Serving: Grand Rapids, Michigan Area
Enrollment in this Plan is
limited; see page 6 for requirements.
Enrollment codes for this Plan:
RL1 Self Only RL2 Self and Family
RI 73-567
GVHP has a 4 star, excellent accreditation from the NCQA. See the
2002
Guide for more information on NCQA.
For changes in benefits
see page 7. 1
1
Page 2 3
2002 Grand
Valley Health Plan 1 Introduction/ Plain Language/ Advisory
Table
of Contents
Introduction
.................................................................................................................................................................
3
Plain
Language..............................................................................................................................................................
3
Inspector General Advisory
..........................................................................................................................................
4
Section 1. Facts about this HMO plan
.........................................................................................................................
5
How we pay providers
................................................................................................................................
5
Your Rights
.................................................................................................................................................
5
Service
Area................................................................................................................................................
6
Section 2. How we change for 2002
............................................................................................................................
7
Program-wide changes
................................................................................................................................
7
Changes to this
Plan....................................................................................................................................
7
Section 3. How you get care
…………........................................................................................................................
8
Identification
cards......................................................................................................................................
8
Where you get covered care
........................................................................................................................
8
Plan providers
.......................................................................................................................................
8
Plan facilities
........................................................................................................................................
8
What you must do to get covered care
........................................................................................................
8
Primary
care..........................................................................................................................................
8
Specialty
care........................................................................................................................................
8
Hospital care
.........................................................................................................................................
9
Circumstances beyond our control
............................................................................................................
10
Services requiring our prior
approval........................................................................................................
10
Section 4. Your costs for covered services
................................................................................................................
11
Copayments
........................................................................................................................................
11
Deductible...........................................................................................................................................
11
Coinsurance
........................................................................................................................................
11
Your out-of-pocket
maximum...................................................................................................................
11
Section 5.
Benefits…………………………………………………………..............................................................
12
Overview...................................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals .......... 13
(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...............................................................................................................................
36 2
2 Page 3 4
2002 Grand Valley Health Plan 2 Introduction/ Plain
Language/ Advisory
Flexible Benefits Option
24 Hour Nurse/ Provider
Line
(h) Dental
benefits................................................................................................................................
37
(i) Non-FEHB benefits available to Plan members
............................................................................. 38
Section 6. General exclusions --things we don't
cover.............................................................................................
39
Section 7. Filing a claim for covered services
...........................................................................................................
40
Section 8. The disputed claims
process......................................................................................................................
41
Section 9. Coordinating benefits with other coverage
...............................................................................................
43
When you have…
Other health coverage
........................................................................................................................
43
Original Medicare
..............................................................................................................................
43
Medicare managed care
....................................................................................................................
46
TRICARE/ Workers'Compensation/ Medicaid
...........................................................................................
46
Other Government agencies
......................................................................................................................
47
When others are responsible for
injuries...................................................................................................
45
Section 10. Definitions of terms we use in this
brochure...........................................................................................
48
Section 11. FEHB
facts..............................................................................................................................................
50
Coverage
information................................................................................................................................
50
No pre-existing condition
limitation...................................................................................................
50
Where you get information about enrolling in the FEHB
Program.................................................... 50
Types of
coverage available for you and your
family.........................................................................
50
When benefits and premiums
start......................................................................................................
51
Your medical and claims records are confidential
..............................................................................
51
When you retire
.................................................................................................................................
51
When you lose benefits
.............................................................................................................................
51
When FEHB coverage
ends................................................................................................................
51
Spouse equity coverage
.....................................................................................................................
51
Temporary Continuation of Coverage (TCC)
....................................................................................
51
Converting to individual
coverage.....................................................................................................
52
Getting a Certificate of Group Health Plan Coverage
....................................................................... 52
Long term care insurance is coming later in 2002
......................................................................................................
53
Index
...............................................................................................................................................................
54
Summary of benefits
...................................................................................................................................................
56
Rates
.................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Grand Valley Health Plan 3 Introduction/ Plain Language/ Advisory
Introduction
Grand Valley Health Plan 829 Forest Hill Ave.,
SE
Grand Rapids, MI 49546
This brochure describes the benefits of Grand
Valley Health Plan under our contract (CS 2632) 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 7. 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 Grand Valley Health
Plan.
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 us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. 4
4 Page 5 6
2002 Grand Valley Health Plan 4 Introduction/
Plain 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 (616) 949-2410
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 Grand Valley Health Plan 5 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.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get
information about us, our networks, providers, and facilities. OPM's FEHB
website (www. opm. gov/ insure) lists the specific types
of information
that we must make available to you. Some of the required information is listed
below.
