For changes in benefits, see
page 6.
-Preferred Plus of Kansas http:// www. phsystems.
com 2002
A Health Maintenance Organization
Serving: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley,
and Chautauqua Counties, in Kansas
Enrollment in this Plan is
limited; see page 5 for requirements.
This plan has 3 years accreditation from JCAHO
Enrollment codes for this Plan:
VA1 Self Only VA2 Self and
Family
RI 73-604 1
1 Page
2 3
2002 Preferred Plus of Kansas Table
of Contents 2
Table of Contents
Introduction…………………………………………………………………………….................................................
4
Plain
Language………………………………………………………………...............................................................
4
Inspector General Advisory………………………………………………………………………….... ……………… 4
Section 1. Facts about this HMO plan
..........................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Who provides my health
care?.....................................................................................................................
5
Your
Rights..................................................................................................................................................
5
Service
Area.................................................................................................................................................
5
Section 2. How we change for
2002………………………………………..................................................................
6
Changes to this Plan
.................................................................................................................................
6
Section 3. How you get care …………...
.....................................................................................................................
7
Identification
cards.......................................................................................................................................
7
Where you get covered
care.........................................................................................................................
7 Plan
providers............................................................................................................................................
7
Plan facilities
.........................................................................................................................................
7
What you must do to get covered care
.........................................................................................................
7
Primary
care...........................................................................................................................................
7
Specialty
care.........................................................................................................................................
7
Hospital care
..........................................................................................................................................
8
Circumstances beyond our
control...............................................................................................................
8
Services requiring our prior
approval...........................................................................................................
8
Section 4. Your costs for covered services
...................................................................................................................
9
Copayments
...........................................................................................................................................
9
Deductible..............................................................................................................................................
9
Coinsurance
...........................................................................................................................................
9
Your Catostrophic protection out-of-pocket
maximum...............................................................................
9
Section 5.
Benefits…………………………………………………………...............................................................
10
Overview....................................................................................................................................................
10
(a) Medical services and supplies provided by physicians and other health
care professionals ........... 11
(b) Surgical and anesthesia services
provided by physicians and other health care professionals........ 20
(c)
Services provided by a hospital or other facility, and ambulance
services...................................... 24
(d) Emergency services/
accidents
.........................................................................................................
26
(e) Mental health and substance abuse benefits
....................................................................................
28
(f) Prescription drug
benefits................................................................................................................
30
(g) Dental
benefits.................................................................................................................................
33
Section 6. General exclusions --things we don't
cover..............................................................................................
34
Section 7. Filing a claim for covered services
............................................................................................................
35 2
2 Page 3 4
2002 Preferred Plus of Kansas Table of Contents 3
Section 8. The disputed claims process……………………………………………………………………………… 36
Section 9. Coordinating benefits with other
coverage……………………………………………………………….. 38
When you have…
Other health
coverage…………………………….…………………………………………………… 38
Original
Medicare…………………………………………………………………………………….. 38
Medicare managed care
plan………………………………………………………………………….. 40
TRICARE/ Workers' Compensation/
Medicaid ………………………………………………………….. 40
Other Government
agencies………………………………………………………………………………. 40
When others are responsible for
injuries………………………………………………………………….. 41
Section 10. Definitions of terms we
use in this brochure……………………………………………………………. 41
Section 11. FEHB
facts……………………………………………………………………………………………… 42
Coverage
information………………………….. ………………………………………………………. 42
No pre-existing condition
limitation
................................................................................................
42
Where you get information about enrolling in the FEHB
Program.................................................. 42
Types of
coverage available for you and your
family...................................................................... 42
When benefits and premiums start
...................................................................................................
43
Your medical and claims records are confidential
........................................................................... 43
When you
retire...............................................................................................................................
43
When you lose benefits
............................................................................................................................
43
When FEHB coverage ends
.............................................................................................................
43
Spouse equity
coverage...................................................................................................................
43
Temporary Continuation of Coverage (TCC)
.................................................................................
43
Converting to individual coverage
..................................................................................................
44
Getting a Certificate of Group Health Plan
Coverage..................................................................... 44
Long Term Care
Insurance.........................................................................................................................
45
Index
................................................................................................................................................................
46
Summary of benefits
....................................................................................................................................................
47
Rates……………………………………………………………………………………………......……….. Back cover 3
3 Page 4 5
2002 Preferred Plus of Kansas 4 Introduction/ Plain Language/
Advisory
Introduction
Preferred Plus of Kansas 8535 E. 21 st
North
Wichita, KS 67206
This brochure describes the benefits of
Preferred Plus of Kansas under our contract (CS 2667) with the Office of
Personnel Management (OPM), as authorized by the Federal Employees Health
Benefits law. This brochure is the official statement of benefits.
No oral
statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are
entitled to the benefits described in this brochure. If you are enrolled for
Self and Family coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2002, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and are summarized on page 6. Rates are shown at
the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use
common words. For instance, "you" means the enrollee or family member; "we"
means
Preferred Plus of Kansas.
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. You may
also write to OPM at the Ooice of Personnel
Management, Office of Insurance Planning and Evaluation Division, 1900 E Street,
NW Washington, DC 20415-3650.
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 to the
following:
Call the provider and ask for an ask for an explanation. There
may be an error.
If the provider does not resolve the matter, call us at
(316) 609-2390 or 1-800-660-8114 and explain the situation
If we do not resolve the issue, call or writer:
THE HEALTH CARE FRAUD
HOTLINE
202/ 418-3300
The United States Office of Personnel Management
4
4 Page 5 6
2002 Preferred Plus of Kansas 5 Section 1
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.
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan providers, you may
have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will
be available and/ or remain
under contract with us.
How we pay providers
We contract with
individual physicians, medical groups, and hospitals to provide the benefits in
this brochure. These Plan providers accept a negotiated payment from us, and you
will only be responsible for your copayments or coinsurance.
Who provides my health care?
