Serving: Eastern and Central South Dakota and Northwestern Iowa.
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.
Enrollment codes for this Plan:
AV1 Self Only AV2 Self and Family
Special notice: This Plan is offered for the first time under the
Federal Employees Health Benefits Program during the 2001 Open Season.
RI 73-811 1
1 Page
2 3
Table of Contents
Introduction ………………………………………………………………….
.......................................................................................
4
Plain Language
.......................................................................................................................................................................................
4
Inspector General Advisory
....................................................................................................................................................................
4
Section 1. Facts about this HMO plan
...................................................................................................................................................
6
We also have point-of service (POS)
benefits.......................................................................................................................
6
How we pay providers
..........................................................................................................................................................
6
Your
Rights...........................................................................................................................................................................
6
Service
Area..........................................................................................................................................................................
7
Section 2. We are a new
plan.................................................................................................................................................................
8
Section 3. How you get care
.................................................................................................................................................................
8
Identification
cards................................................................................................................................................................
8
Where you get covered
care..................................................................................................................................................
8
. Plan providers
.................................................................................................................................................................
8
. Plan facilities
..................................................................................................................................................................
8
What you must do to get covered care
..................................................................................................................................
8
. Primary
care....................................................................................................................................................................
8
. Specialty
care..................................................................................................................................................................
8
. Hospital care
...................................................................................................................................................................
9
Circumstances beyond our control
........................................................................................................................................
9
Services requiring our prior
approval..................................................................................................................................
10
Section 4. Your costs for covered services
..........................................................................................................................................
12
. Copayments
..................................................................................................................................................................
12
.
Deductible.....................................................................................................................................................................
12
. Coinsurance
..................................................................................................................................................................
12
Your out-of-pocket
maximum.............................................................................................................................................
12
Section 5. Benefits
...............................................................................................................................................................................
13
Overview.............................................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals ........................................... 14
(b)
Surgical and anesthesia services provided by physicians and other health care
professionals........................................ 24
(c) Services
provided by a hospital or other facility, and ambulance
services......................................................................
28
(d) Emergency services/ accidents
.........................................................................................................................................
32
(e) Mental health and substance abuse benefits
....................................................................................................................
34
(f) Prescription drug
benefits................................................................................................................................................
36
(g) Special features
...............................................................................................................................................................
39
Employee Assistance program
(h) Dental benefits
...................................................................................................................................................................
41
Avera Health Plans 2002 2 Table of Contents (i) Point of
Service Benefits
...................................................................................................................................................
41 2
2 Page 3 4
Section 6. General exclusions --things we don't
cover........................................................................................................................
43
Section 7. Filing a claim for covered services
.....................................................................................................................................
44
Section 8. The disputed claims
process................................................................................................................................................
46
Section 9. Coordinating benefits with other coverage
........................................................................................................................
48
When you have…
. Other health
coverage....................................................................................................................................................
49
. Original
Medicare..........................................................................................................................................................
49
. Medicare managed care plan
........................................................................................................................................
50
TRICARE/ Workers' Compensation/ Medicaid
...................................................................................................................
50
Other Government
agencies..................................................................................................................................................................
51
When others are responsible for
injuries.............................................................................................................................
51
Section 10. Definitions of terms we use in this
brochure......................................................................................................................
52
Section 11. FEHB facts
.......................................................................................................................................................................
54
Coverage
information........................................................................................................................................................
54
. No pre-existing condition limitation
.........................................................................................................................
55
. Where you get information about enrolling in the FEHB Program
.......................................................................... 55
. Types of coverage available for you and your
family...............................................................................................
55
. When benefits and premiums start
............................................................................................................................
54
. Your medical and claims records are confidential
....................................................................................................
55
. When you
retire........................................................................................................................................................
55
When you lose benefits
.....................................................................................................................................................
55
. When FEHB coverage ends
......................................................................................................................................
55
. Spouse equity
coverage............................................................................................................................................
55
. Temporary Continuation of Coverage (TCC)
..........................................................................................................
55
. Converting to individual coverage
...........................................................................................................................
55
. Getting a Certificate of Group Health Plan
Coverage..............................................................................................
56
Long term care insurance is coming later in 2002
................................................................................................................................
57 Index
.........................................................................................................................................................................................
58
Summary of benefits
.............................................................................................................................................................................
59
Rates
......................................................................................................................................................................................
Back cover
Avera Health Plans 2002 3 Table of Contents 3
3 Page 4 5
Introduction
Avera Health Plans, Inc. 3900
West Avera Drive
Sioux Falls, South Dakota 57108 5721
This brochure
describes the benefits of Avera Health Plans, Inc. under our contract (CS 2863)
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.