Grand Valley Health Plan is a Staff Model Health Maintenance
Organization (HMO) that provides a wide variety of primary medical services at
its health centers. In addition to health care providers (such as physicians,
physician
assistants, nurse practitioners, clinical social workers, and
registered dieticians), lab, X-ray and pharmacy are conveniently located at each
health center. The Plan also arranges and covers care through specialists,
hospitals and
other health care professionals. Different family members may
see different primary care providers at their health center. Women who wish to
see a Plan Gynecologist for their annual routine examination should contact
their Health
Center to obtain a list of Plan providers.
We are a
for-profit plan that has been in existence since 1982.
If you want more
information regarding case management practices, staff provider credentials,
contracted provider credentials, and health center and other facility
information, call 616/ 949-2410, or write to Grand Valley Health Plan,
829
Forest Hill Ave., SE, Grand Rapids, MI 49546. You may also contact us by fax at
616/ 949-4978 or visit our website at www. gvhpchoosewell. com. 6
6 Page 7 8
2002 Grand Valley Health Plan 6 Section 1
Service Area
To enroll with us, you must live or work in our
service area. This is where our providers practice. Our service area is:
All
of Kent County and portions of Allegan, Ionia, and Ottawa Counties defined by
the following zip codes:
Allegan County --49311, 49323, 49355, and 49348
Ionia County --48815
Ottawa County --49401, 49403, 49404, 49426, 49427,
49428, 49430, and 49435.
Ordinarily, you must get your care from providers
who staffed or contracted with us. If you receive care outside our service area,
we will pay only for emergency care. 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 Grand Valley Health Plan 7
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 removed the requirement that services must be needed to restore
functional speech from the speech therapy benefit
Changes to this Plan
Your share of the non-Postal premium will
increase by 12. 4 % for Self Only or 58. 3 % for Self and Family.
You may
receive blood or blood plasma at an ambulatory surgical center, or during
outpatient treatment at a hospital, for no charge.
You will pay $50 for professional ambulance service outside our service area.
We now cover certain intestinal transplants (Section 5( b)) 8
8 Page 9 10
2002 Grand Valley Health Plan 8 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 (616) 949-2410.
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 Grand Valley Health Plan is a Staff Model
Health Maintenance Organization (HMO) that provides a wide variety of primary
medical services at its health
centers. In addition to health care providers
(such as physicians, physician assistants, nurse practitioners, clinical social
workers, and registered dieticians),
lab, X-ray and pharmacy are
conveniently located at each health center. The Plan also arranges and covers
care through specialists, hospitals and other health
care professionals.
Different family members may see different primary care providers at their
health center. Women who wish to see a Plan Gynecologist
for their annual
routine examination should contact their Health Center to obtain a list of Plan
providers.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are our Health Centers, or hospitals
and other facilities in our service area that we contract with to provide
covered services to our members.
We list these in the provider directory,
which we update periodically. The list is also on our website.
It depends on the type of care you need. First, you and each family member
must choose a Health Center. This decision is important since your Health
Center provides or arranges for most of your health care. You choose your
Health Center when you enroll in the plan.
Primary care Primary Care Providers at your Health Center are Family
Practice Physicians and Physicians Assistants. These Primary Care Providers will
provide most of
your health care, or give you a referral to see a
specialist.
If you want to change Health Centers, call us. We will help you
select a new one.
Specialty care Except in a medical emergency, or when a primary care
doctor has designated another doctor to see his or her patients, you must
receive a referral from your
primary care doctor before seeing any other
doctor or obtaining special services. When you receive a referral from your
primary care physician, you must return
to the primary care physician after
the consultation, unless your primary care physician authorized a certain number
of visits. The primary care physician
must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral.
What you must do to get covered care 9
9
Page 10 11
2002
Grand Valley Health Plan 9 Section 3
Here are other things you
should know about specialty care:
If you need to see a specialist frequently
because of a chronic, complex, or serious medical condition, your primary care
physician will develop a
treatment plan and authorization that allows you to
see your specialist for a certain number of visits. Your primary care physician
will use our criteria
when creating your treatment plan. All visits to
specialists must first be arranged and authorized by your primary care
physician. Authorizations
will be made for the adequate number of visits
under an approved treatment plan. Any visits beyond that which is stated in the
treatment plan will not be
covered unless further authorization is obtained
from your GVHP Primary Care Provider.
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 they decide to refer you to a specialist, ask if you
can see your current specialist. If your current specialist does not participate
with us, you must receive treatment from a specialist who does. Generally,
we will not pay for you to see a specialist who does not participate with our
Plan.
If you are seeing a specialist and your specialist leaves the
Plan, call your primary care physician, who will arrange for you to see another
specialist.
