Serving: West Central Illinois and Eastern Iowa
Enrollment in this Plan is limited. You must live in our Geographic
service area to enroll. See page 6 for requirements.
This plan has Excellent accreditation from the NCQA. See the 2002 Guide for
more information on
accreditation.
Enrollment codes for this Plan:
YH1 Self Only
YH2 Self and Family
Special Notice: John Deere Health Plan, Inc. will no longer be
available in the Des Moines and Waterloo, Iowa and Joliet, Illinois service
areas
For changes in benefits
see page 8.
RI 73-661 1
1 Page
2 3
John Deere Health Plan, Inc. Table
of Contents
Table of Contents
Introduction………………………………………………………………….
............................................................ 4
Plain
Language………………………………………………………………............................................................
4
Inspector General Advisory……………………………………………………………………………………………. 5
Section 1. Facts about this HMO
plan.....................................................................................................................
6
How we pay providers
...........................................................................................................................
6
Your Rights
...........................................................................................................................................
6
Service Area
......................................................................................................................................
6-7
Section 2. How we change for
2002………………………………………...............................................................
8
Program-wide
changes...........................................................................................................................
8
Changes to this
Plan...............................................................................................................................
8
Section 3. How you get care …………...
................................................................................................................
9
Identification cards
................................................................................................................................
9
Where you get covered care
...................................................................................................................
9
Plan
providers..................................................................................................................................
9
Plan
facilities...................................................................................................................................
9
What you must do to get covered care
....................................................................................................
9
Primary care
....................................................................................................................................
9
Specialty care
.............................................................................................................................
9-10
Hospital
care..................................................................................................................................
10
Circumstances beyond our
control........................................................................................................
11
Services requiring our prior
approval....................................................................................................
11
Section 4. Your costs for covered services
............................................................................................................
12
Copayments...................................................................................................................................
12
Deductible
.....................................................................................................................................
12
Coinsurance...................................................................................................................................
12
Your out-of-pocket
maximum..............................................................................................................
12
Section 5.
Benefits………………………………………………………….......................................................
13-36
Overview.............................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals ............ 14-21
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ......... 22-25
(c) Services provided by a hospital or other facility, and ambulance
services...................................... 26-27
(d) Emergency services/
accidents......................................................................................................
28-29
(e) Mental health and substance abuse
benefits..................................................................................
30-31
(f) Prescription drug benefits
............................................................................................................
32-33
(g) Special features
................................................................................................................................
34
(h) Dental benefits
.................................................................................................................................
35 2
2 Page 3 4
John Deere Health Plan, Inc. Table of Contents
(i) Non-FEHB benefits available to Plan members
................................................................................
36
Section 6. General exclusions --things we don't cover
........................................................................................
37
Section 7. Filing a claim for covered
services.......................................................................................................
38
Section 8. The disputed claims process
...........................................................................................................
39-40
Section 9. Coordinating benefits with other coverage
...........................................................................................
41
When you have…
Other health coverage
....................................................................................................................
41
Original
Medicare.....................................................................................................................
41-43
Medicare managed care plan
.....................................................................................................
43-44
TRICARE/ Workers' Compensation/
Medicaid......................................................................................
44
Other Government agencies
................................................................................................................
44
When others are responsible for injuries
..............................................................................................
44
Section 10. Definitions of terms we use in this
brochure.......................................................................................
45
Section 11. FEHB facts
..................................................................................................................................
46-48
Coverage
information...................................................................................................................
46-47
No pre-existing condition
limitation...........................................................................................
46
Where you get information about enrolling in the FEHB Program
.............................................. 46
Types of coverage
available for you and your
family.................................................................. 46
When benefits and premiums start
.............................................................................................
47
Your medical and claims records are
confidential.......................................................................
47
When you
retire........................................................................................................................
47
When you lose
benefits......................................................................................................................
48
When FEHB coverage ends
.......................................................................................................
48
Spouse equity
coverage.............................................................................................................
48
Temporary Continuation of Coverage
(TCC).............................................................................
48
Converting to individual
coverage.............................................................................................
48
Getting a Certificate of Group Health Plan Coverage…………………………………………..….
5048
Long term care insurance is coming later in 2002……………………………………………………………………..
49
Index……………................................................................................................................................................
50
Notes…………....................................................................................................................................................
51
Summary of benefits
.......................................................................................................................................
52-53
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2002 John Deere Health Plan, Inc. 4
Introduction / Plain Language
Introduction
John Deere
Health Plan, Inc.
1300 River Drive, Suite 200
Moline, IL 61265
This brochure describes the benefits of John Deere Health Plan, Inc. under
our contract (CS 2746) with the Office of
Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 7. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans staff worked
on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,
Expect for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we" means John Deere Health Plan,
Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPMis the Office of Personnel Management. If we use others, we
tell you what they mean first.
Our brochure and other FEHB plans' brochures
have the same format and similar descriptions to help you compare plans.
