For changes In benefits
See page 8
OSF HealthPlans http:// www.
osfhealthplans. com 2002
A Health Maintenance Organization
Serving: Central Illinois and Central-Northwestern Illinois
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 7 for requirements.
Enrollment codes for this Plan:
9F1 Self Only 9F2 Self and Family
RI 73-762
This Plan has received an Accredited status from
the National
Committee for Quality Assurance
(NCQA). See the 2002 Guide for more
information on accreditation. 1
1 Page 2 3
2002 OSF HealthPlans 2 Table of Contents
Table of
Contents
Introduction………………………………………………………………….
............................................................... 4
Plain
Language………………………………………………………………...............................................................
4
Inspector General advisory
.....................................................................................................
....................................... 5
Section 1.
Facts about this HMO plan
..........................................................................................
................................ 6
How we pay providers
..........................................................................................................
....................... 6
Who provides my health
care?..................................................................................................
................... 6
Your
Rights...................................................................................................................
............................... 6
Service
Area..................................................................................................................
............................... 7
Section 2. How we
change for
2002………………………………………..................................................................
8
Program-wide
changes..........................................................................................................
....................... 8
Changes to this
Plan..........................................................................................................
........................... 8
Section 3. How you get
care …………...
...........................................................................................
.......................... 9
Identification
cards..........................................................................................................
............................. 9
Where you get covered
care....................................................................................................
..................... 9
Plan
providers........................................................................................................................................
9
Plan facilities
.........................................................................................................................................
9
What you must do to get covered care
.........................................................................................................
9
Primary
care...........................................................................................................................................
9
Specialty
care.......................................................................................................................................
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 catastrophic protection out-of-pocket
maximum..............................................................................
12
Section 5.
Benefits…………………………………………………………...............................................................
13
Overview......................................................................................................................
.............................. 13
(a) Medical services and
supplies provided by physicians and other health care professionals ...........
14
(b) Surgical and anesthesia services provided by
physicians and other health care professionals........ 22
(c) Services provided by a hospital or other facility, and ambulance
services ..................................... 25
(d) Emergency services/ accidents
...............................................................................................
.......... 27
(e) Mental health and substance abuse
benefits
....................................................................................
29
(f) Prescription drug
benefits................................................................................................................
31 2
2 Page 3 4
2002 OSF HealthPlans 3 Table of Contents
(g) Special
features..................................................................................................................................
35
Services for deaf and hearing impaired
Centers of excellence for transplants
(h) Dental benefits
...................................................................................................................................
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
Section 9. Coordinating benefits with other
coverage
...............................................................................................
41
When you have…
Other health coverage
......................................................................................................................
41
Original Medicare
............................................................................................................................
41
Medicare managed care
plan............................................................................................................
43
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
Coverage
information................................................................................................................................
46
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
.............................................................................................................................
47
When FEHB coverage
ends............................................................................................................
47
Spouse equity coverage
..................................................................................................................
47
Temporary Continuation of Coverage
(TCC).................................................................................
47
Converting to individual coverage
.................................................................................................
48
Getting a Certificate of Group Health Plan
Coverage .................................................................... 48
Long term care insurance is coming
later in 2002
......................................................................................................
49
Index
............................................................................................................................................................................
50
Summary of benefits
...................................................................................................................................................
51
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2002 OSF HealthPlans 4 Introduction/ Plain Language/ Advisory
Introduction
OSF HealthPlans
7915 N. Hale Ave., Suite D
Peoria, IL 61615-2047
This brochure describes the benefits of OSF HealthPlans under our contract
(CS 2829) with the Office of Personnel
Management (OPM), as authorized by
the Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the
benefits, limitations, and exclusions of
this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 8. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we" means OSF HealthPlans.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel Management. If we use others,
we tell you what they mean first.
Our brochure and other FEHB plans'
brochures have the same format and similar descriptions to help you compare
plans.
If you have comments or suggestions about how to improve the
structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback
area at www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW, Washington, DC 20415. 4
4
Page 5 6
2002 OSF
HealthPlans 5 Introduction/ Plain Language/ Advisory
Inspector
General Advisory
Stop health care fraud! Fraud increases the cost of
health care for everyone. If you suspect that a physician, pharmacy, or hospital
has charged you for services you did not
receive, billed you twice for the
same service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error. If
the provider does not resolve the matter, call us at 800/ OSF-5222
and
explain the situation.
If we do not resolve the issue, call or write:
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300 The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room
6400
Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 OSF
HealthPlans 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, and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change plans because a provider
leaves our Plan. We cannot guarantee that any one physician,
hospital, or
other provider will be available and/ or remain under contract with us.
How
we pay providers
We contract with individual physicians, medical groups,
and hospitals to provide the benefits in this brochure. These
Plan providers
accept a negotiated payment from us, and you will only be responsible for your
copayments or
coinsurance.
Who provides my health care?
OSF HealthPlans, Inc. is a Mixed
Model Prepayment (MMP) plan. The Plan contracts with hospitals, group physician
practices, individual physician practices, and other health care providers
that provide medical care to members in
central Illinois and
central-northwestern Illinois.
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.
We were awarded an Accredited status for our commercial HMO/ POS combined
plans for all 27 Illinois service area counties by the National Committee for
Quality Assurance (NCQA).
We have been in existence for 6 years We are a
for profit entity
We scored above the 90 th percentile nationwide in all
four rating categories of Health Plan Overall, Health Care Overall, Personal
Physician and Specialist Seen Most Often in our HEDIS 2001 Member Satisfaction
Survey.