You may receive services from your current specialist until we
can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop
out of the Federal Employees Health Benefits (FEHB) Program and you enroll in
another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us, or if we drop out of the
Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and
you lose access to your specialist based on the above circumstances, you can
continue to see your
specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled
nursing or other type of facility.
If you are in the
hospital when your enrollment in our Plan begins, call our customer service
department immediately at (616) 949-2410. 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 10
10 Page 11 12
2002 Grand Valley Health Plan 10 Section 3
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 hospital benefit of the hospitalized
person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case,
we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most prior approval 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 the Medical Opinion Review process. The Medical Opinion Review
team, headed by the Vice President of Medical Affairs, will review all
information pertaining to the requested services. The team will review
factors such as whether the service is a covered benefit, medically necessary,
or
experimental, to make this decision.
If we deny the service, you have
the right to pursue resolution through the disputed claims process (see Section
8). 11
11 Page 12
13
2002 Grand Valley Health Plan 11 Section
4
Section 4. Your costs for covered services
You must share
the cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
Deductible We do not have a deductible
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 50% of our
allowance for fertility drugs and growth hormone.
Your out-of-pocket maximum We do not have an out-of-pocket maximum.
for copayments 12
12 Page 13 14
2002 Grand
Valley Health Plan 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 66 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 (616) 949-2410.
(a) Medical services and supplies provided by physicians and other health
care professionals...................................... 13-22
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
...............................................................................................................................
34-35
(g) Special features
....................................................................................................................................................
36 Flexible benefits option
24 Hour Nurse/ Provider Line
(h) Dental benefits
.....................................................................................................................................................
37
(i) FEHB benefits available to Plan
members...........................................................................................................
38
Summary of benefits
...................................................................................................................................................
56 13
13 Page 14
15
2002 Grand Valley Health Plan 13 Section
5( a)
Section 5 (a) Medical services and supplies provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or
arrange your care.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
In an
urgent care center
Office medical consultations
Second surgical opinion
$10 per office visit
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
Nothing
At home Nothing
Diagnostic and treatment services --Continued on next
page 14
14 Page
15 16
2002 Grand Valley Health Plan
14 Section 5( a)
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing
Preventive care, adult
Routine screenings, such as: Routine
Examinations, Physicals
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening – every five years
starting at age 50 Prostate Specific Antigen (PSA test) – one annually for men
age 40 and
older
Routine pap test
Nothing if your receive these services during your office
visit;
otherwise, $10 per 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 through 64,
one every calendar year
At age 65 and older, one every two consecutive
calendar years
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
Not
covered: Physical exams required for obtaining or continuing employment or
insurance, attending schools or camp, or travel. All charges. 15
15 Page 16 17
2002 Grand Valley Health Plan 15 Section 5(
a)
Preventive care, children You pay
Well-child care charges
for routine examinations, immunizations and care (through age 22)
Examinations, such as:
Eye exams through age 17 to determine the need for
vision correction.
Ear exams through age 17 to determine the need for
hearing correction
Examinations done on the day of immunizations (through
age 22)
$10 per office visit
Childhood immunizations recommended by the American Academy of Pediatrics
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Postnatal care
Delivery
Note: Here are some things to keep in mind:
You do not need
to pre-certify your normal delivery; see page xx 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 16
16 Page
17 18
2002 Grand Valley Health Plan
16 Section 5( a)
Family planning
A broad range of
voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable
contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription
drug benefit.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges.
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
intravaginal insemination (IVI)
intracervical insemination
(ICI)
intrauterine insemination (IUI)
$10 per visit
Fertility drugs
Note: We cover injectable fertility drugs under medical
benefits and oral fertility drugs under the prescription drug benefit.
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization
embryo transfer and GIFT
Zygote transfer Services and supplies related to excluded ART
procedures
Cost of donor sperm
Cost of donor egg
All charges. 17
17 Page 18 19
2002 Grand
Valley Health Plan 17 Section 5( a)
Allergy care
Testing and treatment
Allergy injection
Nothing
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges.
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow
transplants 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
$10 per visit
Growth hormone therapy (GHT)
Note: – We cover Growth Hormone under the
Prescription drug benefit
Note: – We will only cover GHT when we
preauthorize the treatment. Call your health center for preauthorization. We
will ask you to submit
information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin treatment;
otherwise, we will only cover
GHT services from the date you submit the
information. If you do not ask or if we determine GHT is not medically
necessary, we will not cover the
GHT or related services and supplies. See
Services requiring our prior approval in Section 3.