If
you have comments or suggestions about how to improve the structure of this
brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www. opm.
gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. Youmay
also write to
OPM at the Office of Personnel Management, Office of Insurance Planning and
Evaluation Division,
1900 # Street, NW Washington, DC 20415-3650. 4
4 Page 5 6
2002 John Deere Health Plan, Inc. 5
Introduction / Plain Language
Inspector General Advisory
Stop
health care fraud! Fraud increases the cost of health care for everyone. If
you suspect that a physician, pharmacy, or hospital has charged you for services
you did not
receive, billed you twice for the same service, or
misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 800/ 247-9110
and explain
the situation.
If we do not resolve the issue, call or write THE HEALTH
CARE FRAUD HOTLINE
202/ 418-3300 The United States Office of Personnel Management
Office of Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 John Deere
Health Plan, Inc. 6 Section 1
Section 1. Facts about this HMO
plan
This Plan is a health maintenance organization (HMO). We require
you to see specific physicians, hospitals, and
other providers that contract
with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change plans because a provider
leaves our Plan. We cannot guarantee that any one physician,
hospital, or
other provider will be available and/ or remain under contract with us.
How
we pay providers
We contract with individual physicians, medical groups,
and hospitals to provide the benefits in this brochure. These
Plan providers
accept a negotiated payment from us, and you will only be responsible for your
copayments.
Participating providers are located throughout the service area. There are
462 primary care doctors, 1, 823 specialists,
and 29 hospitals in the
Illinois service area; and 460 primary care doctors, 2, 702 specialists, and 45
hospitals in the
Iowa service area.
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.
John Deere Health Plan, Inc. is a for profit organization We have been in
existence since 1985.
John Deere Health Plan, Inc. considers a drug, device,
medical treatment or procedure to be experimental or investigational if it has
not bee approved for use by one of the following agencies: the Food and Drug
Administration, National Cancer Institute, or Department of Health and Human
Services.
If you want more information about us, call 800/ 247-9110, or
write to 1300 River Drive, Suite 200, Moline, IL
61265. You may also contact
us by fax at 563/ 359-1665 or visit our website at www. johndeerehealth. com.
Service Area
To enroll in this Plan, you must live in our Service
Area. Our service area is:
Illinois: Bloomington, Moline, Peoria, and Rock Island areas. This
includes the counties of Bureau, Carroll, DeWitt, Henry, Jo Daviess, Knox,
LaSalle, Lee, Livingston, McLean, Marshall, Mercer, Peoria, Rock Island, Stark,
Tazewell,
Warren, Whiteside, and Woodford.
Iowa: Burlington,
Cedar Rapids, Dubuque, Iowa City, Marshalltown, Ottumwa, Quad Cities areas. This
includes the counties of Appanoose, Benton, Cedar, Clayton, Clinton, Davis,
Delaware, Des Moines, Dubuque, Henry, Iowa,
Jackson, Jasper, Jefferson,
Johnson, Jones, Keokuk, Lee, Linn, Louisa, Mahaska, Marshall, Monroe, Muscatine,
Poweshiek, Scott, Tama, Van Buren, Wapello, and Washington. 6
6 Page 7 8
2002 John Deere Health Plan, Inc. 7 Section 1
Ordinarily, you must get your care from providers who contract with us.
If you receive care outside of our service
area, we will pay only for
emergency care. We will not pay for any other health care services outside of
our service
area without a pre-approved referral.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live outside of the service 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 office or
retirement office. 7
7 Page
8 9
2002 John Deere Health Plan, Inc.
8 Section 2
Section 2. How we change for 2002
Do not
rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5
Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will increase 11. 5% for Self Only or
will decrease 7. 2% for Self and Family.
We added a new Section after Section 11 to discuss the Long Term Care
Insurance Program that is coming in 2002.
We no longer limit total blood
cholesterol tests to certain age groups. (Section 5 (a))
We now cover
routine screening for chlamydial infection. (Section 5( a))
We increase
speech therapy benefits by removing the requirement that services must be
required to restore functional speech therapy. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b))
You will now
pay a $15 copay for professional physician services for all office, home, and
nursing facility visits.
You will now pay a $15 copay for adults and
children for preventative
You will now pay a $100 per day copay up to a $500
maximum per inpatient hospital confinement.
You will now pay a $10 copay for
generic prescription drugs
You will now pay a $20 copay for formulary brand
name prescription drugs
You will now pay a $35 copay for non-formulary
prescription drugs 8
8 Page
9 10
2002 John Deere Health Plan, Inc.
9 Section 3
Section 3. How you get care
Identification
cards We will send you an identification (ID) card when you enroll. You
should carry your ID card with you at all times. You must show it
whenever
you receive services from a Plan provider, or fill a prescription
at a Plan
pharmacy. Until you receive your ID card, use your copy of the
Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
800/
247/ 9110.
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.
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.
What you must do
to get covered 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.