We were also above the 90 th percentile nationwide for Customer
Service, Getting Care Quickly, How Well
Doctors Communicate, Claims
Processing and Courteous and Helpful Office Staff. We scored above the 75 th
percentile nationwide for Getting Needed Care.
If you want more information about us, call 800/ OSF-5222, or write to OSF
HealthPlans, 7915 N. Hale Ave., Peoria,
IL, 61615-2047. You may also contact
us by fax at 309/ 677-8259 or visit our website at www. osfhealthplans. com. 6
6 Page 7 8
2002 OSF HealthPlans 7 Section 1
Service Area
To enroll in this Plan, you must live in or work
in our Service Area. This is where our providers practice. Our service
area
is:
Central Illinois: Dewitt, Fulton, Knox, Livingston, Marshall, McLean,
Peoria, Tazewell, and Woodford Counties.
Central-Northwestern Illinois:
Boone, Bureau, DeKalb, Henderson, Henry, Kane, LaSalle, Lee, McDonough,
McHenry, Mercer, Ogle, Putnam, Stark, Stephenson, Warren, Whiteside, and
Winnebago Counties.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care benefits. We will not pay for any other health care services out of our
service
area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other states. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page
8 9
2002 OSF HealthPlans 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 by 17.3% for Self Only or 18.4% for Self and Family. We now cover
certain intestinal transplants. (Section 5( b))
We changed speech therapy
benefits by removing the requirement that services must be required to restore
functional speech. We now provide coverage for speech therapy up to a maximum
Plan benefit of $2,000 per
person per calendar year, subject to a $15 copay
per visit. (Section 5( a))
We now cover physical and occupational
therapies for up to 50 visits per condition per calendar year, subject to a $15
copay per visit. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a)) We clarified Vision services to show that annual diabetic
retinal exams are covered at 100% after a $10 office
visit copay. (Section
5( a))
We clarified Durable medical equipment (DME) to show that lancets
and test strips for diabetic members are covered as a supply at 100% with no
copay. (Section 5( a)) 8
8 Page
9 10
2002 OSF HealthPlans 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/
OSF-5222.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, and/ or coinsurance, and you
will not have to file claims.
x 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. To make sure we
provide high value health care services and
products, we do have guidelines
and policies for providers that request to
participate in our network. In
addition, the National Committee for
Quality Assurance (NCQA) has developed
standards and guidelines that
we also follow.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. You may also call us at
800/ OSF-5222 to receive information about our providers.
x 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 It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for
most of your health care. You should try to choose
a primary care
physician that is familiar with your medical history. If you
must choose
a new physician, we encourage you to schedule an appointment as
soon
as possible so he/ she can become familiar with you and you can become
familiar with him/ her. If you need help choosing a primary care
physician, please call 800/ OSF-5222 and we will assist you.
x Primary care Your primary care physician can be a pediatrician,
family practitioner or internist. Your primary care physician will provide most
of your health
care, or give you a referral to see a specialist.
If you
want to change primary care physicians or if your primary care
physician
leaves the Plan, call us. We will help you select a new one.
You may change
two (2) times a year with a thirty (30) day interval
between changes. If you
contact us by the fifteenth (15 th ) of the month,
your change will be
effective the first of the following month. If you
contact us after the
fifteenth (15 th ), there will be a month between
changes. This allows
enough time for offices to schedule appointments
and to notify Primary Care
Physicians of new patients. 9
9 Page 10 11
2002 OSF
HealthPlans 10 Section 3
x Specialty care Your primary
care physician will refer you to a specialist for needed care. When you receive
a referral from your primary care physician, you must
return to the primary
care physician after the consultation, unless your
primary care physician
authorized a certain number of visits without
additional referrals. The
primary care physician must provide or
authorized all follow-up care. Do not
go to the specialist for return visits
unless your primary care physician
gives you a referral. However,
female members may see network OB/ GYNs
without a referral.
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 and specialist will work
together with you and the Plan
when creating your treatment plan. Your
primary care physician will
use our criteria when creating your treatment
plan (the physician may
have to get an authorization or approval
beforehand).
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.
x 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. 10
10 Page 11 12
2002 OSF HealthPlans 11 Section 3
If
you are in the hospital when your enrollment in our Plan begins, call
our
customer service department immediately at 800/ OSF-5222. If you
are new to
the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval 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 the referral process. Your
physician must obtain a referral for the following services (this list is
intended as an example only): Inpatient hospitalization, outpatient
surgery, certain outpatient diagnostic procedures, specialty physician
office visits, durable medical equipment, home health care, growth
hormone therapy (GHT), physical therapy, occupational therapy, and
speech therapy. It is also your responsibility to notify us within 48 hours
of any Emergency room visit. If you are unsure a service needs a
referral, call us at 800/ OSF-5222.
Except in a medical emergency, you must contact your primary care
physician for a referral before seeing any other doctor or obtaining
special services. Referral to a participating specialist is given at the
primary care physician's discretion; if specialists or consultants are
required beyond those who are Plan doctors, the primary care physician
will make arrangements for appropriate referrals.
On referrals, the primary care physician will give specific instructions to
the consultant as to what services are authorized. Authorizations will be
for an adequate number of direct visits under an approved treatment plan.