$10 per visit 18
18 Page
19 20
2002 Grand Valley Health Plan
18 Section 5( a)
Physical and occupational therapies
Covered for up to two consecutive months per condition if significant
improvement can be expected within two months:
qualified physical therapists and occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to illness or injury.
Cardiac
rehabilitation following a heart transplant, bypass surgery or a
myocardial
infarction, is provided for up to two months per condition.
$10 per outpatient visit
Nothing per visit during covered inpatient
admission
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
Covered for up to two consecutive months per
condition if significant improvement can be expected within two months $10 per
outpatient visit
Nothing per visit during covered inpatient admission
Not covered:
Exercise programs
All charges. 19
19 Page 20 21
2002 Grand Valley Health Plan 19 Section 5(
a)
Hearing services (testing, treatment, and supplies)
First
hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per visit
Not covered: All other hearing testing
Hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies) You pay
One
pair of eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
Nothing
Eye exam to determine the need for vision correction for children through age
17 (see preventive care)
Annual eye refractions
$10 per visit
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per 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. 20
20 Page 21 22
2002 Grand
Valley Health Plan 20 Section 5( a)
Orthopedic and prosthetic
devices You pay
Artificial limbs and eyes; stump hose
Externally
worn breast prostheses and surgical bras, including necessary replacements,
following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy.
Note: See 5( b) for coverage of the surgery to insert the device.
Corrective orthopedic devices for the non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Foot orthotics
Nothing
Not covered:
orthopedic and corrective shoes
arch
supports
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other
supportive devices
All charges.
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
motorized
wheelchairs when medically necessary
blood glucose monitors; and
insulin
pumps.
Nothing
Not covered: luxury or deluxe items, such as bath tub seats,
reachers, raised
toilet seat devices, braces used to affect
performance in sport related
activities
All charges. 21
21 Page 22 23
2002 Grand
Valley Health Plan 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, rehabilitative
All charges.
Chiropractic
No Benefit All Charges
Alternative treatments
Acupuncture – by a doctor of medicine or
osteopathy for: anesthesia/ pain relief $10 per visit
Not covered: naturopathic services
hypnotherapy
biofeedback
All charges. 22
22
Page 23 24
2002
Grand Valley Health Plan 22 Section 5( a)
Educational classes
and programs You pay
Population Based Programs: Any members who fall
into the following categories can participate in the appropriate program
Diabetes Program Asthma Program
Depression Program Congestive Heart
Failure Program
Obstetrical Program
$10 copay for visits with practitioners, $5 copay for
prescription drugs,
otherwise nothing
Health Education Classes: Classes are free to members. A minimal charge for
materials may be required for some classes.
Intuitive Eating: This 8-10
class series will help you say good-bye to dieting forever. Learn to make peace
with food while honoring
healthful eating. Start developing a healthier
relationship with food and your body now!
Managing your Cholesterol: A
Registered Dietitian will help you evaluate you overall risk, interpret
cholesterol numbers, and suggest
ways to eat healthier and fit exercise into
you life. Practical Stress Management: This 2 session class is designed to help
you handle stress overloads that often happen in daily life. Situations from
home to work and families to co-workers will be covered. You
will learn a
number of different methods to help you cope and take control.
Asthma
Classes: Learn and discuss: "What is asthma?," "What causes asthma?,"
"Medications used to treat asthma," and "How to get
asthma under control."
Back Education: Got back pain? Learn correct body mechanics,
appropriate
exercises and stretching techniques. Tobacco Free for Good: This class,
consisting of 7 sessions, is
designed to help tobacco users deal with
triggers, withdrawal symptoms, daily stress and weight control.
Prepared
Childbirth Classes: This 5 class series prepares both the mother and her coach
for a special, shared birth experience.
Topics include labor and delivery,
hospital procedures, breast and bottle feeding and much more. The classes also
include practice
sessions in breathing and relaxation techniques. Refresher
Childbirth Classes are available as well.
Breast Feeding Classes: This 1
session class offers information and support to foster a positive breastfeeding
experience. Before
your baby arrives, learn the "how-to's" of breast feeding
and how to avoid common difficulties.
Nothing 23
23 Page
24 25
2002 Grand Valley Health Plan
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.).
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as: Operative procedures
Treatment of fractures, including casting Normal pre-and post-operative care
by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Correction of congenital
anomalies (see reconstructive surgery) Surgical treatment of morbid obesity --a
condition in which an
individual weighs 100 pounds or 100% over his or her
normal weight according to current underwriting standards; eligible
members
must be age 18 or over Insertion of internal prosthetic devices. See 5( a) –
Orthopedic
and prosthetic devices for device coverage information.