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 Avera Health Plans.
. We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
. Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm.
gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to OPM
at the Office of
Personnel Management, Office of Insurance Planning and
Evaluation Division, 1900 E. Street, NW Washington, DC 20415-3650.
Inspector General Advisory
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: Stop health care fraud!
. Call the provider and ask for an explanation. There may be an error.
.
If the provider does not resolve the matter, call us at 1-888-322-2115 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
Avera Health Plans 2002 4 Introduction/ Plain Language 4
4 Page 5 6
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.
Avera Health Plans 2002 5 Introduction/ Plain Language 5
5 Page 6 7
Section 1. Facts about this HMO plan
This
Plan is a health maintenance organization (HMO). We encourage you to see the
specific physicians, hospitals, and other providers that contract with us. These
Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan providers, you may
have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will
be available and/ or remain
under contract with us.
We also have Point-of-Service (POS) benefits:
Our HMO offers Point-of-Service (POS) benefits. This means you can
receive covered services from a participating provider without a required
referral, or from a non-participating provider. These out-of-network benefits
have higher out-of-pocket costs than our in-network
benefits.
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
deductible, copayment and coinsurance. Participating
physicians and other
health care professionals submit claims to us for services provided to you and
they are reimbursed on a fee for service basis. The fee is an amount negotiated
by the participating provider and Avera Health Plans. Participating hospitals
that
provide services to Avera Health Plans members are reimbursed on a fee
for service basis or on an amount that is calculated by multiplying the number
of days you are hospitalized by a specified dollar amount. There are no
contractual arrangements in place
between Avera Health Plans and
participating providers that would create an incentive for providers to withhold
care.
Your Rights
OPM requires that all FEHB Plans to provide
certain information to their FEHB members. You may get information about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types of information that we must
make available to you.
Some of the required information is listed below.
. Avera Health Plans is a
for profit division of Avera Health that was established to provide health care
financing and delivery
services.
. Avera Health Plans operates under a
Certificate of Authority issued by the South Dakota Division of Insurance and
the Iowa
Division of Insurance.
. Avera Health Plans began operations in
October of 1999 and provides health care coverage and services to over 10,000
individuals
in South Dakota, Iowa, Minnesota, and Nebraska.
. If you
want more information about us, call 605-322-4545 or 888-322-2115, or write to
Avera Health Plans, 3900 W. Avera Drive,
Suite 200, Sioux Falls, SD 57108-5721.
. You may also contact us by fax
at 605/ 322-4535 or visit our website at www. averahealthplans. com.
Avera Health Plans 2002 6 Section 1 6
6 Page 7 8
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 in South Dakota is the following counties in Central and Eastern
South Dakota: Aurora, Beadle, Bon Homme, Brookings, Brown, Brule,
Buffalo,
Charles Mix, Clark, Clay, Codington, Davison, Deuel, Douglas, Edmonds, Faulk,
Grant, Gregory, Hamlin, Hand, Hanson, Hutchinson, Jerauld, McPherson, Kingsbury,
Lake, Lincoln, Marshall, McCook, Miner, Minnehaha, Moody, Roberts, Sanborn,
Tripp,
Turner, Union, Walworth, and Yankton.
In Iowa our Service Area
is: Dickinson, Emmet, Lyon, O'Brien, Plymouth, Osceola, and Sioux.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will pay only for emergency care
benefits. We will not pay for any other health care services out of our service
area unless the services have prior
plan approval.
If you or a covered
family member move outside of our service area, you can enroll in another plan.
If your dependents live out of the area (for example, if your child goes to
college in another state), you should consider enrolling in a fee-for-service
plan or an HMO
that has agreements with affiliates in other areas. If you or
a family member move, you do not have to wait until Open Season to change plans.
Contact your employing or retirement office.
.
Avera Health Plans 2002 7 Section 1 7
7 Page 8 9
Section 2. We are a new plan
This Plan is new
to the FEHB Program. We are being offered for the first time during the 2001
open season.
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 605-322-4545 or 888-322-2115.
Where you get covered care When you get care from "Plan providers" and
"Plan facilities" you will only pay copayments, deductibles, and/ or
coinsurance, and you will not have to file claims. If you
use our
point-of-service program, you can also get care from non-Plan providers, or from
participating providers without a required referral, but it will cost you more.
. Plan providers Plan providers are physicians and other health care
professionals in our service area that
we contract with to provide covered
services to our members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
. Plan facilities Plan
facilities are hospitals and other facilities in our service area that we
contract with to
provide covered services to our members. We list these in
the provider directory, which we update periodically. The list is also on our
website.