If additional services or visits are suggested by the consultant, over and
above the approved treatment plan, you must first check with your
primary care physician. Do not go to the specialist unless your primary
care physician has arranged for, and the Plan has issued an authorization
for, the referral. 11
11 Page 12 13
2002 OSF
HealthPlans 12 Section 4
Section 4. Your costs for covered
services
You must share the cost of some services. You are responsible
for:
x Copayments A copayment is a fixed amount of money you pay to
the provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit and when you go in the hospital, you
pay $100 per day
up to maximum of $300 per admission.
x Deductible We do not have a deductible.
Note: If you change
plans during open season, you do not have to start a
new deductible under
your old plan between January 1 and the effective
date of your new plan. If
you change plans at another time during the
year, you must begin a new
deductible under your new plan.
x Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 20% of our allowance for durable
medical
equipment, prosthetic devices, and orthopedic devices.
Your catastrophic protection After your copayments and/ or coinsurance
total $1,500 per person or out-of-pocket maximum for $3,000 per family
enrollment in any calendar year, you do not have to
coinsurance and copayments pay any more for covered services. However,
copayments or coinsurance for the following services do not count toward your
out-of-pocket
maximum, and you must continue to pay copayments or
coinsurance for these services:
Durable medical equipment; Prosthetic devices;
Orthopedic devices;
and Prescription drugs
Be sure to keep accurate records of your copayments and/ or coinsurance
since you are responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 OSF HealthPlans Section 5 13
Section 5. Benefits
--OVERVIEW
(See page 8 for how our benefits changed this year and
page 51 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing advice, or more
information about our benefits, contact us
at 800/ OSF-5222 or at our
website at www. osfhealthplans. 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
Treatment therapies Physical
and occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies) Foot care
Orthopedic
and prosthetic devices Durable medical equipment (DME)
Home health
services Chiropractic
Alternative treatments Educational classes and
programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals....................... 22-24
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other
facility, and ambulance
services..................................................... 25-26
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/
accidents........................................................................................................................
27-28
Medical emergency Ambulance
(e) Mental health and substance
abuse
benefits....................................................................................................
29-30
(f) Prescription drug
benefits...............................................................................................................................
31-34
(g) Special
features....................................................................................................................................................
35
Services for deaf and hearing impaired Centers of excellence for
transplants
(h) Dental
benefits.....................................................................................................................................................
36
Summary of
benefits...................................................................................................................................................
51 13
13 Page 14
15
2002 OSF HealthPlans Section 5( a) 14
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
In
an urgent care center
Office medical consultations
Second surgical
opinion
$10 per office visit to your primary care
physician
$15 per office visit to a specialist
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
Nothing
At home $10 per visit by your primary care physician
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 OSF HealthPlans Section 5(
a) 15
Preventive care, adult You pay
Routine screenings, such
as:
Total Blood Cholesterol – once every three years
Colorectal
Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy,
screening – every three years starting at age 50
Routine laboratory
testing or screening
Blood pressure checks
Prostate Specific Antigen
(PSA test) – one annually for men age 50 and older
Routine pap test
$10 per office visit
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
and older, one every calendar year
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, travel, or sports.
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
Out of
country travel immunizations
$10 per office visit
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care
(to age 22)
Examinations, such as:
Eye exams through age 17 to
determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( to age 22)
$10 per office visit 15
15 Page 16 17
2002 OSF
HealthPlans Section 5( a) 16
Maternity care You pay
Complete
maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 11 for other
circumstances, such as extended stays for you or your
baby.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery
care of the newborn child during the covered portion of the mother's maternity
stay. We will cover
other care of an infant who requires non-routine treatment only if
we
cover the infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$100 per delivery
Not covered: Routine sonograms to determine fetal age, size or sex All
charges.
Family planning
Limited to:
Voluntary
sterilization
$15 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, and all contraceptive drugs and devices.
All charges. 16
16 Page 17 18
2002 OSF HealthPlans Section 5( a) 17
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine
insemination (IUI)
In vitro fertilization
Embryo transfers
Uterine embryo lavage
Gamete intrafallopian
tube transfer (GIFT)
Zygote intrafallopian tube transfer (ZIFT)
Low
tubal ovum transfer
Fertility drugs (covered under Prescription drug
benefits)
$15 per office visit
Not covered:
Payment for medical services to a surrogate for
purposes of child birth
Non-medical costs of an egg or sperm donor
Cost of donor
sperm
Cost of donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$15 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 17
17 Page 18 19
2002 OSF HealthPlans Section 5( a) 18
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 24.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment.
Have your doctor call 800/ OSF-5222 for
preauthorization. We will ask
your doctor to submit information that
establishes that the GHT is
medically necessary. Your doctor must ask us to
authorize GHT before
you begin treatment; otherwise, we will only cover GHT
services from
the date your doctor submits the information. If your doctor
does not ask
for preauthorization or if we determine GHT is not medically
necessary,
we will not cover the GHT or related services and supplies. See
Services
requiring our prior approval in Section 3.
$15 per office visit
Physical and occupational therapies
50 visits per condition per
calendar year for the services of each of the following:
qualified physical therapists; and
occupational therapists.
Note:
We only cover therapy to restore bodily function when
there has been a total
or partial loss of bodily function due to
illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction.