Vasectomies
Tubal Ligations Treatment of burns
$10 per office visit; nothing for surgical center or hospital visits
Surgical procedures continued on next page. 24
24 Page 25 26
2002 Grand Valley Health Plan 24 Section 5(
b)
Surgical procedures (Continued) You pay
Not covered: Reversal of voluntary sterilization
Cosmetic Surgery Routine treatment of conditions of the foot; see
Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.
Nothing
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to
48 hours
after the procedure.
Nothing
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges 25
25 Page 26 27
2002 Grand
Valley Health Plan 25 Section 5( b)
Oral and maxillofacial
surgery
Oral surgical procedures, limited to: Reduction of fractures of
the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
$10 per office visit
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. 26
26 Page 27 28
2002 Grand Valley Health Plan 26 Section 5(
b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung:
Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors.
Intestinal transplants
(small intestine) and the small intestine with the liver or small intestine with
multiple organs such as the liver,
stomach, and pancreas
National
Transplant Program (NTP)
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
Anesthesia You pay
Professional services provided in –
Hospital (inpatient) Hospital outpatient department
Skilled nursing
facility Ambulatory surgical center
Nothing
Professional services provided in –
Office $10 per visit 27
27 Page 28 29
2002 Grand Valley Health Plan 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).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 28
28 Page 29 30
2002 Grand Valley Health Plan 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 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
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
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: We provide a comprehensive range of benefits for
up to 45 days per member in a 12-month period with no dollar limit
when
full-time skilled nursing care is necessary and confinement in a skilled nursing
facility is medically appropriate as determined by a Plan
doctor. We cover
all necessary services including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and equipment ordinarily provided or arranged
by the skilled nursing facility when
prescribed by a Plan doctor.
Nothing
Not covered: custodial care All charges 29
29 Page 30 31
2002 Grand Valley Health Plan 29 Section 5(
c)
Hospice care
We cover supportive and palliative care for a
terminally ill member 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 doctor who certifies that the patient is in the terminal
stages of
illness, with a life expectancy of approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically
appropriate Nothing 30
30 Page
31 32
2002 Grand Valley Health Plan
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 doctor. In extreme emergencies, if you are unable to contact your doctor,
contact the local emergency system
(e. g., the 911 telephone system) or go
to the nearest hospital emergency room. Be sure to tell the emergency room
personnel that you are a Plan member so they can notify 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, 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.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, 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 a Plan doctor believes
care can be better provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance
charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided by Plan providers. 31
31 Page 32 33
2002 Grand Valley Health Plan 31 Section 5(
d)
Benefit Description You pay
Emergency within our service area
Emergency care at a Grand Valley Health Plan doctor's office
Emergency
care at a Grand Valley Health Plan urgent care center
$10 per visit
Emergency care at a non-Grand Valley Health Plan urgent care center or
doctor's office $25 per visit
Emergency care at a hospital, including
doctors' services
Note: If emergency results in admission to a hospital, we
waive the emergency room copay.
$50 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at an urgent care center or doctor's office $25 per visit
Emergency care at a hospital, including doctors' services
Note: If
emergency results in admission to a hospital, we waive the emergency room copay.
$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 in the service area when
medically appropriate. Nothing
Professional ambulance service outside the service area when medically
appropriate
See 5( c) for non-emergency service.
$50 per service 32
32 Page 33 34
2002 Grand Valley Health Plan 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 PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater
than for other illness
or conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit
Mental health and substance abuse benefits -continued on next page 33
33 Page 34 35
2002 Grand Valley Health Plan 33 Section 5(
e)
Mental health and substance abuse benefits (continued)
You pay
Diagnostic tests $10 per visit
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:
Please contact your Grand Valley Health Plan health center for services.
34
34 Page 35
36
2002 Grand Valley Health Plan 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 practitioner must write the prescription
Where you can
obtain them. You must fill the prescription at a plan pharmacy, or by mail
for a maintenance medication
These are the dispensing limitations. All prescriptions will be filled
at a 30 day supply unless noted on approved 90-day drug list
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, plus the copay
amount.
Why us Generic Drugs. Generic drugs contain the same active
ingredients and are equivalent in strength and dosage to the original brand name
product. Generic drugs cost you and your plan less
money than a name-brand
drug.
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 Grand Valley Health Plan 35 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 those
listed as Not
covered.
Insulin
Disposable needles and syringes for the
administration of covered medications
Diabetes supplies, including insulinsyringes, needles, glucose test tablets
and test tape, Benedict's solution, or equivalent, and acetone
test tablets.