It depends on the type of care you need. First, you and each family member
must choose a primary care physician. This decision is important since your
primary care physician
provides or arranges for most of your health care.
The name of the selected primary care physician will appear on your
identification card. You do have the right to change your
primary care
physician. Primary care physicians are listed in a primary care physician
section of our provider directory.
What you must do to get covered care
. Primary care Your primary care physician can be a Family
Practitioner, Internist, General Practitioner,
Obstetrician/ Gynecologist,
or Pediatrician. Your primary care physician will provide most of your health
care, or may give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
.
Specialty care Your primary care physician may refer you to a specialist
for needed care. However, you
may see a specialist without a referral.
Avera Health Plans 2002 8 Section 3 8
8 Page 9 10
Here are other things you should know about specialty
care:
. If you need to see a specialist frequently because of a chronic,
complex, or serious
medical condition, your primary care physician will work
with the specialist and with us to develop a treatment plan that allows you to
access specialty care. 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 may continue to
receive services under point-of-service (POS) benefits, but it will cost you
more.
. 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.
. 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 approved by us. Contact us, 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 may obtain approval to see your
specialist until the end of your postpartum care, even if it is beyond the
90 days.
. Hospital care Your Plan primary care physician or
specialist will make necessary hospital arrangements
and supervise your
care. This includes admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 605-322-4545 or 888-322-2115. 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.
Avera Health Plans 2002 9 Section 3 9
9 Page 10 11
Your primary care physician has authority to refer you
for most services. For certain services, however, your physician must obtain
approval from us. Before giving approval,
we consider if the service is
covered, medically necessary, and follows generally accepted medical practice.
We call this review and approval process precertification. Your physician
must obtain precertification for the following services:
Services requiring our prior approval
Chemotherapy Consideration of In Network Benefits for Out of Network Care
(except emergency and
urgent care) Coronary Angiography/ Catheterization
Dialysis Durable Medical Equipment (Purchase or Total Rental), over $200
Home Health Services Hospice Care
Hyperbaric Chamber Treatment
Infertility Studies
Inpatient Hospital Admissions Inpatient and Outpatient
Alcoholism & Chemical Dependency Treatment
Inpatient and Outpatient
Mental Health Services Lithotripsy
MRI/ MRA Non-Emergency Ambulance
Transport
Occupational Therapy Organ Transplants
Outpatient Surgeries/
Procedures not performed in the Physician's Office Penile Implant
PET scans
Physical Therapy
Prosthetic or Orthotic Devices, over $300 Radiation Therapy
Skilled Nursing Facility Admissions Sleep Studies
Speech Therapy Video
EEGs
The following services do not require precertification : CT Scans,
Cystoscopy, Doppler studies, ECG's/ Cardiac Stress tests/ Event Monitors, EEG's,
EMG's/ NVC's, Flexible
Sigmoidoscopy, Mammography, Nuclear Medicine Scans,
Pulmonary Function tests, Routine Lab and Xrays, and Ultrasounds.
Injections of the following drugs when given in a Physician's Office must be
precertified before administration of the drug:
Botulin Growth Hormone
Interferon Lupron
Betaserons
Under your point-of-service (POS)
benefit these services need to be precertified. The ultimate responsibility for
requesting precertification remains with you, however,
information provided
by your provider's office will also satisfy this requirement. If you require any
of the services listed above, you must contact Medical Management at
1-888-
605-1331 as soon as possible after the indication of need for
the services.
Avera Health Plans 2002 10 Section 3 10
10 Page 11 12
The AHP Medical Management Department will review the
Member profile information against standard criteria. A determination will be
made by the Medical Management
Department within forty-eight (48) hours of
the initial request or the next business day if the request is made on a weekend
or holiday. The determination shall either be an
authorization for the
requested service or additional review by the AHP Medical Director.
If the
determination is to authorize the requested service, you, the attending
provider, and those providers involved in the provision of the service shall be
notified of the decision in
writing. When the service is approved, the
Medical Management Department will assign an authorization number.
When the request requires a need for further review, an intensified review
will be performed by the AHP Medical Director. If additional documentation is
required, you,
your representative, and/ or the Provider shall be
responsible for submitting any necessary information. A determination either
authorizing or denying the request for services will
be made in writing. The
attending practitioner, those providers involved in the provision of the service
and you shall be notified of the decision.
If the decision is to deny the service, you and those providers who are
involved in the provision of the service shall be informed of the reasons for
the denial and AHP's appeal
procedures.
AHP will not deny coverage for
the health care services listed in this section which you have already received
solely on the basis of lack of precertification to the extent that the
health care services would otherwise have been covered had precertification
been obtained.