Primary care Your primary care physician can be a family practitioner,
internist 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. However, you may see any specialist participating in
our plan without a
referral. This would include a woman being able to see
her Plan
gynecologist for her annual routine examination.
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). 9
9
Page 10 11
2002
John Deere Health Plan, Inc. 10 Section 3
If you are seeing a
specialist when you enroll in our Plan, talk to your primary care physician.
Your primary care physician will decide
what treatment you need. If he or
she decides to refer you to a
specialist, ask if you can see your current
specialist. If your current
specialist does not participate with us, you
must receive treatment
from a specialist who does. Generally, we will not
pay for you to see
a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another
specialist.
You may receive services from your current specialist
until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop
out of the Federal Employees Health Benefits (FEHB) Program and you enroll in
another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
You may be
able to continue seeing your specialist for up to 90 days
after you receive
notice of the change. Contact us or, if we drop out of
the Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/ 247-9110. 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. 10
10 Page 11 12
2002 John Deere Health Plan, Inc. 11 Section
3
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most services.
For certain services, however,
your physician must obtain approval from
us. Before giving approval, we
consider if the service is covered,
medically necessary, and follows
generally accepted medical practice.
We call this review and approval process precertification. Your
physician
must obtain precertification for the following services: services
outside
the service area, services provided by non-Plan providers, and
experimental
or investigational procedures or treatments. 11
11
Page 12 13
2002
John Deere Health Plan, Inc. 12 Section 5
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
$15 per office visit and when you go in the hospital, you pay
$100 per day.
Deductible We do not have a deductible.
Coinsurance We do
not have coinsurance
Your out-of-pocket maximum for copayments After
your copayments total $1, 500 per person or $3, 000 per family
enrollment in
any calendar year, you do not have to pay any more for
covered services.
However, copayments for the following services do not
count toward your
out-of-pocket maximum, and you must continue to pay
copayments for these
services:
prescription drugs
Be sure to keep accurate records of your copayments
since you are
responsible for informing us when you reach the maximum.
Section 4 12
12 Page
13 14
2002 John Deere Health Plan,
Inc. 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our benefits changed this year and pages 52-53
for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us
at 800/ 247-9110
or at our website at www. johndeerehealth. com
(a) Medical services and
supplies provided by physicians and other health care professionals
......................... 14-21
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family
planning
Infertility services Allergy care
Speech therapy Hearing services
Vision services Treatment therapies
Physical and occupational therapies Foot care
Orthopedic and prosthetic
devices Durable medical equipment (DME)
Home health services Educational
classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals...................... 22-25
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services .................................................. 26-27
Inpatient hospital Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/
accidents...................................................................................................................
28-29
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits...............................................................................................
30-31
(f) Prescription drug benefits
.........................................................................................................................
32-33
(g) Special features
.............................................................................................................................................
34
(h) Dental benefits
..............................................................................................................................................
35
(i) Non-FEHB benefits available to Plan
members..............................................................................................
36
Summary of benefits
.......................................................................................................................................
52-53 13
13 Page
14 15
2002 John Deere Health Plan,
Inc. 14 Section 5
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 $15 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
$15 per office visit
Nothing for hospital visits
At home $15 copay per house call
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing 14
14 Page
15 16
2002 John Deere Health Plan,
Inc. 15 Section 5
Preventive care, adult You pay
Routine screenings, such as:
Total Blood Cholesterol – once every
three years
Colorectal Cancer Screening, including
Fecal occult
bloodtest
Sigmoidoscopy, screening – every five years starting at age 50
Prostate Specific Antigen (PSAtest) – one annually for men age 40 and older
Routine pap test
Note: The office visit is covered if pap test is
received on the same day;
see Diagnosis and Treatment, above.
$15 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
Age 40 and
above, one every calendar year
$15 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$15 per office visit
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $15 per office visit
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 (under age 22)
Well-child
care charges for routine examinations, immunizations and care (under age 22)
$15 per office visit 15
15 Page 16 17
2002 John Deere
Health Plan, Inc. 16 Section 5
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 23 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
Nothing
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.
$15 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges. 16
16 Page 17 18
2002 John Deere
Health Plan, Inc. 17 Section 5
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
intravaginal insemination (IVI)
intracervical
insemination (ICI)
intrauterine insemination (IUI)
in
vitro fertilization
embryo transfer and GIFT
Injectable
fertility drugs
Note: We cover injectable fertility drugs under medical
benefits and oral
fertility drugs under the prescription drug benefit.
$15 per office visit
$100 copay per inpatient surgery
$100 per day
copay for inpatient
hospital confinement up to a $500
maximum
Not covered:
Cost of donor sperm
All charges.
Allergy care You pay
Testing and treatment
Allergy injection
$15 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges.
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone
marrow
transplants is limited to those transplants listed under
Organ/ Tissue
Transplants on page 22.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we
preauthorize the treatment.
Your Plan provider will arrange for
authorization if the treatment is
found to be medically necessary.