Preferred Plus of Kansas is an
individual practice prepayment (IPP) model HMO. As a member of Preferred Plus of
Kansas, you will select a primary care doctor for yourself and each member of
your family. Each member may designate his or her own primary care
doctor.
You will be able to choose from a list of doctors located throughout the service
area. Preferred Plus of Kansas has more than 300 primary care doctors in its
Kansas service area and more than 1,100 referral specialists.
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.
Preferred Plus of Kansas is licensed under
the laws of Kansas, as a Health Maintenance Organization. Preferred Plus of
Kansas was incorporated in 1991.
Preferred Plus of Kansas is a for-profit
company.
If you want more information about us, call (316) 609-2390 or (800)
990-0345, or write to Preferred Health Systems, 8535 E. 21 st North, Wichita, KS
67206. You may also contact us by fax at (316) 609-2483, or visit our website at
www. phsystems. com.
Service Area
To enroll in this plan, you must live or work in our
Service Area. This is where our providers practice. Our service area is the
following counties in Kansas: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner,
Cowley and Chautauqa. 5
5 Page
6 7
2002 Preferred Plus of Kansas 6
Section 2
You may also enroll with us if you live or work in the
following places: The Kansas counties of Saline, Dickenson, Morris, McPherson,
Chase, Reno, Harper, Greenwood and Elk.
Ordinarily, you must get your care
from providers who contract with us. If you receive care outside our service
area, we will pay only for emergency care. We will not pay for any other health
care services.
If you or a covered family member move outside of our service
area, you can enroll in another plan. If your dependents live out of the area
(for example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO
that has agreements
with affiliates in other areas. If you or a family member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office.
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5 Benefits. Also, we edited and clarified language throughout the
brochure; any language change not shown here is a clarification that does not
change
benefits.
Changes to this Plan
Your share of the
non-Postal premium will increase by 41. 2% for Self Only or 34. 7% for Self and
Family.
We changed speech therapy benefits by removing the requirement that services
must be required to restore functional speech. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
We cover
compression stockings for up to two pair per member per calendar year (Section
5( a))
We cover specific disposable medical supplies with your proof of
purchase for up to $500 per calendar year when prescribed or authorized by a
primary care physician.
We expanded the durable medical equipment benefit to include blood pressure
monitors
We expanded the orthopedic devices benefit to include orthopedic
braces and orthopedic shoes which are a part of a brace and custom fabricated
shoe inserts
We expanded the rehabilitative therapy benefit to include osteopathic
manipulative treatment, chiropractic manipulative treatment, neuropsychological
testing, and pulmonary rehabilitation
We added a hospital admission copay of
$50 per day up to a $500 maximum per person per calendar year and a $1,000
maximum per family per calendar year
We increased the prescription mail
order copay from $10 to $12 for each generic mail order and $40 for each brand
name mail order prescription unit or refills.
We changed the vision benefit
for eyeglasses or contact lenses immediately following cornea transplants or
cataract surgery to up to a maximum benefit of $150
We Changed the address
for sending disputed claims to OPM. (Section 8 6
6
Page 7 8
2002
Preferred Plus of Kansas 7 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 (316) 609-2390.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
Plan providers Plan providers are physicians and other health
care professionals in our service area that we contract with to provide covered
services to our members. We credential Plan
providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in the provider directory, which
we update
periodically. The list is also on our website.
It depends on the type of
care you need. First, you and each family member must choose a primary care
physician. This decision is important since your primary care physician
provides or arranges for most of your health care. A list of primary care
providers can be reviewed in our provider directory for Preferred Plus of
Kansas. You must complete a
physician selection form or you may call
Customer Services Department at (316) 609-2390, or (800) 660-8114.
Primary care Your primary care physician can be a family practitioner,
internist, general practitioner or pediatrician. Your primary care physician
will provide most of your health care, or give
you a referral to see a
specialist.
If you want to change primary care physicians or if your primary
care physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain number of
visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may see a
contracting
OB/ Gyn for an annual well-women exam once a year without a
referral.
When services are needed for Mental Health and Substance Abuse
treatment, you will need to contact Mental Health Network at (800) 456-5641, to
coordinate your care.
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 that
allows you to see your specialist for a certain number of visits without
additional referrals. Your primary care physician will use our criteria when
creating your
treatment plan (the physician may have to get an authorization
or approval beforehand).
What you must do to get covered care 7
7
Page 8 9
2002
Preferred Plus of Kansas 8 Section 3
If you are seeing a
specialist when you enroll in our Plan, talk to your primary care physician.
Your primary care physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current
specialist. If your current specialist does not participate with us, you must
receive treatment from a
specialist who does. Generally, we will not pay for
you to see a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive
services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other
than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your
new
plan.
If you are in the second or third trimester of pregnancy and
you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until
the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of
facility.
If you are in the
hospital when your enrollment in our Plan begins, call our customer service
department immediately at (316) 609-2390 or (800) 660-8114. If you are new to
the FEHB Program, we will arrange for you to receive care.
If you
changed from another FEHB plan to us, your former plan will pay for the hospital
stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most services. For certain
services, however,
your physician must obtain approval from us. Before giving approval, we consider
if the service is covered, medically necessary, and follows generally
accepted medical practice. 8
8 Page 9 10
2002 Preferred
Plus of Kansas 9 Section 4
we call this review and approval
process, pre-certification. Your physician must obtain pre-certification for the
following services:
cardiac catheterization; developmental therapy;
durable medical equipment; home IV services;
hospice; inpatient
hospitalizations;
matrix therapy; OB care;
occupational therapy, under
age 12; outpatient IV services;
out of the service area referrals;
outpatient surgical procedures;
pain management programs; physical therapy,
under age 12;
prosthetics; request for use of non-contracting provider;
speech therapy, under age 12. Mental conditions and substance abuse services
– Contact Mental
Health Network at (800) 456-5641. Weight loss program
It is the responsibility of the provider to receive precertification from us
for the primary care physician authorized services. If the provider fails to
pre-certify the services, he/ she
will be held responsible for the services.