Service listed in this section that you obtain under the point-of-service
(out of network) are subject to precertification.
Avera Health Plans 2002 11 Section 3 11
11 Page 12 13
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
.
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy,
etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit and when you go in the hospital, you pay $250 per admission.
. Deductible A deductible is a fixed expense you must incur for
certain covered services and supplies
before we start paying benefits for
them. Copayments do not count toward any deductible.
. The calendar year deductible is $350 per person under our Plan. Under a
family enrollment, the deductible is considered satisfied and benefits are
payable for all
family members when the combined covered expenses applied to
the calendar year deductible for family members reach $700 under our Plan.
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.
And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your old
option to the
deductible of your new option.
. Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Coinsurance doesn't begin until you meet your
deductible.
Example: In our Plan, you pay 20% of our allowance for infertility services
and durable medical equipment for services received in network.
After your coinsurance totals $1,500 per person or $3,000 per family
enrollment in any calendar year, you do not have to pay any more for covered
services. However,
copayments for the following services do not count toward
your out-of-pocket maximum, and you must continue to pay copayments for these
services:
Your catastrophic protection out-of-pocket maximum for
coinsurance
. Physician office visits .
Preventive care examinations . Chiropractic
office visits
. Hospital services .
Skilled nursing facility services . Outpatient
mental health services
. Inpatient chemical dependency treatment .
Partial day chemical
dependency treatment . Prescription drugs
Avera Health Plans 2002 12 Section 4 12
12 Page 13 14
Section 5. Benefits – OVERVIEW
(See
page 59 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 (888) 322-2115 or
at our website at www. averahealthplans. com.
(a) Medical services and supplies provided by physicians and other health
care professionals……………………………………. 14-23
. 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.................................................. 24-27
.
Surgical procedures .
Reconstructive surgery . Oral and maxillofacial
surgery . Organ/ tissue transplants . Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services................................................................................
28-31
. Inpatient hospital .
Outpatient hospital or ambulatory surgical
center . Extended care benefits/ skilled nursing care facility benefits .
Hospice care . Ambulance
(d) Emergency services/
accidents...................................................................................................................................................
32-33 . Medical emergency . Ambulance
(e) Mental health and substance abuse
benefits
..............................................................................................................................
34-35
(f) Prescription drug benefits
..........................................................................................................................................................
36-38
(g) Special features
..............................................................................................................................................................................
39 . Employee assistance program
(h) Dental benefits
................................................................................................................................................................................
40
(i) Point of service benefits
...................................................................................................................................................................
41
Summary of benefits
.............................................................................................................................................................................
59
Avera Health Plans 2002 13 Section 5 13
13 Page 14 15
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.
. The calendar year deductible is $350 per person
and $700 per family for In Network Services. For Out of
Network Services the
calendar year deductible is $1,500 per person and $3,000 per family. The
calendar year deductible applies to almost all benefits in this Section.
. 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 Medicare.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible… NOTE: The
calendar year deductible applies to almost all benefits in this Section.
Diagnostic and treatment services Professional services of physicians
. In physician's office
In Network : $10 per visit to your primary care
physician
$35 per visit to a specialist
Out of Network: 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Professional services of physicians
. In an urgent care center
.
During a hospital stay
. In a skilled nursing facility
. Office medical
consultations
. Second surgical opinion
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference
between our allowable charge and the provider's actual
charge.
Avera Health Plans 2002 14 Section 5( a) 14
14 Page 15 16
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap
tests
. Pathology
. X-rays
. Non-routine Mammograms
. Cat Scans/
MRI
. Ultrasound
. Electrocardiogram and EEG
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference
between our allowable charge and the provider's actual
charge.
Preventive care, adult You Pay
Routine screenings, such as:
.
Total Blood Cholesterol
. Colorectal Cancer Screening, including:
.
Fecal occult blood test
. Sigmoidoscopy, screening— every 5 years starting
at age 50
Prostate Specific Antigen (PSA test) – one annually for men age 50
and older; age 45-49 annual if history of prostate cancer.
Routine Pap test
Note: The office visit is covered if pap test is
received on the same day; see Diagnosis and Treatment, above.
In Network: $10 Copay with PCP
Out of Network: All charges.