$15 per office visit 17
17 Page 18 19
2002 John Deere
Health Plan, Inc. 18 Section 5
Physical and occupational
therapies
60 visits per condition for the services of each of the
following:
qualified physical therapists;
occupational therapists; and
cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction
Note: We only cover therapy to restore bodily function when there
has
been a total or partial loss of bodily function due to illness or
injury.
Nothing
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy You pay
60 visits per condition Nothing
Hearing services (testing, treatment, and supplies) You pay
First
hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$15 per office visit
Not covered:
all other hearing testing hearing aids,
testing and examinations for them All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
$15 per office visit
Eye exam to determine the need for vision correction for children throughage
17( see preventive care) $15 per office visit 18
18
Page 19 20
2002
John Deere Health Plan, Inc. 19 Section 5
Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
Refractions, including lens prescriptions
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.
$15 per office visit
Not covered:
Podiatric services
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.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
$15 per office visit 19
19 Page 20 21
2002 John Deere
Health Plan, Inc. 20 Section 5
Not covered:
orthopedic and
corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other
supportive devices
prosthetic replacements provided less than 3 years after the last one we
covered
All charges.
Durable medical equipment (DME)
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 glucose
monitors; and
insulin pumps. Note: Call us at 800/ 247-9110 as soon as your
Plan physician
prescribes this equipment. We will arrange with a health care
provider to
rent or sell you durable medical equipment at discounted
rates and will tell
you more about this service when you call.
Nothing
Home health services You pay
Home health care ordered by a Plan
physician and provided by a registered nurse (R. N.), licensed practical nurse
(L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family;
nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.
All charges. 20
20 Page 21 22
2002 John Deere
Health Plan, Inc. 21 Section 5
Alternative treatments
Not covered:
acupuncture chiropractic services
naturopathic services hypnotherapy
biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
Diabetes self-management
Smoking Cessation
Nothing
All charges 21
21 Page
22 23
2002 John Deere Health Plan,
Inc. 22 Section 5
Section 5 (b). Surgical and anesthesia
services provided by physicians and other
health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professi onal for your surgical care. Look in
Section 5( c) for charges associated with the facility
(i. e. hospital, surgical center, etc.).
I M
P O
R T
A N
T
Benefit Description You pay…
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting Normal pre-and post-operative care
by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy
procedures Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery) Surgical treatment of morbid obesity --a condition
in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members
must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
Voluntary sterilization Norplant (a surgically implanted contraceptive) and
intrauterine
devices (IUDs) Note: Devices are covered under 5( a).
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.
$15 per office visit;
Nothing for hospital visits
$100 copay per
inpatient surgical
procedure
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care. All charges. 22
22 Page 23 24
2002 John Deere Health Plan, Inc. 23 Section
5
Reconstructive surgery You pay
Surgery to correct a
functional defect
Surgery tocorrectaconditioncausedby injury orillnessif:
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.
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.
$15 per office visit;
Nothing for hospital visits
$100 copay per
inpatient surgical
procedure
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.
$15 per office visit
Nothing for hospital visits
$100 copay per
inpatient surgical
procedure
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
All charges. 23
23 Page 24 25
2002 John Deere
Health Plan, Inc. 24 Section 5
Organ/ tissue transplants You
pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as liver,
stomach, and
pancreas
National Transplant Program – We participate with Centers of Excellence
across the nation
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing 24
24 Page
25 26
2002 John Deere Health Plan,
Inc. 25 Section 5
Professional services provided in –
Hospital outpatient department Skilled nursing facility
Ambulatory
surgical center Office
Nothing 25
25 Page
26 27
2002 John Deere Health Plan,
Inc. 26 Section 5
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
Section5( a) or (b).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general nursing
care; and
meals and special diets.
NOTE: If you want a private room when it is not
medically necessary,
you pay the additional charge above the semiprivate
room rate.
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
$100 per day copay for an
inpatient confinement stay up
to a $500
maximum
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. 26
26 Page 27 28
2002 John Deere
Health Plan, Inc. 27 Section 5
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.
$100 copay per admission
Extended care benefits/ skilled nursing care facility benefits
Extended care is provided when full-time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically
appropriate
Nothing
Not covered: custodial care All charges
Hospice care
Hospice care All charges
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically
appropriate Nothing 27
27 Page
28 29
2002 John Deere Health Plan,
Inc. 28 Section 5
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services for valuable information about howcost 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 notify
us in a timely manner.
If you need to be hospitalized, the Emergency Room copay will be waived. If
you need to be hospitalized
at a non-Plan facility, we must be notified as
soon as reasonably possible. If your doctor believes care can
be better
provided in a Plan hospital, you will be transferred when medically feasible
with any ambulance
charges covered. Follow-up care by a non-Plan provider is
not covered.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of an
injury or sudden illness.