If you choose to seek any services without coordinating them with your primary
care physician, you will be responsible for the costs
of the services.
Section 4. Your costs for covered services
You must share the cost
of some services. You are responsible for:
Copayments A copayment is
a fixed amount of money you pay to the provider, facility pharmacy, etc.. when
you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit and when you go in the hospital you pay $50 per day.
Deductible We do not have a deductible
Coinsurance We do
not have coinsurance
Your catastrophic protection out-of-pocket maximum We do not have an
out of pocket maximum 9
9 Page
10 11
2002 Preferred Plus of Kansas
10 Section 5
Section 5. Benefits – OVERVIEW
(See
page 6 for how our benefits changed this year and page 43 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 (316) 609-2390 or
(800) 660-8114 or at our website at www. phsystems. com.
(a) Medical services and supplies provided by physicians and other health
care professionals........................... 11-19
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
Oral Surgery
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 ....................... 20-23
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Temporal Mandibular Joint
(TMJ) Syndrome
Organ/ tissue transplants Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
..................................................... 24-25
Inpatient
hospital Outpatient hospital or ambulatory
surgical center
Extended care
benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents
........................................................................................................................
26-27 Medical emergency Ambulance
(e) Mental health and substance abuse
benefits
...................................................................................................
28-29
(f) Prescription drug benefits
...............................................................................................................................
30-32
(g) Dental benefits
......................................................................................................................................................
33
Summary of benefits
....................................................................................................................................................
47 10
10 Page 11
12
2002 Preferred Plus of Kansas 11 Section
5( a)
Section 5 (a) Medical services and supplies provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of
physicians
In physician's office
$10 per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
$10 per office visit
At home Nothing
Lab, X-ray and other diagnostic tests
Tests,
such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services during your office visit;
otherwise, $10 per visit. 11
11 Page 12 13
2002 Preferred
Plus of Kansas 12 Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as:
Total Blood Cholesterol – once every
three years
Colorectal Cancer Screening, including
Fecal occult blood
test
Sigmoidoscopy, screening – every five years starting at age 50
$10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
$10 per office visit
Routine pap test
Note: The office visit is covered
if pap test is received on the same day; see Diagnosis and Treatment,
above.
$10 per office visit
Routine mammogram –covered for women age 35 and older, as follows:
From
age 35 through 39, one during this five year period
From age 40 through 64,
one every calendar year
At age 65 and older, one every two consecutive
calendar years
$10 per office visit
Dietitian services for up to 4 visits per member, per calendar year when
authorized by your primary care doctor $10 per office visit
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
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges
Preventive care, children
Childhood immunizations recommended
by the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
Eye exams through age 17 to determine
the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( up to age 22)
$10 per office visit 12
12 Page 13 14
2002 Preferred
Plus of Kansas 13 Section 5( a)
Maternity care You Pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Prospective parents may receive
authorization to select a primary care physician for their unborn child and we
will cover one visit to
that physician prior to the birth of the child
Note: Here are some things
to keep in mind:
You do not need to precertify your normal delivery:
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
We cover childbirth classes from a participating hospital or OB/ GYN up to a
maximum benefit of $30. 50% of the charges up to a maximum Plan benefit of $30.
You
must submit proof of payment and class completion to our Member
Services Department.
Not covered: Routine sonograms to determine
fetal age, size or sex All charges
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Surgically implanted
contraceptives, (such as Norplant)
Injectable contraceptive drugs, (such as
Depo Provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover
oral contraceptives under the prescription drug benefit
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, or elective abortions All charges. 13
13 Page 14 15
2002 Preferred Plus of Kansas 14 Section 5(
a)
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
Artificial insemination:
intravaginal
insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Diagnostic services to
establish the cause or reason for infertility, including:
Medical evaluation limited to sperm counts
Hysterosalpingography
Endometrial biopsy
Counseling
Surgical correction of physiological
abnormalities causing infertility
$10 per office visit
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization
embryo transfer, gamete
GIFT and zygote ZIFT
Zygote transfer
Services and supplies
related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
Fertility
drugs and surrogate parenting
All charges.
Allergy care
Testing and treatment
Allergy injection
Nothing
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges 14
14 Page 15 16
2002 Preferred Plus of Kansas 15 Section 5(
a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on pages 19-20.
Respiratory and inhalation
therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous
(IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone
therapy (GHT)
Note: Growth hormone therapy is covered under the prescription
drug benefit.
Note: – We will only cover GHT when we preauthorize the treatment. Call 1-(
800)-424-0345 or (316) 609-2359 for preauthorization. We will
ask you to
submit information that establishes if the GHT is medically necessary. Ask us to
authorize GHT before you begin treatment;
otherwise, we will only cover GHT
services from the date you submit the information. If you do not ask or if we
determine GHT is not medically
necessary, we will not cover the GHT or
related services and supplies. See Services requiring our prior approval
in Section 3.
$10 per office visit
Physical and occupational therapies
60 outpatient visits per
condition for the services of each of the following:
qualified physical
therapists
occupational therapists
osteopathic manipulative treatment
neuropsychological testing
pulmonary rehabilitation
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to 60 sessions per
condition
$10 per office visit
Not covered:
long-term rehabilitative therapy
exercise programs
All charges 15
15 Page 16 17
2002 Preferred
Plus of Kansas 16 Section 5( a)
Developmental therapy You pay
Developmental therapy includes physical and occupational therapy. Your
primary care physician must pre-certify your care. We will cover
as follows:
for children under age 6 up to a maximum benefit of $1, 000
for each therapy listed in this section per calendar year
Nothing up to our maximum payment of $1,000 per calendar year; all charges
thereafter
Speech therapy
60 visits per condition $10 per visit
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered: all other hearing testing
hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
Lenses and
Frames immediately following cataract surgery or cornea transplant surgery will
be paid up to a maximum benefit of $150. All charges above our allowance
Eye exam to determine the need for vision correction for children through age
17 (see preventive care) $10 per office visit
Not covered:
Eyeglasses or contact lenses. Eye examinations for persons over age
17
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit 16
16 Page 17 18
2002 Preferred
Plus of Kansas 17 Section 5( a)
Not covered:
Cutting,
trimming or removal of corns, calluses, or the free edge of toenails, and
similar routine treatment of conditions of the foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices You pay
Artificial limbs and
eyes; 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: We pay internal prosthetic devices as hospital benefits; see Section 5 (c)
for payment information. See
5( b) for coverage of the surgery to insert the
device.