Routine mammogram –covered for women age 35 and older, as follows:
. From
age 35 through 39, one during this five year period
. From age 40 through
64, one every calendar year
. At age 65 and older, one every two consecutive
calendar years
In Network: Nothing
Out of Network: All Charges
Avera Health Plans 2002 15 Section 5( a) 15
15 Page 16 17
Preventive care, adult (continued) You Pay
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All Charges
Preventive care, children You Pay
. Childhood immunizations
recommended by the American Academy of
Pediatrics
In Network: Nothing
Out of Network: All charges
. Well-child care charges for routine
examinations, immunizations and
care (through age 18)
. Examinations, such as:
Eye exams to determine the need for vision
correction. Ear exams to determine the need for hearing correction
(through age 17) Examinations done on the day of immunizations (through age
18)
In Network: Nothing with PCP to age 6
$10 with PCP age 7 to 18 $35 with a
Specialist
Out of Network: All Charges
For Lab and X-ray: In Network:
20% after
deductible Out of Network:
All Charges
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 10 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).
In Network: Nothing
Out of Network: 40% after deductible plus any
difference
between our allowable charge and the provider's actual charge.
Avera Health Plans 2002 16 Section 5( a) 16
16 Page 17 18
Family planning You Pay
A broad range of
voluntary family planning services, limited to:
. Voluntary sterilization
. Surgically implanted contraceptives (such as Norplant)
. Injectable
contraceptive drugs (such as Depo provera)
. Intrauterine devices (IUDs)
. Diaphragms
NOTE: We cover oral contraceptives under the prescription
drug benefit.
In Network : $10 per visit to your primary care physician
$35 per visit
to a specialist
Out of Network: 40% after deductible plus any difference
between our
allowable charge and the provider's actual charge.
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
. Artificial insemination:
intravaginal
insemination (IVI)
intracervical insemination (ICI)
In Network : 20% after deductible
Out of Network: 40% after deductible
plus any difference between our
allowable charge and the provider's actual
charge.
Not covered:
. Assisted reproductive technology (ART)
procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT
and zygote ZIFT
Zygote transfer
. Services and supplies related
to excluded ART procedures
. Cost of donor sperm
. Cost of donor egg
.
Infertility services after voluntary sterilization
All charges
. .
. .
.
Avera Health Plans 2002 17 Section 5( a) 17
17 Page 18 19
Allergy care You Pay
Testing and treatment
Allergy Injection
In Network: 20% after deductible
Out of Network 40% after deductible plus any difference
between our
allowable charge and the provider's actual charge.
Allergy serum In Network: Nothing
Out of Network: 40% after deductible
plus any difference
between our allowable charge and the provider's actual
charge.
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 18
. 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.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference
between our allowable charge and the provider's actual
charge.
Not covered:
. Chelation Therapy All Charges
Avera Health Plans 2002 18 Section 5( a) 18
18 Page 19 20
Physical and occupational therapies You pay
Up to 2 consecutive months per condition for physical and occupational
therapy
Phase II.
Note: These services all require precertification
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Not covered:
. Long term rehabilitative therapy
.
Lifestyle improvement services such as physical fitness programs, health
or weight loss clubs or clinics.
All charges
Speech Therapy You Pay
Up to 2 consecutive months per condition.
In Network: 20% after deductible
Out of Network : 40% after deductible plus any difference between
our
allowable charge and the provider's actual charge.
Avera Health Plans 2002 19 Section 5( a) 19
19 Page 20 21
Hearing services (testing, treatment, and supplies)
You pay
. Hearing testing for children through age 17 (see Preventive
care,
children)
In Network: $35 Copay
Out of Network: All charges
Not covered:
. All other hearing tests
. Hearing
aids, testing and examination for them
All charges
Vision services (testing, treatment, and supplies) You pay
One
complete exam per Calendar Year for eyeglasses (spectacles) or up to the
spectacle exam amount for a contact lens exam. In Network Nothing
Out of
Network All Charges
Vision Services for aphakia patients and for treatment of a disease or
injury, limited to services for the prescribing and fitting of eyeglasses or
contact lenses
for aphakia patients or soft contact lenses or scleral shells
intended for use in the treatment of a eye disease or injury (one pair per
calendar year).
In Network: 20% after deductible
Out of Network 40% after deductible plus any difference between
our
allowable charge and the provider's actual charge
Not Covered:
. Examination, purchase, or fitting of Eyeglasses
or Contact Lenses, except
as specifically covered elsewhere. . Radial
Keratotomy and other refractive surgery.
. Eye exercises and orthoptics
All Charges
Foot care You pay
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.
In Network: $35 copay
Out of Network 40% after deductible plus any
difference
between our allowable charge and the provider's actual charge.
Podiatry Services In Network: 20% after deductible
Out of Network 40%
after deductible plus any difference
between our allowable charge and the
provider's actual charge.