$15 per visit
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
$2,000 maximum benefit per person per calendar
year for the services of the following:
qualified speech therapists
$15 per visit 18
18 Page
19 20
2002 OSF HealthPlans Section 5(
a) 19
Hearing services (testing, treatment, and supplies) You pay
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 following cataract surgery. Nothing
Eye exam to determine the need for vision correction for children through
age 17 (See Preventive care, children)
An eye refraction every twenty-four
(24) months
A retinal exam for diabetic members every twelve (12) months.
$10 per office visit
Not covered:
Eyeglasses or contact lenses (except as above)
and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$15 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat
feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot (unless the
treatment is by open cutting surgery)
All charges. 19
19 Page 20 21
2002 OSF
HealthPlans Section 5( a) 20
Orthopedic and prosthetic devices You
pay
Artificial limbs and eyes; stump hose
Externally worn breast
prostheses and surgical bras, including necessary replacements, following a
mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: See 5( b) for coverage of the surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Braces
Trusses
Corrective shoes or foot orthotics which are an
integral part of a lower body brace
20% of eligible charges
Not covered:
Orthopedic and corrective shoes( except as
above)
arch supports or lifts
foot orthotics (except
as above)
heel pads and heel cups
lumbosacral supports
corsets, elastic stockings, support hose, and other supportive
devices
the cost of a penile implanted device
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 (non-motorized);
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
Note: Call us at 800/ OSF-5222 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.
20% of eligible charges
lancets and test strips for diabetic members Nothing
Not covered:
Motorized wheelchairs All charges. 20
20
Page 21 22
2002
OSF HealthPlans Section 5( a) 21
Home health services You pay
Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include
oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the
convenience of, the patient or the patient's family;
home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges.
Chiropractic
No benefit. All charges.
Alternative treatments
No benefit. All charges.
Not covered:
acupuncture naturopathic services
hypnotherapy biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
Diabetes self-management
Notes to Mom – A program for women planning to become pregnant or already
pregnant. Call 877/ 615-2447 to sign up.
Your Choice – A program available to members who smoke that is a self-help
mail program that consists of letters, educational information
and
motivational workbooks. Our goal is to increase your desire to quit
smoking.
If you would like to register, please call 877/ 761-8618 or e-mail
yourchoice@ osfhealthcare. org.
Nothing 21
21 Page
22 23
2002 OSF HealthPlans 22
Section 5( b)
Section 5 (b). Surgical and anesthesia services
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no
calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e., hospital,
surgical center, etc.) .
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF
SOME SURGICAL PROCEDURES. Please refer to the precertification information shown
in Section 3 to be sure
which services require precertification and identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative Procedures Treatment
of fractures, including casting
Normal pre-and post-operative care by the surgeon Correction of amblyopia
and strabismus
Endoscopy procedures Biopsy procedures
Removal of
tumors and cysts Correction of congenital anomalies (see reconstructive
surgery)
Surgical treatment of morbid obesity --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 Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a
pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per office visit to a primary
care physician
$15 per office visit to a specialist
Nothing for hospital visits
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges.
22
22 Page 23
24
2002 OSF HealthPlans 23 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a
functional defect
Surgery to correct a condition caused by injury or
illness if:
the condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes.
All stages of breast reconstruction surgery following a mastectomy, such
as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
Nothing
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones; Surgical
correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or
their supporting structures.
Nothing
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 23
23 Page 24 25
2002 OSF
HealthPlans 24 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors.
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach,
and pancreas
The transplant must be performed at a Plan approved facility.
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 performed at a
non-approved facility
Transplants not listed as covered
All charges.
Anesthesia
Professional services provided in –
Hospital
(inpatient) Hospital outpatient department
Skilled nursing facility Ambulatory surgical center
Office
Nothing 24
24 Page
25 26
2002 OSF HealthPlans 25
Section 5( c)
Section 5 (c). Services provided by a hospital or
other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
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 the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in
Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general
nursing care; 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.
$100 per day up to maximum of 3
days or $300 per admission
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Take-home items Medical supplies, appliances, medical equipment, and any
covered
items billed by a hospital for use at home
Nothing
Not covered:
Custodial care Non-covered facilities,
such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges. 25
25 Page 26 27
2002 OSF
HealthPlans 26 Section 5( c)
Outpatient hospital or ambulatory
surgical center You pay
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced Pre-surgical testing
Dressings,
casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and
supplies related to dental
procedures when necessitated by a non-dental
physical impairment.
We do not cover the dental procedures.
$150 per surgery
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/ skilled nursing care facility
benefits
Extended care benefit: We cover a full range of benefits up to 45 days
per calendar year for full-time skilled nursing care in a skilled
nursing facility. A Plan doctor must determine that confinement is
medically necessary and it must be approved by the Plan. All
necessary
services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a
Plan doctor.
Nothing
Not covered: custodial care All charges.
Hospice care
Care for a terminally ill member is covered in the home or a hospice
facility. Services include inpatient and outpatient care and family
counseling. A Plan doctor must direct these services and certify the
patient is terminally ill with a life expectancy of six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when
medically appropriate. Nothing 26
26 Page 27 28
2002 OSF
HealthPlans 27 Section 5( d)
Section 5 (d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
We have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including
with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your
life or could result in serious
injury or disability, and requires immediate medical or surgical care. Some
problems are
emergencies because, if not treated promptly, they might become
more serious; examples include deep cuts and
broken bones. Others are
emergencies because they are potentially life-threatening, such as heart
attacks, strokes,
poisonings, gunshot wounds, or sudden inability to
breathe. There are many other acute conditions that we may
determine are
medical emergencies – what they all have in common is the need for quick action.