Orthopedic braces
Shoes which are a part of a brace and custom
fabricated shoe inserts
One pair of orthopedic shoes per diabetic member,
per calendar year
Note: We will cover one standard appliance device per
lifetime, unless repair/ replacement is medically necessary as a result of
normal usage or
changes in condition.
Nothing
Not covered:
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other
supportive devices
All charges.
Medical supplies
Two pair compression stockings per member, per
calendar year Nothing
Not covered:
over-the-counter bandages, gauze, and skin
preparations All charges 17
17 Page 18 19
2002 Preferred
Plus of Kansas 18 Section 5( a)
Durable medical equipment
(DME) You pay
Rental or purchase, at our option, including repair and
adjustment, of durable medical equipment prescribed by your Plan physician, such
as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood
pressure monitors;
blood glucose monitors; and
insulin pumps
All charges over the $1,000 yearly benefit maximum.
Not covered: Motorized wheel chairs All charges.
Disposable Medical Supplies You pay Members may be reimbursed up
to $500 per person per calendar year
with proof of purchase for specific
disposable supplies when prescribed by the primary care physician. Covered
disposable supplies are limited
to supplies relating to the care of:
An
ostomy (appliance pouches, skin care agents, support belts An open wound (gauze
pads, wound packing strips, ABD pads);
A venous access catheter (alcohol
pads, benzoin, OP site); Supplies used in conjunction with covered Durable
Medical
Equipment; Urinary supplies limited to catheters, bags and related
supplies; and
Tracheostomy supplies.
All charges above $500 per person per calendar year
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.
$10 per visit
Not covered: nursing care requested by, or for the convenience of,
the patient or
the patient's family; home care primarily for personal
assistance that does not include a
medical component and is not diagnostic,
therapeutic, or rehabilitative.
All charges. 18
18 Page 19 20
2002 Preferred
Plus of Kansas 19 Section 5( a)
Chiropractic You pay
Manipulation of the spine and extremities
Adjunctive procedures such
as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack
application
Note: These services require primary care physician authorization.
$10 per office visit
Alternative treatments
Not covered: any alternative treatment
not shown as covered, including, but not limited to:
Naturopathic services Hypnotherapy
Biofeedback
music therapy
guided imagery therapeutic touch
aroma therapy acupressure
reflexology
cranio-sacred therapy
acupuncture
All Charges
Educational classes and programs
Coverage is limited to:
Smoking cessation when prescribed as part of a mental health treatment plan
Diabetes self-management
Outpatient self management training, and
education for diabetics is covered if treated in an approved program, and such
treatment is rendered by a
person certified by the National Certification
Board of Diabetic Educators.
Nothing 19
19 Page
20 21
2002 Preferred Plus of Kansas
20 Section 5( b)
5 (b). Surgical and anesthesia services
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility
(i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET
PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the
pre-certification information shown in Section 3 to be
sure which services require pre-certification and identify which surgeries
require pre-certification.
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.
Note: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital benefits for a
pacemaker
and Surgery benefits for insertion of the pacemaker.
$10 per office visit; nothing for hospital visits.
Voluntary sterilization Treatment of burns
Note: Generally, we pay for
internal prostheses (devices) according to where the procedure is done. For
example, we pay Hospital benefits for
a pacemaker and Surgery benefits for
insertion of the pacemaker.
$10 per office visit
Surgical procedures-Continued on next page. 20
20 Page 21 22
2002 Preferred Plus of Kansas 21 Section 5(
b)
Surgical procedures (Continued) You pay
Not covered: Reversal of voluntary sterilization
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.
$10 per office visit
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours
after the procedure.
See above.
Not covered: Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
$10 per 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)
Services performed by a dentist unless specified in section 5g 21
21 Page 22 23
2002 Preferred Plus of Kansas 22 Section 5(
b)
Temporal Mandibular Joint Syndrom (TMJ) You Pay
Coverage
for TMJ is provided for examinations, diagnostic x-rays and testing to diagnose
the condition. If the diagnosis is organic in
nature (fracture, tumor, arthritis) then treatment of the condition will be
covered including appliances; as the condition is non-dental in
origin.
$10.00 per office visit
Not covered:
Non-organic conditions
All Charges
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single
–Double
Pancreas
Allogenic (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) -United Resource Network
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. We also cover transportation costs for the
member and a
companion when the member resides more than 50 miles from the transplant site
and if the transplant is performed outside our
service area. We define
transportation costs as commercial transportation for the member receiving the
transplant, and a
companion, to and from the site of the transplant. We also
cover reasonable and necessary lodging and meal costs of the member and
companion beginning 24 hours prior to the hospitalization and 48 hours after
discharge. We cover transportation, lodging and meals up to $125
per day up
to a maximum benefit of $2,000.
$50 per day per hospital admission up to a $500 maximum per person
per
calendar year
Organ/ tissue transplants – continued on next page 22
22 Page 23 24
2002 Preferred Plus of Kansas 23 Section 5(
b)
Organ/ tissue transplant (Continued) You Pay
Not covered: Donor screening tests and donor search expenses,
except those
performed for the actual donor Implants of artificial
organs
Transplants not listed as covered
All charges
Anesthesia Professional services provided in –
Hospital
(inpatient) Nothing
Professional services provided in –
Hospital
outpatient department
Skilled nursing facility
Ambulatory center
Office
$10 per visit 23
23 Page
24 25
2002 Preferred Plus of Kansas
24 Section 5( c)
Section 5 (c). Services provided by a
hospital or other facility, and ambulance services
I M
P O
R T
A
N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Section 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require pre-certification.