Avera Health Plans 2002 20 Section 5( a) 20
20 Page 21 22
Foot care (continued) You pay
Not
covered:
. Cutting, trimming or removal of corns, calluses, or the
free edge of
toenails, and similar routine treatment of conditions of the
foot, except as stated above
. Treatment of weak, strained or flat feet or bunions or spurs; and of any
instability, imbalance or subluxation of the foot (unless the treatment is
by open cutting surgery)
All Charges
Orthopedic and prosthetic devices You pay . Artificial limbs and eyes;
stump hose
. Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
. Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: We pay internal prosthetic devices as hospital
benefits; see Section 5( c) for payment information. See 5( b) for coverage
of the surgery to insert the device.
. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Not covered:
. orthopedic and corrective shoes
.
arch supports
. foot orthotics
. heel pads and heel
cups
. lumbosacral supports
. corsets, trusses, elastic
stockings, support hose, and other supportive
devices
. prosthetic replacements provided more frequently than the product's
useful life as stated by the manufacturer
All charges
Avera Health Plans 2002 21 Section 5( a) 21
21 Page 22 23
Durable medical equipment (DME) You pay
Durable Medical Equipment includes, but is not limited to: . crutches
. walkers .
wheelchairs . nebulizers
Note: AHP reserves the option to rent or purchase Durable Medical Equipment,
and the option to select appropriate new, used or refurbished
Durable
Medical Equipment. Rental costs shall not exceed the allowable charge for
Durable Medical Equipment purchase. Covered services include
replacement and
repairs when medically necessary and appropriate, but does not include
replacement due to damage or loss. Coverage for wheelchairs are
limited to
the cost of one standard, manual wheelchair. Coverage for oxygen units are
limited to one stationary and one portable unit depending on medical
necessity.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Not covered: benefits for motorized equipment or standard, commonly
available batteries for durable medical equipment. All charges
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
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Out of Network services are limited to 60 visits per calendar year.
Not covered:
. Nursing care requested by or for the convenience
of the patient or
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
Avera Health Plans 2002 22 Section 5( a) 22
22 Page 23 24
Chiropractic You Pay
Chiropractic Services
from a doctor of chiropractic who deals with the relationship of the nervous
system and the spinal column in the restoration and
maintenance of health.
Note: Services are limited to 20 visits per
calendar year.
In Network: $35 Copay
Out of Network: All charges
Alternative treatments You Pay
No benefit. All charges
Educational classes and programs You Pay Diabetic Education, Supplies
and Equipment
. Equipment, supplies, and self-management training and education, including
medical nutrition therapy, for treatment of persons diagnosed with diabetes
if prescribed by a physician or other licensed health care provider legally
authorized to prescribe such treatment.
Diabetes self-management training and education shall be covered if the
service is provided by a physician, nurse, dietitian, pharmacist, or other
licensed health care provider who satisfies the current academic eligibility
requirements of the National Certification Board for Diabetic Educators and
has completed a course in diabetes education and training or has been
certified as a diabetes educator.
Coverage of diabetes self-management training is limited to (a) persons who
are newly diagnosed with diabetes or have received no prior diabetes
education; (b) persons who require a change in current therapy; (c) persons
who have a co-morbid condition such as heart disease or renal failure; or (d)
persons whose diabetes condition is unstable. Under these circumstances, no
more than two comprehensive education programs per lifetime and up to
eight
follow-up visits per year need be covered.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Smoking Cessation
. Prescription drugs including oral and topical
medications
Note: Smoking cessation drug products are limited to $300 per
lifetime.
. Smoking Cessation Programs
Note: One smoking cessation program approved
by AHP will be covered per lifetime of the contract, and limited to $200.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Avera Health Plans 2002 23 Section 5( a) 23
23 Page 24 25
Section 5 (b). Surgical and anesthesia services
provided by physicians And other health care professionals
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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.
. The calendar year deductible is $350 per person and $700 per family for In
Network Services. For Out of Network
Services the calendar year deductible
is $1,500 per person and $3,000 per family. The calendar year deductible applies
to almost all benefits in this Section.
. 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 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.
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Benefit Description You pay After the calendar year deductible…
NOTE:
The calendar year deductible applies to almost all benefits in this Section.
Surgical procedures You Pay 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.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
. 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.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Avera Health Plans 2002 24 Section 5( b) 24
24 Page 25 26
Surgical procedures You Pay Not covered:
. Cosmetic surgery and other supplies and services for conditions
that are
not the result of disease, injury, trauma, congenital, or
developmental abnormalities, which are meant to improve appearances, including
but not limited to breast augmentation or reduction, rhinoplasty,
liposuction, and cosmetic dental services.
. Sexual reassignment.
. Elective Termination of pregnancy.