Drugs for sexual dysfunction
Contraceptive drugs and devices
$5 per prescription
Fertility Drugs
Growth Hormone
50% of charges
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins and nutritional supplements that can be administered without
a prescription
Drugs to enhance athletic performance
Drugs obtained at a
non-Plan pharmacy; except for out-of-area emergencies
Nonprescription medicines
Smoking Cessation drugs and
medication, including nicotine patches
Medications for Travel
All charges. 36
36 Page 37 38
2002 Grand
Valley Health Plan 36 Section 5( g)
Section 5 (g). Special
features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By
approving an alternative benefit, we cannot guarantee you will get it in the
future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse/ provider line For any of your health concerns, 24 hours
a day, 7 days a week, you may call your Health Center number, and talk with a
provider who will discuss treatment options and answer your health questions.
The
Health Center phone numbers are listed below.
Beckwith Health Center
– (616) 224-1515 Cascade Health Center – (616) 949-6003
Jenison Health
Center – (616) 457-3830 Kentwood Health Center – (616) 534-8323
Rockford
Health Center – (616) 866-9568 Walker Health Center – (616) 784-4717
Wyoming
Health Center – (616) 532-1100 37
37 Page 38 39
2002 Grand
Valley Health Plan 37 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 non-dental 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. The need for these services must
result from an accidental injury.
$10 per office visit
Dental benefits
We cover the following dental services when
provided by participating Plan dentists:
Oral exam; two in 12 months
Prophylaxis (cleaning); two in 12 months
Topical applications of fluoride to age 19
Oral cancer exam
Study
models
Emergency services and supplies necessary to promptly relieve pain
Nothing 38
38 Page
39 40
2002 Grand Valley Health Plan
38 Section 5( i)
Section 5 (i). Non-FEHB benefits available to
Plan members
The benefits on this page are not part of the FEHB contract
or premium, and you cannot file an FEHB disputed claim about them. Fees
you pay for these services do not count toward FEHB
deductibles or
out-of-pocket maximums.
Expanded Dental Care
Basic services are covered at 50% after an
annual deductible of $50.00 per person (maximum of three deductibles per
family). Coverage would include fillings, root canals, X-rays, periodontic
services and oral surgery. Maximum benefit of $500.00 per member per year.
Expanded Vision Care
Discounts are available through SVS Shoppes
for Grand Valley Health Plan members. 39
39 Page 40 41
2002 Grand
Valley Health Plan 39 Section 6
Section 6. General exclusions
--things we don't cover
The exclusions in this section apply to all
benefits. Although we may list a specific service as a benefit, we will not
cover it unless your Plan doctor determines it is medically necessary to
prevent, diagnose, or
treat your illness or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program 40
40 Page 41 42
2002 Grand
Valley Health Plan 40 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay
your copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical,
hospital and In most cases, providers and facilities file claims for you.
Physicians 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 (616) 949-2410. 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:
Grand Valley Health Plan 829 Forest Hill Ave., SE
Grand Rapids, MI 49546
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. 41
41 Page
42 43
2002 Grand Valley Health Plan
41 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for services,
drugs, or supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must:
(a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: Grand Valley Health Plan, 829
Forest Hill Ave. SE, Grand Rapids, MI 49546; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to:
(a)
Pay the claim (or arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your medical provider for more information. If we ask your
provider, we will send you a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us --if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630 42
42 Page 43 44
2002 Grand Valley Health Plan 42 Section 8
Send OPM the following information:
A statement about why you
believe our decision was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims,
you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies, or from the year in which you were denied
pre-certification 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 616/ 949/ 2410 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 43
43
Page 44 45
2002
Grand Valley Health Plan 43 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays
medical expenses
without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is primary according to
the National Association of Insurance
Commissioners' guidelines.
When we
are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal
employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65 or older, you may
be able to buy it.
Contact 1-800-MEDICARE for more information.
Part B
(Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the
various
health plan choices available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits
with Medicare, depending on
the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan is available
everywhere in the United States. It (Part A or Part B) 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. Medicare pays its
share and you pay your
share. Some things are not covered under Original Medicare, like prescription
drugs. 44
44 Page
45 46
2002 Grand Valley Health Plan
44 Section 9
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 be authorized and coordinated by your health
center team in order for you to be covered.
We will not waive any of our copayments.