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.
$50 per day up to a $500 maximum per person per
calendar year and a
$1,000 maximum per family per
calendar year
Other hospital services and supplies, such as: Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products Blood or blood plasma, if not donated or replaced
Dressings,
splints, casts, and sterile tray services Medical supplies and equipment,
including oxygen
Anesthetics, including nurse anesthetist services Take-home
items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home
Nothing
Not covered: Custodial care
Non-covered facilities, such
as nursing homes, schools Personal comfort items, such as telephone,
television, barber
services, guest meals and beds Private nursing
care
All charges 24
24 Page 25 26
2002 Preferred
Plus of Kansas 25 Section 5( c)
Outpatient hospital or
ambulatory surgical center You Pay
Operating, recovery, and other
treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits We cover all necessary services with no dollar or day limit,
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
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, and homemaker services All charges
Ambulance
Ambulance service when medically appropriate
Nothing 25
25 Page
26 27
2002 Preferred Plus of Kansas
26 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no deductible.
Be sure to read Section 4, Your costs for
covered services for valuable information about how cost sharing works. Also
read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some problems
are emergencies because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are emergencies
because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to breathe. There are many
other acute conditions that we may determine are medical emergencies – what they
all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
local emergency system (e. g., the 911
telephone system) or go to the
nearest hospital emergency room. Be sure to tell the emergency room personnel
that you are a Plan member so they can notify us. You or a family member should
notify us within 48 hours. It is your
responsibility to ensure that we have
been timely notified. We can be reached by phone at (316) 609-2390, or (800)
660-8114.
If you need to be hospitalized, we must be notified within 48 hours or on the
first working day following your admission, unless it was not reasonably
possible to notify us 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 the
service area: Benefits are available for any medically necessary health
service that is immediately required because of injury or unforeseen illness. If
you need to be hospitalized, we must be notified within
48 hours or on the
first working day following your admission, unless it was not reasonably
possible to notify us 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. 26
26 Page 27 28
2002 Preferred Plus of Kansas 27 Section 5(
d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
$10 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 per visit
Not covered: Elective care or
non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
$10 per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $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
Ambulance service when medically appropriate including,
air ambulance
See 5( c) for non-emergency service.
Nothing 27
27 Page 28 29
2002 Preferred Plus of Kansas 28 Section 5(
e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for
similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater
than for other illness
or conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
Smoking cessation is covered when part of a
behavioral modification
program
Cognitive Therapy when prescribed as part of a mental health program
(including, but not limited to):
behavioral training
educational testing and training
dyslexia testing
learning disabilities and/ or
mental retardation
Diagnostic tests
$10 per office visit
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, residential
treatment, full-day hospitalization, facility based intensive outpatient
treatment
Nothing 28
28 Page
29 30
2002 Preferred Plus of Kansas
29 Section 5( e)
Mental health and substance abuse benefits
-Continued
Mental health and substance abuse benefits
(Continued) You pay
Not covered: Services not approved in advance by Preferred Health Systems
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.
Pre-authorization
To be eligible to receive these benefits you
must follow your treatment plan and all of the following authorization
processes:
All services for mental conditions/ substance abuse benefits must be
coordinated by Preferred Health Systems prior to receiving services. Please
contact Preferred Health Systems at 316/ 609-2541 in Wichita or 1/ 866/ 338-4281
outside of
Wichita.
Limitation
We may limit your benefits if you do not obtain a treatment plan. 29
29 Page 30 31
2002 Preferred Plus of Kansas 30 Section 5(
f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you
should be aware of. These include:
Who can write your prescription.
A licensed physician must write the prescription
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. A generic equivalent will be
dispensed if it is available, unless your physician specifically requires a
brand name. If you receive a brand name drug when a
Federally-approved
generic drug is available, and your physician has not specified Dispense as
Written for the brand name drug, you have to pay the difference in cost between
the brand name
drug and the generic as well as the copayment.
Participating Retail Pharmacy: Covered prescriptions are limited to a
34 day supply or 100 unit dose, whichever is less. Covered prescriptions for
erectile dysfunction are limited to an eight (8)
unit dose per 34 day supply. Oral Contraceptives may be dispensed in a three
month supply, however, a co-payment is required for each months supply. If we
authorize an exception to the
dispensing limitation, each supply given will
be subject to a co-payment.
Participating Mail Order or Internet Pharmacy
(Express Scripts): Covered prescriptions are limited to a 90 day supply,
except as follows:
Covered narcotic prescriptions, except Ritalin, are limited to a 34 day
supply or a 100 dose of tablets or capsules, whichever is less.
Covered
prescriptions for erectile dysfunction are limited to a twenty-four (24) unit
dose per 90 day supply.
Why use generic drugs? Generic drugs are lower-priced drugs that are
the therapeutic equivalent to more expensive brand-name drugs. They must contain
the same active ingredients and must be
equivalent in strength and dosage to
the original brand-name product. Generics cost less than the equivalent
brand-name product. The U. S. Food and Drug Administration sets quality
standards for
generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand-name drugs.
You can save money by using generic drugs. However, you and your physician
have the option to request a name-brand if a generic option is available. Using
the most cost-effective medication saves
money.
When you have to file
a claim. The pharmacy will file the claim for you. If you have a situation
where the pharmacy is unable to file the claim for your prescription, contact
our Member Service
Department at (316) 609-2390 or (800) 660-8114, and ask
them to send you a prescription reimbursement form. 30
30 Page 31 32
2002 Preferred Plus of Kansas 31 Section 5(
f)
Benefit Description You pay
Covered medications and supplies
.