All charges
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.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference
between our allowable charge and the provider's actual
charge.
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
Avera Health Plans 2002 25 Section 5( b) 25
25 Page 26 27
Oral and maxillofacial surgery You Pay
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.
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Not covered:
. Mouth conditions due to periodontal or
periapical disease, or the teeth, their surrounding tissue or structure, the
alveolar process, or the gingival tissue
unless the service is for the treatment or removal of tumors not
incidental to the fitting or continued use of dentures
. Services and Supplies related to Ridge Augmentation, Implantology, and
Preventive Vestivuloplasty
. Dental Services, not specifically listed
as Covered Services, including dental x-rays, shortening of the mandible or
maxillae for cosmetic purposes
All charges
Organ/ tissue transplants You pay
Limited to: .
Cornea
.
Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
.
Lung: Single –Double
. Pancreas
. Allogenic (donor) bone marrow
transplants
. Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast
cancer; multiple myeloma; epithelial
ovarian cancer; and testicular,
mediastinal, retroperitoneal and ovarian germ cell tumors
. Intestinal
transplants (small intestine) and the small intestine with the
liver or
small intestine with multiple organs such as the liver, stomach, and pancreas.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
In Network: 20% after deductible
Out of Network All charges
Avera Health Plans 2002 26 Section 5( b) 26
26 Page 27 28
Organ/ tissue transplants (continued) You pay
Medical expenses for the testing to identify a suitable donor, surgical
extraction, storage and transportation costs incurred that are directly
related to the donation of the organ used in an organ transplant
procedure. The
maximum benefit payable for organ procurement shall not
exceed $20,000 for each covered organ transplant procedure that is not covered
by any other group
health plan or coverage arrangement.
In Network:
20% after deductible
Out of Network
All charges
Necessary and reasonable transportation, lodging and meal expenses are
covered benefits subject to all of the following conditions:
. Expenses will
be a covered benefit if incurred for the confinement period
during which the
transplant occurs and the immediate inpatient post operative care period,
including expenses incurred for travel to the site of the
covered transplant procedure. . Meal and Lodging expenses will be a covered
benefit during the transplant
confinement period and immediate
post-operative care period up to a combined daily maximum of $150 for the
recipient, attendant, and if a bone
marrow transplant procedure, the bone
marrow transplant donor. . In no event shall the total of the necessary and
reasonable expenses exceed
$10,000 for each transplant procedure. . Coverage
for transportation, lodging and meal expenses are per transplant
procedure
and are not an annual benefit. . Expense reimbursement is available only while
the Organ Transplant
Recipient is covered by AHP.
All charges in excess of $150 per day and in excess of $10,000 transplant
limit.
Not covered: . Donor screening tests and donor search expenses,
except those
performed for the actual donor . Implants of artificial
organs
. Transplants not listed as covered .
Expenses
related to transplants of animal organs.
All charges
Anesthesia You pay
Professional services provided in –
.
Hospital (inpatient)
In Network: 20% after deductible
Out of Network 40% after deductible plus any difference between
our
allowable charge and the provider's actual charge.
Professional services provided in –
. Hospital outpatient department
. Skilled nursing facility .
Ambulatory surgical center . Office
In Network: 20% after deductible
Out of Network 40% after deductible plus
any difference between
our allowable charge and the provider's actual
charge.
Avera Health Plans 2002 27 Section 5( b) 27
27 Page 28 29
Section 5 (c). Services provided by a hospital or
other facility, and ambulance services
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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. . Unlike Sections (a) and (b), in this section the
calendar year deductible applies to only a few benefits. In that case we
added "calendar year deductible applies". The calendar year deductible is
$350 per person and $700 per family for In Network Services. For Out of Network
Services the calendar year deductible is $1,500 per person and $3,000 per
Family. The calendar year deductible applies to almost all benefits in this
Section. . 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.
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Benefit Description You pay
NOTE: The calendar year deductible applies
to some benefits in this Section.
Inpatient hospital You Pay
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.
In Network $250 Copay
Out of Network 40% after deductible plus any
difference between
our allowable charge and the provider's actual charge.
Avera Health Plans 2002 28 Section 5( c) 28
28 Page 29 30
Inpatient hospital (continued) You Pay
Other hospital services and supplies, such as: . Operating, recovery,
maternity, and other treatment rooms
. Prescribed drugs and medicines .
Diagnostic laboratory tests and X-rays
. Administration of blood and blood products
. Blood or blood plasma, if not donated or replaced .
Dressings, splints,
casts, and sterile tray services . Medical supplies and equipment, including
oxygen
. Anesthetics, including nurse anesthetist services .