If you need to be hospitalized, the Emergency Room copay will be waived. If
you need to be hospitalized
at a non-Plan facility, we must be notified as
soon as reasonably possible. If your doctor believes care can
be better
provided in a Plan hospital, you will be transferred when medically feasible
with any ambulance
charges covered. Follow-up care by a non-Plan provider is
not covered.
Benefit Description You pay…
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
$15 copay per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $35 copay per visit
($ 35 copay waived, if
admitted)
28
28 Page 29 30
2002 John Deere Health Plan, Inc. 29 Section
5
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
$15 copay per visit
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $35 copay per visit
($ 35 copay waived, if
admitted)
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance
Professional ambulance service, including air when
medically
appropriate.
See 5( c) for non-emergency service.
Nothing 29
29 Page
30 31
2002 John Deere Health Plan,
Inc. 30 Section 5
Section 5 (e). Mental health and substance
abuse benefits
I M
P O
R T
A N
T
Parity
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
$15 copay per office visit
Mental health and substance abuse benefits (continued) You
Pay…
Diagnostic tests $15 copay per office visit
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, half-way house,
residential treatment, full-day
hospitalization, facility based intensive
outpatient treatment.
$100 per day copay per
confinement up to a $500
maximum 30
30 Page 31 32
2002 John Deere Health Plan, Inc. 31 Section
5
Mental health and substance abuse benefits (continued)
You Pay…
Not covered: Services we have not approved.
Note:
OPM will base its review of disputes about treatment plans on the
treatment
plan's clinical appropriateness. OPM will generally not
order us to pay or
provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
We
offer convenient and confidential access to mental health and
substance
abuse services. By calling 800/ 867-6758, an experienced mental
health care
professional will assess your needs and refer you to the
appropriate
qualified provider. This process is called authorization – it
helps you get
the care you need quickly and conveniently.
Please note that all inpatient and outpatient services need to be authorized
prior to treatment. 31
31 Page 32 33
2002 John Deere
Health Plan, Inc. 32 Section 5
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.
We use a formulary. The formulary is a list of preferred drugs in
each therapeutic drug category. A member may select a drug not listed on this
formulary, but the member will be expected to pay the
higher copay amount
based on their selection.
These are the dispensing limitations.
You are limited to a 30 day supply of drug medications per visit at the
retail pharmacy and a 90 day supply of maintenance medications obtained via mail
order.
Two copays will be applied to the 90 day mail order supply based on the
drug tier level of the drugs
prescribed or selected.
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. The U.
S. Food and Drug
Administration set quality standards for generic drugs to
ensure that these drugs meet the same
standards of quality and strength as
brand-name drugs.
Generics cost less that the equivalent brand-name product. However, you and
your physician have
the option to request a name-brand drug if a generic
option is not available. Using the most cost-effective
medication saves
money.
When you have to file a claim. You should send a copy of your paid
receipt with you name address and Social Security number clearly written at the
top. Receipts may be mailed to: Attn: Claims
Department, 3800 -23 rd Avenue,
Moline IL 61265
A generic equivalent will be dispensed if it is available,
unless your physician specifically requires a name brand. If you receive a name
brand drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as Written for the
name brand drug, you
have to pay the difference in cost between the name
brand drug and the generic.
We have an open formulary. If your physician believes a name brand product is
necessary or there is no generic drug available, your physician may prescribe a
name brand drug from a formulary list.
This list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a
lower
cost. To order a prescription drug brochure, call 800/ 247-9110. 32
32 Page 33 34
2002 John Deere Health Plan, Inc. 33 Section
5
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:
Fertility drugs Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except as those
listed as Not covered.
Insulin Disposable needles and syringes for the administration of covered
medications
Drugs for sexual dysfunction (see Prior authorization below)
Contraceptive drugs and devices
$10 copay for generic drugs for a
30 day supply
$20 copay for formulary brand
name drugs for a 30 day supply
$35 copay for non-formulary
brand name drugs for a 30 day
supply
Mail Order
$20 copay for generic drugs for a
90 day supply
$40 copay for formulary brand
name drugs for a 90 day supply
$70 copay for non-formulary
brand name drugs for a 90 day
supply
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation
drugs and medications
Drugs prescribed for weight loss/ appetite
suppressants and dietary supplements
Drugs for which there is a nonprescription equivalent available
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Nonprescription medicines
Drugs obtained at a non-Plan
pharmacy, except of out-of-area emergencies
All Charges 33
33 Page 34 35
2002 John Deere
Health Plan, Inc. 34 Section 5
Section 5 (g). Special Features
Feature Description
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call the number that appears on the reverse of your
membership
card and talk with a registered nurse who will discuss treatment
options and answer your health questions.