What to do in case of emergency:
If you are in an emergency
situation, go to the nearest emergency care facility. If you have questions
about whether
or not it is an emergency, your primary care physician or
covering physician will be available 24 hours a day, 7 days a
week to help
you.
If you do go to an emergency facility, you or a family member must call the
Plan's HealthCare Management at
800/ 284-CARE within 48 hours unless it was
not reasonably possible to do so. It is your responsibility to ensure that
the Plan has been timely notified. If you are hospitalized in non-Plan
facilities and a Plan doctor believes care can be
provided in a Plan
Hospital, you will be transferred to a Plan Hospital when you are medically able
to do so. Any
ambulance charges from this transfer are covered in full.
Within the service area, benefits are available for care from non-Plan
providers in a medical emergency only if delay
in reaching a Plan provider
would result in death, disability or significant jeopardy to your condition.
Outside the
service area, benefits are available for any medically necessary
health service that is immediately required because of
injury or unforeseen
illness. To be covered by this Plan, any follow-up care recommended by non-Plan
providers
must be approved by the Plan.
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
$10 per office visit to your primary care
physician
$15 per office visit charge to a specialist
$10 per visit to an urgent
care center
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services $50 per visit, waived if admitted
Not covered: Elective care or non-emergency care All charges. 27
27 Page 28 29
2002 OSF HealthPlans 28 Section 5( d)
Emergency outside our service area You pay
Emergency care
at a doctor's office
Emergency care at an urgent care center
$10 per office visit to your primary
care physician
$15 per office visit to a specialist
$10 per visit to an urgent care
center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services $50 per visit, 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 ambulance,
when
medically appropriate.
See 5( c) for non-emergency service.
Nothing 28
28 Page
29 30
2002 OSF HealthPlans 29
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and
limitations for Plan mental health and substance
abuse benefits will be no greater than for similar
benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See
the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
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
illnesses or
conditions
Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
Medication management
$15 per office visit to a specialist
Mental health and substance abuse benefits -Continued on next page 29
29 Page 30 31
2002 OSF HealthPlans 30 Section 5( e)
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in
approved alternative care settings such as partial
hospitalization, full-day
hospitalization, facility based intensive outpatient
treatment
$100 per day up to maximum of
3 days or $300 per admission
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the
treatment plan's clinical
appropriateness. OPM will generally not order
us to pay or provide one
clinically appropriate treatment plan in favor of
another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
Call our mental health and substance abuse provider, United Behavioral
Health (UBH), at 800/ 420-5729. An intake coordinator will assist you with
your needs. You may then be referred to a participating provider.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 30
30 Page
31 32
2002 OSF HealthPlans 31
Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
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
There are important features you should be aware of. These include:
Who can write your prescription. A licensed Plan 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
contract with PCS HealthSystems (PCS) to provide you with full
prescription drug benefits through local pharmacies. Present your PCS card at
any participating
pharmacy, and after you pay your copayment for each new or
refill prescription, we will pay the rest
of the cost to the pharmacy.
We use a Preferred Drug List (PDL). The PDL is made up of drugs
meeting careful clinical and therapeutic standards created by physicians and
pharmacists. Preferred drugs include generic and
specific name brand drugs. Generic drugs on the PDL will cost you the least
amount of money out-of-
pocket. Name brand drugs on the PDL are your next
best option if no generic drug is available.
You will pay the most if you
use any drugs that are not on the preferred drug list. If you or a family
member are currently taking a nonpreferred drug, you will be receiving a
letter showing you what
nonpreferred drugs you are taking and what
alternative drugs are available. If you have a question
about whether your
prescription medications are generic or name brand drugs, contact your doctor or
pharmacist.
We administer an open PDL. If your physician believes a name brand product is
necessary or there is
no generic available, your physician may prescribe a
name brand drug from the PDL. This list of
name brand drugs is a preferred
list of drugs that we selected to meet patient needs at a lower cost.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor and obtained at a Plan pharmacy will either be
dispensed for up to a 34-day supply or for a 35-90 day
supply, depending on
the pharmacy you receive them at. You will pay a $7 copay per prescription
unit or refill for up to a 34-day supply of preferred generic drugs and a
$14 copay per prescription
unit or refill for a 35-90 day supply. You will
pay a $15 copay for up to a 34-day supply of
preferred name brand drugs when
no generic drug is available and a $30 copay for a 35-90 day
supply. You
will pay a $25 copay for up to a 34-day supply of non-preferred name brand drugs
when no generic drug is available and a $50 copay for a 35-90 day supply.
You will pay a $7 copay
plus the price difference in the cost of the name
brand drug over the generic drug for up to a 34-day
supply of preferred or
non-preferred name brand drugs when you or your physician requests a name
brand drug and a generic drug is available. You will pay a $14 copay plus
the price difference in the
cost of the name brand drug over the generic
drug for a 35-90 day supply of preferred or non-preferred
name brand drugs
when you or your physician requests a name brand drug and a generic
drug is
available.
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, as well
as the applicable $7 or
$14 copay. 31
31
Page 32 33
2002
OSF HealthPlans 32 Section 5( f)
Why use generic drugs?
To reduce your out-of-pocket expenses! A generic drug is the chemical
equivalent of a corresponding name brand drug. Generic drugs are less expensive
than name brand
drugs; therefore, you may reduce your out-of-pocket costs by
choosing to use a generic drug.
