 24
Syringes 36 Temporary continuation of
coverage 53 Transplants 25
Treatment therapies 17 Vision services
19
Well child care 15
Wheelchairs 20 Workers' compensation 49
X-rays 14 56
56 Page
57 58
2002 Health N et of New York,
Inc. 57
NOTES: 57
57 Page 58 59
2002 Physicians
Health Services of New York, Inc. 58 Summary
Summary of
benefits for Physicians Health Services of New York, Inc. -2002
Do
not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the
definitions, limitations, and exclusions in
this brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the
office.................... Office visit copay: $10 14
Services provided by a hospital:
Inpatient.......................................................................................................
Outpatient....................................................................................................
Nothing
Nothing
27
28
Emergency benefits:
In-area.........................................................................................................
Out-of-area.................................................................................................
$10 per office visit; $25 per visit to urgent care center; $50 per visit
to hospital emergency room
$10 per office visit; $25 per visit to urgent care center; $50 per visit
to hospital emergency room
30
30
Mental health and substance abuse
treatment.......................................... Regular cost sharing. 32
Prescription drugs
..........................................................................................
$10 for generic formulary drugs;
$20 for preferred brand name drugs; $35 for
all other drugs
34
Dental Care-(as described in section 5(
h))............................................ Nothing 39
Vision Care
..................................................................................................
$10 per visit 19
Special features: Personal Health Advisor Interactive
Provider Directory
Disease State Management Programs
38
Protection against catastrophic costs (your out-of-pocket
maximum)................................................................ Nothing
after $1,500/ Self Only or $3,000/ Family enrollment per year
Some costs do
not count toward this protection
12 58
58
Page 59
2002 Physicians Health
Services of New York, Inc. 59
2002 Rate Information for Physicians
Health Services of New York, Inc.
Non-Postal rates apply to most
non-Postal enrollees. If you are in a special enrollment category,
refer to
the FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB
Guide for United States Postal Service Employees,
RI 70-2. Different postal rates apply and
special FEHB guides are published
for Postal Service Nurses (see RI 70-2B); and for Postal Service Inspectors and
Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization. Refer to the applicable
FEHB Guide.
Type of
Enrollment Code
Non-Postal Premium
Biweekly Monthly
Gov't Your
Gov't Your Share Share Share Share
Postal Premium
Biweekly
USPS Your
Share Share
Dutchess. Orange, Putnam, Rockland
and Westchester Counties, the five boroughs of New York City, Nassau and Suffolk
Counties, New York
High Option Self Only
High Option Self & Family
PD1
PD2
$97.86 $71.02 $212.03 $153.88
$223.41 $213.13 $484.06 $461.78
$115.52 $53.36
$263.75 $172.79 59