Services for deaf and
hearing impaired
TDD Phone available: 800/ 884-4327
High risk pregnancies Members may enroll in our prenatal program, "New
Generations" by simply calling our customer service representatives as 800/
247-9110
Centers of excellence for transplants/ heart
surgery/ etc
We participate with Centers of Excellence across the nation. Contact
customer services at 800/ 247-9110 for details
Travel benefit/ services
overseas
You are eligible for worldwide emergency coverage. If you are
planning a
trip, contact our customer service department at 800/ 247-
9110 for details
34
34 Page 35 36
2002 John Deere Health Plan, Inc. 35 Section
5
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
This Plan has no dental coverage except for dental services rendered as a
result of an accidental injury.
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.
Nothing
Dental benefits
We have no other dental benefits. 35
35 Page 36 37
2002 John Deere Health Plan, Inc. 36 Section
5
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed
claim about them. Fees you pay
for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Dental Care
A nationwide network of dentist have agreed to limit
their charges to a specific reduced fee schedule for John Deere
Health Plan,
Inc. members. To locate current dentist in your area, call 888/ 596-5300. You
can also nominate dentist
by asking your dentist to call for an information
package at 800/ 949-5449.
This non-FEHB benefit is not an insurance plan. Refer to your dental fee
schedule to find the maximum charge
payable by you. If you chose a
participating dentist, show your John Deere Health ID card to the dentist's
office
before you receive services. You pay only up to the maximum charge
and the dentist should not bill you for the
balance.
Vision Care
A nationwide network of ophthalmologists and
optometrists have agreed to offer John Deere Health Plan, Inc.
members
discounts on frames and lenses, coatings and option, contact lenses and
disposable contacts through any
participating provider locations. This
network currently contracts with approximately 10, 000 providers in fifty
states.
To locate a participating provider in your area, call 800/ 999-5431. When you
purchase eyewear, show the provider
your John Deere Health ID card before
you receive services. 36
36 Page 37 38
2002 John Deere
Health Plan, Inc. 37 Section 6
Section 6. General exclusions
--things we don't cover
The exclusions in this section apply to all
benefits. Although we may list a specific service as a benefit, we
will
not cover it unless your Plan doctor determines it is medically necessary to
prevent, diagnose, or treat your illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 37
37 Page 38 39
2002 John Deere
Health Plan, Inc. 38 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at
Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, Hospital, 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 800/ 247-9110.
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 foreachservice orsupply;
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:
3800 -23 rd Avenue, Moline, IL 61265
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. 38
38 Page
39 40
2002 John Deere Health Plan,
Inc. 39 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: John Deere Health Plan 3800 23 rd Ave.
Moline, Ill 61265
(c) Include a statement about why you believe our initial
decision was wrong, based on specific
benefit provisions in this brochure;
and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to:
(a) Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy
of our request— go to step 3.
3 You or your provider must send the information so that we receive it within
60 days of our request. We will then decide within 30 more days.
If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us --if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
1900 E Street, NW, Washington, D. C.
20415-3630. 39
39 Page
40 41
2002 John Deere Health Plan,
Inc. 40 Section 8
The Disputed Claims process
(Continued)
Send OPMthe 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 OPMto review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the information it
collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no
other administrative
appeals.
6 If you do not agree with OPM's decision, your only recourse is to sue. If
you decide to sue, you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies or from the year in which your were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at
800/ 247-9110 and we
will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division III at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 40
40
Page 41 42
2002
John Deere Health Plan, Inc. 41 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was
a
Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise,
if you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE
for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices
in how you get your health
care. Medicare managed care plan is the term used
to describe the various health
plan choices available to Medicare
beneficiaries. The information in the next few
pages shows how we coordinate
benefits with Medicare, depending on the type of
Medicare managed care plan
you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is a Medicare+ Choice plan (Part A or Part B) that 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. Medicare pays its share and you pay your share.
Some things are
not covered under Original Medicare, like prescription
drugs.
When you are enrolled 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, coinsurance, and deductibles. 41
41 Page 42 43
2002 John Deere Health Plan, Inc. 42 Section
9
The following chart illustrates whether the Original Medicare
or this Plan should be the primary payer for you
according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or
a covered family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a family member are eligible for
Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for
Part B
services)
(for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee 42
42 Page
43 44
2002 John Deere Health Plan,
Inc. 43 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 800/ 247-9110 or send
us an e-mail
at www. johndeerehealth. com.
We do not waive some costs when you have the Original Medicare
Plan--When Original Medicare is the primary payer, we do not waive
some
out-of-pocket costs.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a
Medicare managed care plan. These are health care
choices (like HMOs)
in some areas of the country. In most Medicare managed
care plans, you
can only go to doctors, specialists, or hospitals that are
part of the plan.