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program: Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except as excluded
below.
Insulin, with a copay charge applied to each vial Disposable needles
and syringes for the administration of covered
medications Contraceptive
drugs and devices
Oral contraceptive drugs -up to a three-cycle supply may
be obtained at one time with a copay charge applied to each cycle.
Contraceptive devices, such as diaphragms and IUD's Diabetic supplies,
including syringes, diagnostic strips, alcohol swabs
and lancets. Diagnostic
strips will be subject to the name brand copayment. All other diabetic supplies
will be subject to the generic
copayment. Intravenous fluids and medication
for home use, implantable drugs,
such as Norplant and some injectable drugs,
such as Depo Provera are covered under Medical and Surgical Benefits.
Drugs
to treat sexual dysfunction are limited to an 8 unit dose per 34-day supply and
a 24 unit dose per 90-day supply
$5 copay per generic prescription – retail.
$15 copay per brand name
prescription – retail
$12 copay per generic mail-order prescription and $40
copay per
brand name mail order prescription
When generic substitution is permissible (i. e., a generic drug is
available and the prescribing doctor does not require the use of
a brand
name drug), but you request the brand name drug, you
pay the difference
between the generic and brand name drug as
well as the $15 copay
Note:
If there is no generic equivalent available, you will still
have to pay the brand name copay.
Here are some things to keep in mind about our prescription drug program:
Medications requiring pre-authorization include: Adderal, Dexedrine and
Desoxyn; Oral Anabolic Steroids; Medications to treat acne for persons over
the age of 30 including, but not limited to, Retin-A, Accutane, and
Differin; Hormone suppositories and powders; Anti-fungal medication including,
but
not limited to, Lamisil or Sporanox; and Wellbutrin SR/ 150 mg. 31
31 Page 32 33
2002 Preferred Plus of Kansas 32 Section 5(
f)
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Drugs available without a prescription or for which there is a
nonprescription equivalent available.
Drugs obtained at a non-Plan
pharmacy except for out-of-area emergencies.
Medical supplies such as
dressings and antiseptic.
Drugs to enhance athletic performance.
Drugs to aid in smoking cessation, including nicotine patches.
Fertility drugs.
Appetite suppressants, except for
treatment of morbid obesity.
All Charges 32
32 Page 33 34
2002 Preferred
Plus of Kansas 33 Section 5( g)
Section 5 (g). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization
for dental procedures only when a nondental physical impairment exists which
makes hospitalization necessary to safeguard the health of the patient; we do
not
cover the dental procedure unless it is described below.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage,
including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury. Treatment must be initiated within 30 days
of the date of injury.
$10 copay per office visit
Dental benefits
We cover the administration of general anesthetic
and hospital inpatient charges (not the dental procedure) we determine to be
medically
necessary for dental care for the following persons:
Dependent children
five years of age or under; or
A member who is severely disabled; or
A
member who has a medical or behavioral condition which requires hospitalization
or general anesthesia when dental care is
provided.
Nothing
We have no other dental benefits. 33
33 Page 34 35
2002 Preferred
Plus of Kansas Section 6 34
Section 6. General exclusions --things we
don't cover
The exclusions in this section apply to all benefits.
Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent,
diagnose, or treat your illness, disease, injury,
or condition.
We
do not cover the following:
Care by non-Plan providers except for authorized
referrals or emergencies (see Emergency Benefits);
Services, drugs, or
supplies you receive while you are not enrolled in this Plan;
Services,
drugs, or supplies that are not medically necessary;
Services, drugs, or
supplies not required according to accepted standards of medical, dental, or
psychiatric practice;
Experimental or investigational procedures,
treatments, drugs or devices;
Services, drugs, or supplies related to
abortions, except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or
incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program. 34
34 Page
35 36
2002 Preferred Plus of Kansas
35 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, drug benefits In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance Claim Form. Facilities will file on the UB-92 form.
For
claims questions and assistance, call us at 1-( 800)-660-8114 or 316-(
609)-2390.
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:
Preferred Health Systems, 8535 E. 21 st North, Wichita, Kansas 67206
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. 35
35 Page
36 37
2002 Preferred Plus of Kansas
36 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: 8535 E. 21 st Street North,
Wichita, Kansas 67206; and
(c) Include a statement about why you believe our
initial decision was wrong, based on specific benefit provisions in this
brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we
will send you a copy of our request— go to
step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us --if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
Send OPM the following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim. 36
36 Page 37 38
2002 Preferred
Plus of Kansas 37 Section 8
The Disputed Claims Process
(Continued) Note: You are the only person who has a right to
file a disputed claim with OPM. Parties acting as your representative, such as
medical providers, must include a copy of your specific written consent with
the review request.
Note: The above deadlines may be extended if you show
that you were unable to meet the deadline because of reasons beyond your
control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision,
your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in
which you received the disputed services, drugs, or supplies or from the year in
which you were denied precertification or prior approval. This is the only
deadline that may not
be extended.
OPM may disclose the information I
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 1-( 800)-424-0345 or
(316)-609-2359; 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 Benefits Contracts Division 3 at 202/ 606-0737 between 8
a. m. and 5 p. m. eastern time. 37
37 Page 38 39
2002 Preferred
Plus of Kansas 38 Section 9
Section 9. Coordinating benefits
with other coverage
When you have other health coverage You must tell us
if you are covered or a family member is covered under another group health plan
or have automobile insurance that pays health care expenses without regard to
fault. This is called "double coverage."
When you have double coverage,
one plan normally pays its benefits in full as the primary payer and the other
plan pays a reduced benefit as the secondary payer. We, like
other insurers,
determine which coverage is primary according to the National Association of
Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. .If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to
qualify for premium-free Part A insurance. (Someone who was a Federal
employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you
are age 65 or
older, you may be able to buy it. Contact 1-800-MEDICARE for
more information.