(Primary payer chart begins
on next page.) 45
45 Page
46 47
2002 Grand Valley Health Plan
45 Section 9
The following chart illustrates whether Original
Medicare or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or a covered
family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then
the primary payer is… A. When either you --or your covered spouse --are age 65
or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely
because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB
b) Or, 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,
a) And are an
annuitant
b) And are an active employee
c) Are a former spouse of an annuitant
d) Are a former spouse of an
active employee 46
46 Page
47 48
2002 Grand Valley Health Plan 46 Section 9
Medicare
managed care If you are eligible for Medicare, you may choose to enroll in a
Medicare managed care plan. To learn more about enrolling in a Medicare
managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. If you
enroll in a Medicare managed
care plan, the following options are available
to you:
This Plan and another plan's Medicare managed care plan: You
may enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your Medicare
managed care plan is primary, even out of the managed care
plan's network
and/ or service area (if you use our Plan providers), but we will not waive any
of our copayments, coinsurance, or deductibles. If
you enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare
managed care plan so we can correctly
coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your
FEHB coverage to
enroll in a Medicare managed care plan, eliminating your FEHB premium. (OPM does
not contribute to your Medicare
managed care plan premium). For information
on suspending your FEHB enrollment, contact your retirement office. If you later
want to re-enroll
in the FEHB Program, generally you may do so only at the
next open season unless you involuntarily lose coverage or move out of the
Medicare managed care service area.
If you enroll in Medicare If
you do not have one or both Parts of Medicare, you can still be Part A or
Part B covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you can't get premium-free Part A, we will not ask
you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of
Workers' Compensation Programs (OWCP) or a similar
Federal or State agency
determines they must provide; or
OWCP or a similar agency pays for through a
third party injury settlement or other similar proceeding that is based on a
claim you
filed under OWCP or similar laws.
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. 47
47 Page 48 49
2002 Grand Valley Health Plan 47 Section 9
When other Government agencies We do not cover services and
supplies when a local, State, are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are
responsible When you receive money to compensate you for for injuries
medical or hospital care for injuries or illness caused by another person,
you must reimburse us for any expenses we paid. However, we will cover the
cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation
procedures. 48
48 Page
49 50
2002 Grand Valley Health Plan
48 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Coinsurance
Coinsurance is the percentage of our allowance that you must pay for your
care. See page 11.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Room and board, nursing care, and personal care designed to assist a person
in the activities of daily living.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services. See page 11.
Experimental or A procedure,
drug, device or biological product is experimental or investigational
services investigational when:
a. There is not sufficient outcome data
available from controlled clinical trials published in the peer reviewed
literature to substantiate its safety and effectiveness for the disease or
injury involved, or:
b. Required FDA approval has not been granted for
marketing; or
c. A recognized national medical or dental society or
regulatory agency has determined, in writing, that it is
experimental or for
research purposes; or d. The written protocol( s) used by the treating facility
or the
protocol( s) of any other facility studying substantially the same
drug, device, procedure or treatment or the written
informed consent used by
the treating facility or by another facility studying the same drug, device,
procedure or
treatment states that it is experimental or for research
purposes; or it is not of proven benefit for the specific
diagnosis or
treatment of a member's particular condition; or
e. It is not generally
recognized by the medical community as effective or appropriate for the specific
diagnosis or
treatment of a member's particular condition; or it is provided
or performed in special settings for research
purposes.
Group health
coverage Health care coverage that a member is eligible for because of
employment by, membership in, or connection with, a particular
organization
or group that provides payment for hospital, medical, or other health care
services or supplies. 49
49 Page 50 51
2002 Grand
Valley Health Plan 49 Section 10
Medical necessity A
service, procedure, treatment, supply or accommodation prescribed, ordered,
supplied, authorized or provided to you, which has been
determined by your
Health Center Team to be necessary for your general care and well being, and
which is generally acceptable according to the
standards of medical
practice.
Us/ We Us and we refer to Grand Valley Health Plan
You You refers to the enrollee and each covered family member. 50
50 Page 51 52
2002 Grand Valley Health Plan 50 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. 51
51 Page
52 53
2002 Grand Valley Health Plan
51 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you are new premiums start to
this Plan, your coverage and premiums begin on the first day of your first pay
period
that starts on or after January 1. Annuitants' premiums begin on
January 1.
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.