Medicare managed care plans provide all the benefits that
Original
Medicare covers. Some cover extras, like prescription drugs. To
learn
more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In
this case, we do/ do not waive any of our copayments,
coinsurance, or
deductibles for your FEHB coverage
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when
your Medicare managed
care plan is primary, even out of the managed
care plan's network and/ or
service area (if you use our Plan providers),
but we will not waive any of
our copayments, coinsurance, or
deductibles. If you enroll in a Medicare
managed care plan, tell us. We
will need to know whether you are in the
Original Medicare Plan or in a
Medicare managed care plan so we can
correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your
FEHB coverage to
enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM
does not contribute to your Medicare
managed care plan premium.) For
information on suspending your
FEHB enrollment, contact your retirement
office. If you later want to re-enroll
in the FEHB Program, generally you
may do so only at the next
open season unless you involuntarily lose
coverage or move out of the
Medicare managed care plan's service area. 43
43 Page 44 45
2002 John Deere Health Plan, Inc. 44 Section
9
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be Medicare Part A or Part B covered under the
FEHB Program. We will not require you to enroll in
Medicare Part B and, if
you can't get a premium-free Part A, we will not
ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a
similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your
treatment, we will cover your care. You must use
our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for injuries medical or hospital care for injuries or illness caused by another
person, you must
reimburse us for any expenses we paid. However, we will
cover the cost
of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 44
44 Page 45 46
2002 John Deere
Health Plan, Inc. 45 Section 10
Section 10. Definitions of
terms we use in this brochure
Calendar year January 1 through December
31 of the same year. For new enrollees, the calendar year begins on the
effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 13
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Care provided to a patient for the purpose
of meeting personal needs rather than being able to cure a medical condition.
This care includes
such things as changing dressings, assisting walking and
dressing, and
applying medications.
Experimental or A drug, device, treatment or procedure that has not
been approved for use investigational services by a major governmental
agency.
Us/ We Us and we refer to John Deere Health Plan, Inc.
You You refers to the enrollee and each covered family member. 45
45 Page 46 47
2002 John Deere Health Plan, Inc. 46 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. 46
46 Page
47 48
2002 John Deere Health Plan,
Inc. 47 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you joined this Plan
premiums
start during Open Season, your coverage begins on the first day of your
first pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on
January 1. If you joined at any other time during the year, your employing
office
will tell you the effective date of coverage.
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, orother
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. 47
47 Page
48 49
2002 John Deere Health Plan,
Inc. 48 Section 11
Enrolling in TCC. Get the RI 79-27,
which describes TCC, and the RI 70-5, the Guide to Federal Employees Health
Benefits Plans for
Temporary Continuation of Coverage and Former Spouse
Enrollees,
from your employing or retirement office or from www. opm.
gov/ insure.
Itexplainswhatyouhaveto 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 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. Se also the
FEHB web site (www.
opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked
question. These highlight HIPAA rules, such
as the requirement that Federal
employees must exhaust any TCC
eligibility as one condition for guaranteed
access to individual health
coverage under HIPAA, and have information about
Federal and State
agencies you can contact for more information. 48
48 Page 49 50
002 John Deere Health Plan, Inc. 49 Long
Term Care Insurance
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 It's insurance to help pay for long term care
services you may (LTC) insurance? 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 can supplement care provided by family
members, reducing the burden you place on them.
I'm healthy. I won't
need Welcome to the club!
long term care. Or will I? 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 the people needing long term care are under age 65. They
may
need chronic care due to a serious accident, a stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to
be vital to their financial and retirement planning.
Is long term care expensive? Yes, it can be very expensive. A year in
a nursing home can exceed $50,000. Home care for only three 8-hour shifts a week
can exceed
$20,000 a year. And that's before inflation.
Long term care
can easily exhaust your savings. Long term care insurance can protect your
savings.
But won't my FEHB plan, Not FEHB. Look at the "Not covered" blocks in
sections 5( a) Medicare or Medicaid cover and 5( c) of your FEHB
brochure. Health plans don't cover
my long term care? 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 bed and with other
activities of daily
living. Limited stays in skilled nursing facilities can be
covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit.
Medicaid covers
long term care for those who meet their state's poverty guidelines, but has
restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and
preserve your independence.
When will I get more information Employees will get more information
from their agencies on how to apply for this new during the LTC open
enrollment period in the late summer /
insurance coverage? early fall
of 2002.
Retirees will receive more information at home.
How can I find out more about the Our toll-free teleservice center
will begin in mid-2002. In the Program NOW? meantime, you can learn more
about the program on our web
site at www. opm. gov/ insure/ ltc. 49
49 Page 50 51
002 John Deere Health Plan, Inc. 50 Long
Term Care Insurance
Index
Do not rely on this page; it is for
your convenience and may not show all pages where the terms appear.