When you have to file a claim. Normally you will not have to file a
claim. If you do, contact us at 800/ OSF-5222 and we can send you a claim form
that must be completed. You will then send the
claim to the address on the
form.
Prescription drug benefits begin on the next page. 32
32 Page 33 34
2002 OSF HealthPlans 33 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as excluded below.
Insulin; a copay charge applies to each vial Disposable needles and syringes
for the administration of covered
medications; a copay charge applies to
each 34-day supply
Drugs for sexual dysfunction are subject to dosage
limits set by the Plan. Contact the Plan for details.
Fertility drugs
FOR UP TO A 34-DAY SUPPLY
A $7 copay for a preferred generic drug;
A $15 copay for a preferred name brand drug when no
generic drug is
available;
A $25 copay for a non-preferred name brand drug when no
generic drug is available; and
A $7 copay plus the price difference in
the cost of the
name brand drug over the
generic drug for a preferred or
non-preferred name brand drug
when you or your physician
requests a
name brand drug
when a generic drug is available.
FOR A 35-90 DAY SUPPLY
A $14 copay for a preferred generic drug;
A $30 copay for a preferred
name brand drug when no
generic drug is available;
A $50 copay for a
non-preferred name brand drug when no
generic drug is available; and
A $14 copay plus the price difference in
the cost of the
name brand drug over the
generic drug for a preferred or
non-preferred name brand drug
when you or your physician
requests a
name brand drug
when a generic drug is available.
Covered medications and supplies -Continued on next page. 33
33 Page 34 35
2002 OSF HealthPlans 34 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, and nutritional substances that can be purchased without
a prescription
Nonprescription medicines
Drugs obtained at a non-Plan
pharmacy except for out-of-area emergencies
Medical supplies such as dressings and antiseptics
Drugs to
enhance athletic performance
Contraceptive drugs and devices;
including, but not limited to, oral contraceptives; Intrauterine devices (IUDs);
diaphragms; Norplant;
and Depo Provera
Diabetic supplies, except needles, syringes, and insulin (Additional
equipment, i. e., blood glucose monitors, insulin pumps, and supplies,
i.
e., lancets and test strips, are covered under "Durable medical
equipment,"
see page 20)
Smoking cessation drugs and medication
Drugs prescribed for
weight loss and appetite suppressants, except for treatment of Morbid Obesity
All Charges. 34
34 Page 35 36
2001 OSF
HealthPlans 35 Section 5( g)
Section 5 (g). Special Features
Feature Description
Services for deaf and hearing impaired We offer a TDD line at 1-888/
817-0139
Centers of excellence for transplants We utilize centers of excellence
for transplants. It is a national organ and tissue network consisting of 48
transplant medical centers and 120 transplant
programs. In order to become a
center of excellence, the program is strictly
credentialed using program and
physician experience, transplant volume,
outcomes, comprehensive services,
quality assessment and complications
rate. 35
35
Page 36 37
2001
OSF HealthPlans 36 Section 5( h)
Section 5 (h). Dental
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
We have no calendar year deductible.
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
Restorative services and
supplies necessary to promptly repair and
replace sound natural teeth due to
accidental injury within 90 days of the
injury are covered. The need for
these services must result from an
accidental injury. Accidental injury does
not include injury caused by or
arising out of the act of chewing.
Nothing
Dental benefits
We have no other dental benefits. 36
36 Page 37 38
2002 OSF HealthPlans Section 6 37
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we
will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or
treat your
illness, disease, injury, or condition and we agree, as discussed under
What Services Require
Our Prior Approval on page 11.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions;
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 OSF HealthPlans 38 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or fill your
prescription drugs at Plan
pharmacies, you will not have to file claims.
Just present your identification card and pay your copayment, or
coinsurance.
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 and hospital 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/ OSF-5222.
When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown
below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the
physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of
each service or supply;
The charge for each service or supply;
A
copy of the explanation of benefits, payments, or denial from any primary payer
--such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to: OSF
HealthPlans, P. O. Box 5128, Peoria, IL 61601-5128.
Prescription drugs In most cases, participating pharmacies file claims
for you. If you need to file a prescription drug claim directly to PCS
HealthSystems (PCS),
call us at 800/ OSF-5222 and we will provide you with a
form that must
be completely filled out and sent to PCS.
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 OSF HealthPlans 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
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: OSF HealthPlans, 7915 N. Hale Ave., Suite D, Peoria, IL 61615;
and
(c) Include a statement about why you believe our initial decision was
wrong, based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
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 medical provider for more information. If we ask your
provider, we will send you a
copy of our request— go to step 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.
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.
Send OPM the following information:
A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies
of all letters we sent to you about the claim; and
Your daytime phone
number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim. 39
39
Page 40 41
2002
OSF HealthPlans 40 Section 8
Note: You are the only person who
has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must 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.
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.
If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
800/ OSF-5222 and we will
expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so
that they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 40
40
Page 41 42
2002
OSF HealthPlans 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 +Choice is the term used to
describe the various health plan choices
available to Medicare
beneficiaries. The information in the next few pages shows
how we coordinate
benefits with Medicare, depending on the type of Medicare
managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere
in
the United States. It is the way everyone used to get Medicare benefits
and
is the way most people get their Medicare Part A and Part B benefits
now.
You may go to any doctor, specialist, or hospital that accepts
Medicare. The
Original Medicare Plan pays its share and you pay your
share. Some things
are not covered under Original Medicare, like
prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your care.