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 52
52 Page 53 54
2002 Grand Valley Health Plan 52 Section 11
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
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 Group Health Plan Coverage (HIPAA) is a
Federal law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If
you leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that
indicates how long you have been enrolled with us. You can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or
eliminate waiting periods, limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing
coverage under
this Plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. Also, see 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. 53
53 Page 54 55
2002 Grand Valley Health Plan 53 Long Term
Care
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? 54
54 Page 55 56
2002 Grand Valley Health Plan 54 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 19,
24, 37 Alternative treatment 12, 21
Ambulance 2, 12, 27, 29, 30, 31
Anesthesia 2, 12, 21, 23, 26, 28
Autologous bone marrow transplant 17, 26
Blood and blood plasma 28 Casts 28
Chemotherapy 17 Claims
2, 8, 10, 12, 36, 40, 41, 42,
45, 51 Coinsurance 2, 5, 11, 46, 48
Colorectal cancer screening 14 Congenital anomalies 23, 24
Crutches 20
Deductible 2, 5, 11, 38, 46, 48
Definitions 2, 13, 23, 27, 30, 32,
34, 37, 48
Dental care 38, 55 Diagnostic services 12, 13, 14, 28,
32,
33, 55 Disputed claims 2, 10, 36, 41, 42
Dressings 28 Durable medical
equipment
(DME) 12, 20 Educational classes and programs
12, 22
Emergency 2, 5, 6, 8,12, 30, 31,
37, 39, 40 Experimental or investigational
10, 39, 48 Eyeglasses 19
Family planning 12, 16 Fecal occult
blood test 14
General Exclusions 2, 12, 39 Hearing services
12, 19
Home health services 12, 21 Hospice care 12, 29
Hospital 2, 4, 5, 7, 8, 9, 10, 12, 13, 15, 20, 22, 23, 24, 26, 27,
28,
30, 31, 33, 37, 40, 43, 47, 48
Immunizations 5, 14, 15 Infertility
12, 16
Insulin 20, 35 Mammograms 14
Maternity Benefits 12, 15, 28
Medicaid 2, 46
Medically necessary 10, 13, 15, 17, 20, 23, 27, 30, 34, 37,
39
Medicare 2, 13, 23, 27, 30, 32, 34, 37, 40, 43, 44-46
Members 2, 5,
8, 12, 22, 23, 38, 48, 50, 57
Mental Conditions/ Substance Abuse Benefits 1,
12, 32, 33,
56 Newborn care 15
Non-FEHB Benefits 2, 38 Nurse
Licensed Practical Nurse 21 Nurse Anesthetist 28
Nurse Practitioner 5, 8
Registered Nurse 21
Obstetrical care 22 Occupational therapy 18
Ocular injury 19 Office visits 5
Oral and maxillofacial surgery 12
Orthopedic devices 20
Oxygen 20, 21, 28 Pap test 14
Physical
examination 5, 12, 14 Physical therapy 18
Physician 1, 4, 5, 8, 9, 10, 12,
13, 21, 23, 27, 34, 35, 40, 41, 42
Preventive care, adult 12, 14, 15
Preventive care, children 12, 15, 19
Prescription drugs 22, 40, 43 Preventive services 5, 12-15,
19 Prior
approval 1, 10, 17, 42
Prosthetic devices 12, 19, 20, 23, 24
Psychologist 32 Radiation therapy 17
Room and board 27, 48
Second surgical opinion 13
Skilled nursing facility care 9, 12, 13,
26, 28
Smoking cessation 35 Speech therapy 7, 12, 18
Splints 28
Subrogation 47
Substance abuse 1, 12, 32, 33 Surgery 12, 15, 18, 19, 23,
24, 25, 27, 38 Anesthesia 1, 12, 21, 23,
26, 28 Oral 12, 25, 37
Reconstructive 12, 23, 24 Syringes 35
Temporary continuation of
coverage 2, 51, 52
Transplants 7, 12, 17, 25, 26 Treatment therapies 12, 18
Vision services 12, 17 Wheelchairs 20
Workers'
compensation 45, 46, 51
X-rays 14, 28, 38 55
55 Page 56 57
2002 Grand Valley Health Plan 55 Index
NOTES: 56
56 Page 57 58
2002 Grand
Valley Health Plan 56 Summary
Summary of benefits for Grand
Valley Health Plan -2002
Do not rely on this chart alone. All
benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we
summarize specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $10 primary care; $10 specialist 13-22
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
Nothing
In office: $10 copay Surgical Center: Nothing
27-29
23-26
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$50 per visit
$50 per visit
30-31
30-31
Mental health and substance abuse
treatment..................................... Regular cost sharing. 32-33
Prescription drugs
................................................................................
$5 per prescription 34-35
Dental Care
.......................................................................................
Nothing for preventive services; scheduled allowance for other
services
37-38
Vision Care
.......................................................................................
$10 per visit 19
Special features: Flexible Benefits, 24 Hour Health Center
Line 36
Protection against catastrophic costs (your out-of-pocket
maximum).........................................................
No
out-of-pocket maximums 57
57 Page 58
2002 Grand Valley Health Plan 57
Rates
2001 Rate Information for Grand Valley Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply
and special FEHB guides are published for
Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only RL1 $87.72 $29.24 $190.06 $63.35 $103.80 $13.16
Self and
Family RL2 $223.41 $105.39 $484.06 $228.34 $263.75 $65.05 58