Accidental injury 17, 21,32 Alternative treatment 19
Allogenic
(donor) bone marrow
transplant 22
Ambulance 12, 23, 24, 25
Anesthesia 22 Autologous bone marrow
transplant 22 Biopsies 20
Blood and blood plasma 23 Breast cancer
22
Casts 20, 23, 24 Catastrophic protection 51
Changes for 2002 8
Chemotherapy 16
Cholesterol tests 14 Claims 35
Coinsurance 11 Colorectal
cancer screening 14
Congenital anomalies 20, 21 Contraceptive devices and
drugs 15,
20, 30 Coordination of benefits 38-41
Covered charges 11
Covered providers 8, 9
Crutches 18
Deductible 11 Definitions 42
Dental care 32 Diagnostic services 13, 24, 27
Disputed claims review 36,
37 Donor expenses (transplants) 22
Dressings 23, 24 Durable medical
equipment
(DME) 18 Educational classes and programs 19
Effective
date of enrollment 44 Emergency 25, 26
Experimental or investigational 5,
10, 34, 42
Eyeglasses 17 Family planning 15
Fecal occult blood test 14
General Exclusions 34
Hearing services 17 Home health services
19
Hospice care 24 Hospital 23, 24
Immunizations 14 Infertility
15
Inhospital physician care 20-22 Inpatient Hospital Benefits 23
Insulin 18, 30 Laboratory and pathological
services 23, 24
Magnetic Resonance Imagings
(MRIs) 13 Mail Order Prescription Drugs
29,
30 Mammograms 13, 14
Maternity Benefits 15, 23 Medicaid 41
Medically necessary 10 Medicare 40
Mental Conditions/ Substance Abuse
Benefits 27, 28
Newborn care 13, 15 Non-FEHB Benefits 33
Nurse
Nurse Anesthetist 23
Registered Nurse 23, 31 Nursery charges 15
Obstetrical care 15 Occupational therapy 16
Ocular injury 17
Office visits 13-20
Oral and maxillofacial surgery 21 Orthopedic devices 18,
20
Out-of-pocket maximum 11 Outpatient facility care 24
Oxygen 18, 19,
23, 24
Pap test 13, 14 Physical therapy 16
Physician 8 Precertification
10
Preventive care, adult 14 Preventive care, children 14
Prescription
drugs 29, 30 Prior approval 10
Prostate cancer screening 14 Prosthetic
devices 17, 18, 20
Psychologist 27 Radiation therapy 16
Renal
dialysis 16, 18 Room and board 23
Second surgical opinion 13 Skilled
nursing facility care 13,
22, 24 Smoking cessation 19, 30
Speech therapy
16 Splints 23
Sterilization procedures 15, 20
Subrogation 41 Substance
abuse 27, 28
Surgery 20-24
Anesthesia 22 Oral 21
Outpatient 22, 24, 26 Reconstructive 20, 21
Syringes 30 Temporary
continuation of
coverage 44, 47 Transplants 22
Treatment therapies
16 Vision services 14, 17, 33
Wheelchairs 18 Workers'
compensation 41
X-rays 13, 23, 24 50
50
Page 51 52
2002
John Deere Health Plan, Inc. 51 Notes
Notes 51
51 Page 52 53
2002 John Deere Health Plan, Inc. 52 Summary
of Benefits
Summary of benefits for the John Deere Health Plan, Inc.
-2002
Do not rely on this chart alone. All benefits are provided
in full unless indicated and are subject to the
definitions, limitations,
and exclusions in this brochure. On this page we summarize specific expenses we
cover;
for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................
Office visit copay: $15 primary care; $15 specialist 14
Services provided by a hospital:
Inpatient
.......................................................................................
Outpatient.....................................................................................
$100 per day copay up to a $500
maximum
$15 copay per visit
26
27
Emergency benefits:
In-area.........................................................................................
Out-of-area
..................................................................................
$35 per visit ($ 35 copay waived,
if admitted)
$35 per visit ($ 35 copay waived,
if admitted)
28
29
Mental health and substance abuse
treatment.................................... Regular cost sharing. 30
Prescription drugs
.............................................................................
$10 copay for generic drugs for a
30 day supply
$20 copay for formulary brand
name drug for a 30 day supply
$35 copay for non-formulary
brand name drug for a 30 day
supply
32
Dental
Care....................................................................................
No benefits, except for dental
services rendered as a result of an
accidental injury.
35
Vision
Care....................................................................................
$15 copay per office visit and
coverage for one pair of glasses or
lenses.
36
24 hour NurseLine, Services for the deaf and hearing impaired, High risk
pregnancy program (New
Generations), Transplant Centers of Excellence,
Worldwide coverage
34 52
52 Page 53 54
2002 John Deere
Health Plan, Inc. 53 Summary of Benefits
Protection against
catastrophic costs
(your out-of-pocket
maximum)......................................................
Nothing after meeting the $1, 500
maximum for Self Only or $3, 000
maximum for Family enrollment
per calendar year.
Some costs do not count toward
this protection
14 53
53 Page
54
2002 John Deere Health Plan, Inc. 54
2002 Rate
Information for
John Deere Health Plan, Inc.
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and
special FEHB guides are published for
Postal Service Nurses 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 YH1 $95.12 $31.70 $206.09 $68.69 $112. 55 $14.27
Self and
Family YH2 $223.41 $103.35 $484.06 $223.92 $263. 75 $63.01 54