We will not waive any of our copayments, or coinsurance.
(Primary
payer chart begins on next page.)
xThe Original Medicare Plan (Part A or Part B) 41
41 Page 42 43
2002 OSF HealthPlans 42 Section 9
The following chart illustrates whether the Original Medicare Plan
or this Plan should be the primary payer for you
according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or
a covered family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a family member are eligible for
Medicare solelybecause of a disability), 9
2) Are an annuitant, 9
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or 9
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
9
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), 9
5) Are enrolled in Part B only, regardless of your employment status, 9 (for
Part B
services)
9
(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,
9
(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, 9
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD, 9
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision, 9
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 9
b) Are an active employee, or 9
c) Are a former spouse of an annuitant, or
9
d) Are a former spouse
of an active employee 9
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare. 42
42
Page 43 44
2002 OSF HealthPlans 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 309/
677-8205, toll free 877/ 677-
8205, or TDD 888/ 817-0139.
We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan – a
Medicare managed care plan. These are health care
choices (like HMOs)
in some areas of the country. In most Medicare managed
care plans, you
can only go to doctors, specialists, or hospitals that are
part of the plan.
Medicare managed care plans provide all the benefits that
Original
Medicare covers. Some cover extras, like prescription drugs. To
learn
more about enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments, or
coinsurance for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You
may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when
your Medicare managed
care plan is primary, even out of the managed
care plan's network and/ or
service area (if you use our Plan providers),
but we will not waive any of
our copayments or coinsurance. If you
enroll in a Medicare managed care
plan, tell us. We will need to 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 OSF HealthPlans 44 Section 9
If you do not enroll in If you do not have one or both parts of Medicare,
you can still be covered Medicare Part A or Part B under the FEHB
Program. We will not require you to enroll in Medicare
Part B and, if you
can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or
State agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or other similar proceeding that is based on a claim you filed
under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital for injuries care for injuries or illness caused
by another person, you must reimburse
us for any expenses we paid. However,
we will cover the cost of
treatment that exceeds the amount you received in
the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 44
44 Page 45 46
2002 OSF
HealthPlans 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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Deductible A deductible is a fixed amount of covered
expenses you must incur for certain covered services and supplies before we
start paying benefits for
those services. See page 12
The Plan uses a
range of sources to decide if a new procedure, process, or
pharmaceutical is
or is not experimental or investigational. These
sources include an
independent third party evaluation where valid, an
agreement of specialists
in the related field, the Food and Drug
Administration, Medicare Guidelines,
Hayes Technology Assessment
and other available sources of medical
information. All information is
given to the Plan's Utilization Management
Committee by the Plan's
Medical Director for a decision. The Medical
Director also uses the
resources of the Plan's Technology Assessment
Committee.
Us/ We Us and we refer to OSF HealthPlans.
You You refers
to the enrollee and each covered family member.
Experimental or
investigational services 45
45 Page 46 47
2002 OSF HealthPlans 46 Section 10
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.
Section 11 46
46 Page
47 48
2002 OSF HealthPlans Section 11
47
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 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
x 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.
x Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
x Temporary Continuation of If you leave Federal service, or if you
lose coverage because you no Coverage (TCC) 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 OSF HealthPlans Section 11 48
Enrolling in TCC. Get
the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal
Employees Health Benefits Plans for
Temporary Continuation of Coverage and
Former Spouse Enrollees,
from your employing or retirement office or
from www. opm. gov/ insure.
It explains what you have to do to enroll.
x 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.
The Health Insurance Portability and Accountability Act of 1996
(HIPAA)
is a Federal law that offers limited Federal protections for
health coverage
availability and continuity to people who lose employer
group coverage. If
you leave the FEHB Program, we will give you a Certificate
of Group Health
Plan Coverage that indicates how long you have been enrolled
with us. You
can use this certificate when getting health insurance or other health
care
coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the
information in
the certificate, as long as you enroll within 63 days of
losing coverage under this
Plan. If you have been enrolled with us for less
than 12 months, but were
previously enrolled in other FEHB plans, you may
also request a
certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health): refer to
the "TCC and
HIPAA" frequently asked questions. These highlight HIPAA
rules, such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information.
Getting a Certificate of
Group Health Plan Coverage 48
48 Page 49 50
2002 OSF HealthPlans 49 Long Term Care Insurance
Long
Term Care Insurance Is Coming Later in 2002!
The Office of Personnel
Management (OPM) will sponsor a high-quality long term care insurance program
effective
in October 2002. As part of its educational effort, OPM asks you
to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury,
or an
age-related disease such as Alzheimer's.
LTC insurance can provide broad,
flexible benefits for nursing home care, care in an assisted living facility,
care in your home, adult day
care, hospice care, and more. LTC insurance can supplement care
provided by family members, reducing the burden you place on them.
Welcome to the club! 76% of Americans believe they will never need long
term care, but the
facts are that about half of them will. And it's not just
the old folks.
About 40% of people needing long term care are under age 65.
They
may need chronic care due to a serious accident, a stroke, or
developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care
insurance to be vital to their financial and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed
$50,000. Home care for only three 8-hour shifts a week can exceed
$20,000 a
year. And that's before inflation!
Long term care can easily exhaust your
savings. Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a
stay
in an assisted living facility or a continuing need for a home health
aide
to help you get in and out of bed and with other activities of daily
living.