Part B (Medical Insurance). Most people pay monthly for
Part B. Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement
check
If you are eligible for Medicare, you may have choices in how you
get your health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries.
The information in
the next few pages shows how we coordinate benefits with Medicare, depending on
the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere in the United States. It is the way everyone
used to get Medicare benefits and is the way most people
get their Medicare
Part A and Part B benefits now. You may go to any doctor, specialist, or
hospital that accepts Medicare. The Original Medicare Plan pays its share and
you pay
your share. Some things are not covered under Original Medicare,
like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. We will not
waive any of our
copayments. Your care must continue to be authorized by
your primary care physician, or precertified as required.
(Primary payer chart begins on next page.)
(Part A or Part B) 38
38 Page 39 40
2002 Preferred
Plus of Kansas 39 Section 9
The following chart illustrates
whether the Original Medicare Plan or this Plan should be the primary
payer for you according to your employment status and other factors determined
by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you
--or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or afamilymemberare
eligibleforMedicaresolely becauseofadisability), !
2) Are an annuitant, !
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or !
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.) !
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge), !
5) Are enrolled in Part B
only, regardless of your employment status, ! (for Part B
services)
!
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
!
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD, !
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD, !
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision, !
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or !
b) Are an active employee, or !
c) Are a former spouse of an annuitant, or{ RV: 4-30}
d) Are a
former spouse of an active employee{ RV: 4-30} ! 39
39 Page 40 41
2002 Preferred Plus of Kansas 40 Section 9
Claims
process when you have the Original Medicare Plan --You probably will never
have to file a claim form when you have both our Plan and the Original Medicare
Plan.
When we are the primary payer, we process the claim first.
When
Original Medicare is the primary payer, Medicare processes your claim first.
In most cases, your claims will be coordinated automatically and we will pay
the balance of covered charges. You will not need to do anything. To find out if
you
need to do something about filing your claims, call us
at (316) 609-2390 or 1-( 800) -660-8114 or locate us at www. phsystems. com.
We do not waive any costs when you have Medicare.
Medicare managed
care plan If you are eligible for Medicare, you may choose to enroll in and
get your Medicare benefits from another type of Medicare+ Choice plan --a
Medicare managed care plan.
These are health care choices (like HMOs) in
some areas of the country. In most Medicare managed care plans, you can only go
to doctors, specialists, or hospitals that
are part of the plan. Medicare
managed care plans provide all the benefits that Original Medicare covers. Some
cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care
plan: You may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan.
We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed care plan's
network and/ or service area (if you use our Plan
providers), but we will
not waive any of our copayments. If you enroll in a Medicare managed care plan,
tell us. We will need to know whether you are in the Original
Medicare Plan
or in a Medicare managed care plan so we can correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan, eliminating your FEHB premium (OPM
does not contribute to your Medicare managed care plan premium). For information
on suspending your FEHB
enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not have one or both
Parts of Medicare, you can still be covered under the FEHB Program. We will not
require you to enroll in Medicare Part B and, if you can't
get premium-free
Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they
must provide; or
OWCP or a similar agency pays for through a third party
injury settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
If you do not enroll in Medicare Part A or Part B 40
40 Page 41 42
2002 Preferred Plus of Kansas 41 Section 10
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.
Medicaid
When you have this Plan and Medicaid, we pay first.
When other
Government agencies We do not cover services and supplies when a local,
State, are responsible for your care or Federal Government agency
directly or indirectly pays for them.
When others are responsible for injuries When you receive money to
compensate you for 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.
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 xx.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services.
Covered services Care we provide benefits
for, as described in this brochure.
Experimental or If a service has
not been approved by the Federal Drug Administration investigational services
(FDA) or is labeled experimental or investigational on the protocol, the
Plan considers
the service experimental or investigational.
Medical necessity Means a service or item (intervention) that is
delivered or undertaken primarily to prevent, diagnose, treat or palliate a
disease, illness or injury, genetic or congenital
defect, pregnancy, or
psychological condition that lies outside the range of normal, age appropriate
human variation.
Interventions must be: Effective for the patient's medical
condition and indications, which is determined by
scientific evidence
consisting primarily of controlled clinical trails that demonstrate the effect
of the intervention on health outcomes. If clinical trails have not been
conducted, effectiveness is evaluated on the basis of professional standards
of care or expert opinion.
Expected to produce the intended results and have
expected outcomes that outweigh potential harmful effects.
Measurable by
positive changes in the patient's health status as determined by length or
quality of life.
Appropriate for the patient's medical condition and
indications. The expected outcome relative to cost must represent an
economically efficient use of resources.
Performed in the proper setting, at
the proper time, in the proper amounts, and by the proper provider of care
relative to the patient's condition.
Recommended by the PCP and treating
physician and determined by the Health Plan medical director to meet the above
criteria.
Us/ We Us and we refer to Preferred Plus of Kansas
You You
refers to the enrollee and each covered family member. 41
41 Page 42 43
2002 Preferred Plus of Kansas 42 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition before
you
enrolled.
Where you can get information See www. opm. gov/
insure. Also, your employing or retirement office about enrolling in the
can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your employing or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue
coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is
born or becomes an eligible family member. When you change to Self
and Family because you marry, the change is effective on the first day of the
pay
period that begins after your employing office receives your enrollment
form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us
immediately when you add or remove family members from your coverage
for any reason, including divorce, or when your child under age 22 marries or
turns
22.
If you or one of your family members is enrolled in one FEHB
plan, that person may not be enrolled in or covered as a family member by
another FEHB plan. 42
42 Page
43 44
2002 Preferred Plus of Kansas
43 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you joined this Plan during premiums
start Open Season, your coverage begins on the first day of your first pay
period that starts on or
after January 1. Annuitants' coverage and premiums
begin on January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of the
coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating
benefit payments and subrogating claims;
Law enforcement officials when
investigating and/ or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you may
be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary Continuation of Coverage and Former
Spouse Enrollees, or
other information about your coverage choices.