Limited stays in skilled nursing facilities can be covered in
some
circumstances.
Medicare only covers skilled nursing home care (the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit.
Medicaid covers
long term care for those who meet their state's poverty guidelines, but has
restrictions on covered services and where
they can be received. Long term care insurance can provide choices of
care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
Our toll-free teleservice
center will begin in mid-2002. In the meantime,
you can learn more about the program on our web site at
www. opm. gov/
insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need? You should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 49
49 Page 50 51
2002 OSF HealthPlans 50 Summary
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury
36 Allergy tests 17
Allogenetic (donor) bone marrow transplant 24
Alternative treatment 21 Ambulance 28
Anesthesia 24 Autologous bone
marrow
transplant 24 Biopsies 22
Blood and blood plasma 25 Breast
cancer screening 15
Casts 25 Catastrophic protection 12
Changes
for 2002 8 Chemotherapy 18
Childbirth 16 Chiropractic 21
Cholesterol
tests 15 Claims 38
Coinsurance 12 Colorectal cancer screening 15
Congenital anomalies 23 Contraceptive devices and drugs 34
Coordination
of benefits 41 Covered providers 6
Crutches 20
Deductible 12
Definitions 45
Dental care 36 Diagnostic services 14
Disputed claims review 39 Donor
expenses (transplants) 24
Dressings 25 Durable medical equipment
(DME)
20 Educational classes and programs 21
Effective date of enrollment
47 Emergency 27
Experimental or investigational 45
Eyeglasses 19 Family planning 16
Fecal occult blood test 15
General Exclusions 37
Hearing services 19 Home health services
21
Hospice care 26 Home nursing care 21
Hospital 25 Immunizations
15
Infertility 17 Inhospital physician care 25
Inpatient Hospital
Benefits 25 Insulin 33
Laboratory and pathological services 15
Magnetic Resonance Imagings (MRIs) 14
Mammograms 15 Maternity Benefits
16
Medicaid 44 Medicare 41
Mental Conditions/ Substance Abuse Benefits
29
Newborn care 16 Nurse
Licensed Practical Nurse 21 Nurse
Anesthetist 25
Registered Nurse 21 Nursery charges 16
Obstetrical
care 16 Occupational therapy 18
Office visits 14 Oral and maxillofacial
surgery 23
Orthopedic devices 20 Out-of-pocket expenses 12
Outpatient
facility care 26 Oxygen 25
Pap test 15 Physical examination 15
Physical therapy 18 Physician 9
Precertification 11 Preventive care,
adult 15
Preventive care, children 15 Prescription drugs 31
Preventive
services 15 Prior approval 11
Prostate cancer screening 15 Prosthetic
devices 20
Psychologist 29 Radiation therapy 18
Room and board 25
Second surgical opinion 14
Skilled nursing facility care 26 Smoking
cessation 21, 34
Speech therapy 18 Splints 25
Sterilization procedures
16 Subrogation 44
Substance abuse 29 Surgery 22
Anesthesia 24 Oral
23
Outpatient 26 Reconstructive 23
Syringes 33 Temporary
continuation of
coverage 47 Transplants 24
Treatment therapies 18
Vision services 19 Well child care 15
Wheelchairs 20 Workers' compensation 44
X-rays 14
Index 50
50 Page
51 52
2002 OSF HealthPlans 51
Summary
Summary of benefits for OSF HealthPlans -2002
Do not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the definitions, limitations, and exclusions in
this brochure. On this page we summarize specific expenses we cover;
for
more detail, look inside.
If you want to enroll or change your enrollment
in this Plan, be sure to put the correct enrollment code from the cover on your
enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by
physicians:
Diagnostic and treatment services provided in the
office................. Office visit copay: $10 primary care; $15 specialist 14
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
$100 per day up to a maximum of
$300 per admission
$150 per outpatient surgery
25
26
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$50 per emergency room visit at a
hospital (waived if admitted).
$50 per emergency room visit at a
hospital (waived if admitted)
27
28
Mental health and substance abuse
treatment..................................... Regular cost sharing 29
Prescription drugs
................................................................................
For up to a 34-day supply or 35-90 day supply per prescription unit or
refill, depending on where you fill your prescription. The first copay
is for up to a 34-day supply, and the second copay is for a 35-90 day
supply.
$7/$ 14 copay for generic drugs;
$15/$ 30 copay for preferred name
brand drugs when no generic drug
is available; $25/$ 50 copay for
non-preferred name brand drugs
when no generic drug is available;
and $7/$ 14 copay plus the price
difference between the name
brand
drug and the generic drug
for the preferred or non-preferred
name brand
drug when requested
by you or the physician when a
generic drug is
available.
31
Dental Care ....................................... Accidental injury benefit
only Nothing 36
Vision Care .............. One refraction every twenty-four
(24) months $10 per visit 19
Special features: Services for deaf and hearing
impaired; and Centers of excellence for transplants. 35
Protection against
catastrophic costs
(your out-of-pocket
maximum).........................................................
Nothing after $1,500/ Self Only or
$3,000/ Family enrollment per year
Some costs do not count toward
this protection
12 51
51 Page
52
2002 OSF HealthPlans 52 Rates
2002 Rate
Information for
OSF HealthPlans, 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 9F1 $85.22 $28.40 $184.64 $61.54 $100. 84 $12.78
Self and
Family 9F2 $223.41 $75.39 $484.06 $163.34 $263. 75 $35.05 52