Temporary continuation of
coverage TCC If you leave Federal service, or if you lose coverage because
you no longer
qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are not
able to
continue your FEHB enrollment after you retire, if you lose your
job, if you are a covered dependent child and you turn 22 or marry, etc..
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary
Continuation of Coverage and Former Spouse Enrollees, from
your employing 43
43 Page
44 45
2002 Preferred Plus of Kansas 44 Section 11
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 Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) is a
Federal
law that offers limited Federal protections for health coverage availability and
continuity to people who lose employer group coverage. If you
leave the FEHB
Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us. You can use this certificate
when
getting health insurance or other health care coverage. Your new plan
must reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on
the information in the certificate, as long as
you enroll within 63 days of losing coverage under this Plan. If you have been
enrolled with us for less than 12 months, but
were previously enrolled in
other FEHB plans, you may also request a certificate from those plans.
For more information get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB
Program. See also the FEHB web site
(www. opm. gov/ insure/ health);
refer to the "TCC and HIPAA" frequently asked questions. These highlight
HIPAA rules, such as the requirement that Federal
employees must exhaust
any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and has information about
Federal and State agencies
you can contact for more information. 44
44 Page 45 46
2002 Preferred
Plus of Kansas 45 Long Term Care
Long Term Care Insurance Is
Coming Later in 2002
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.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in October 2002. As part of its
educational effort. OPM asks you to consider these questions:
What is long term care (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/
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. Helath 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 then can be received. Long term
care insurance can
provide choices of care and preserve your independence.
Employees will
get more information from their agencis 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. 45
45 Page
46 47
2002 Preferred Plus of Kansas
46 Index
Index Do not rely on this page; it is for your
convenience and may not show all pages where the terms appear.
Accidental
injury 33 Allergy tests 14
Alternative treatment 19 Ambulance 27
Anesthesia 23 Autologous bone marrow transplant
22 Allogenetic (donor)
bone marrow transplant 22
Biopsies 20 Blood and blood plasma 24
Casts 25
Changes for 2002 6
Chemotherapy 15 Childbirth 13
Chiropractic 19
Cholesterol tests 12
Claims 35 Cognitive Therapy 28
Colorectal cancer screening 12 Compression Stockings 17
Congenital
anomalies 20 Contraceptive devices and drugs 13, 31
Coordination of benefits
38 Covered providers 7
Crutches 18 Definitions 41
Dental care 33
Developmental therapy 16
Diagnostic services 11 Disposable medical supplies 18
Disputed claims
review 36 Donor expenses (transplants) 23
Dressings 25 Durable medical
equipment (DME)
18 Educational classes and programs 19
Effective date of enrollment 43 Emergency 26
Experimental or
investigational 34
Eyeglasses 16 Family planning 13
Fecal occult
blood test 12 General Exclusions 34
Hearing services 16 Home
health services 18
Hospice care 25 Home nursing care 18
Hospital 24
Immunizations 12
Infertility 14 In-hospital physician care 24
Inpatient Hospital Benefits 24 Insulin 31
Laboratory and
pathological services 11
Machine diagnostic tests 11 Magnetic
Resonance Imagings (MRIs)
11 Mail Order Prescription Drugs 30
Mammograms
12 Maternity Benefits 13
Medicaid 41 Medicare 38
Mental Conditions/
Substance Abuse Benefits 28
Newborn care 12 Nursery charges 13
Obstetrical care 13 Occupational therapy 16
Office visits 11 Oral
and maxillofacial surgery 21
Orthopedic devices 17 Out-of-pocket expenses 9
Outpatient facility care 25
Oxygen 18 Pap test 12
Physical examination 12 Physical therapy 15
Precertification 8 Preventive care, adult 12
Preventive care, children
12 Prescription drugs 30
Preventive services 12 Prior approval 8
Prostate cancer screening 12 Prosthetic devices 17
Radiation therapy 15
Renal dialysis 15
Room and board 24 Second surgical opinion 11
Skilled nursing facility care 25 Smoking cessation 28, 32
Speech therapy
16 Sterilization procedures 13
Substance abuse 28 Surgery 20
Anesthesia
23 Oral 21
Outpatient 25 Reconstructive 21
Syringes 31 Temporary
continuation of coverage
43 Transplants 22
Treatment therapies 15
Vision services 16
Well child care 12 Wheelchairs 18
Workers' compensation 40 X-rays 11 46
46
Page 47 48
2002
Preferred Plus of Kansas 47 Summary
Summary of benefits for
the Preferred Plus of Kansas -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 11
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
$50 copay per day up to $500 maximum per person per calendar
year/$ 1,000
maximum per family
Nothing
24
25
Emergency benefits:
In-area..............................................................................................
Out-of-area
......................................................................................
$50 per visit
$50 per visit
26
27
Mental health and substance abuse treatment
....................................... Regular cost sharing 28
Prescription
drugs
.................................................................................
$5 generic copay; $15 name brand copay; $12 generic mail-order
copay; $40
name brand mail order copay
30
Dental Care
.......................................................................................
Accidental injury benefit; $10 copay per visit 33
Vision Care
.......................................................................................
No benefit. 16 47
47 Page
48 49
2002 Preferred Plus of Kansas
2002 Rate Information for Preferred Plus of Kansas
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 and
Tool & Die employees (see RI 70-2B); and for Postal Service Inspectors and
Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization. Refer to the applicable
FEHB Guide.
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 VA1 $ 97.86 $ 40.15 $ 212. 03 $ 86.99 $ 115.52 $ 22.49
Self
and Family VA2 $ 223. 41 $ 143. 68 $ 484. 06 $ 311. 30 $ 263.75 $ 103. 34 48
48 Page 49 50
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Telephone: 316.609.2345 1.800.990.0345 (Outside Wichita)
Fax:
316.609.2346
e-mail: phsimail@
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