Take-home items .
Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home (Note: calendar year deductible
applies.)
.
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.
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.
Calendar year deductible applies In Network
20% after deductible
Out of Network 40% after deductible plus any difference between
our
allowable charge and the provider's actual charge.
Blood and Blood Products. The administration of whole blood and blood plasma
is a Covered Service. The purchase of whole blood and blood
components is
not covered unless such blood components are classified as drugs in the
United States Pharmacopoeia.
Nothing
Avera Health Plans 2002 29 Section 5( c) 29
29 Page 30 31
Extended care benefits/ skilled nursing care
facility benefits You Pay Must be approved by AHP in lieu of continued or
anticipated hospitalization.
The following services are covered:
.
Skilled nursing care, whether provided in an inpatient skilled nursing unit, a
skilled nursing facility, or in a home health care program. . Room and board
in a skilled nursing facility.
. Special diets in a skilled nursing facility, if specifically ordered. .
100 days per calendar year.
In Network
$250 copay
Out of Network
40% after deductible plus
any difference between our allowable charge and the
provider's actual charge.
Not covered: Confinement in a nursing home for custodial, convalescent,
intermediate level, or domiciliary care, rest cures or care, or services to
assist in activities of daily living.
All Charges
Hospice care You Pay Coverage is provided when:
. the member
elects hospice care instead of traditional covered services;
. the member
has been diagnosed with a terminal disease and a life
expectancy of six
months or less; and
. hospice has been approved by AHP.
The following services are covered:
. Admission to a hospice facility, hospital, skilled nursing care facility
for
room and board, supplies and services for pain management and other
acute/ chronic symptom management.
. Part-time or intermittent nursing care by a Registered Nurse (RN),
Licensed Practical Nurse/ Licensed Vocational Nurse (LPN/ LVN), or home
health aide for patient care up to 8 hours per day.
. Social services under the direction of a participating provider.
.
Psychological and dietary counseling.
Note: Hospice care may be provided as
inpatient or outpatient services with a combined benefit limit of 185 days.
Calendar year deductible applies In Network:
20% after deductible
Out
of Network 40% after deductible plus any difference between
our allowable
charge and the provider's actual charge.
Avera Health Plans 2002 30 Section 5( c) 30
30 Page 31 32
Ambulance You Pay
. Local professional
ambulance service when medically appropriate Calendar year deductible applies
In Network:
20% after deductible
Out of Network
20% after
deductible
Not covered: . Non-Emergency Travel, unless approved
and arranged by AHP All charges
Avera Health Plans 2002 31 Section 5( c) 31
31 Page 32 33
Section 5 (d). Emergency services/ accidents
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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.
. The calendar year deductible is $350 per
person and $700 per family for In Network Services. For Out of Network Services
the calendar year deductible is $1,500 per person and $3,000 per family. The
calendar year deductible applies to almost all benefits in this Section.
. 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.
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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical care. Some problems
are emergencies because, if
not treated promptly, they might become more serious; examples include deep
cuts and broken bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to
breathe. There are many other acute conditions that we
may determine are medical emergencies – what they all have in common is the need
for quick action.
What to do in case of emergency:
Emergencies within our service area:
If an emergency condition arises, members should proceed to the nearest
emergency facility. If the emergency condition is such that a member cannot go
safely to the nearest participating emergency facility, then
the member
should seek care at the nearest emergency facility. An urgent care situation is
a degree of illness or injury which is less severe than an emergency condition,
but requires prompt medical attention within twenty-four (24) hours. If an
urgent care
situation occurs, members should contact their primary care
provider immediately and follow the primary care provider's instructions.
Emergencies outside our service area: If an emergency occurs when
traveling outside of AHP's service area, members should go to the nearest
emergency facility to receive care. The member or a designated relative or
friend must notify AHP and the
member's primary care provider as soon as
reasonably possible, and no later than 48 hours after physically or mentally
able to do so. In-Network coverage will be provided for emergency conditions
outside of the service area unless the member has
traveled outside the
service area for the purpose of receiving such treatment.
Benefit Description You pay
Emergency within our service area You pay
. Emergency care at a doctor's office
. Emergency care at an urgent care center
. Emergency care as an
outpatient or inpatient at a hospital, including
doctors' services
20% after deductible
Avera Health Plans 2002 32 Section 5( d) 32
32 Page 33 34
Emergency outside our service area You Pay
. Emergency care at a doctor's office .
Emergency care at an urgent
care center . Emergency care as an outpatient or inpatient at a hospital,
including
doctors' services
20% after deductible
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
All charges.
Ambulance You Pay
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
In Network: 20% after deductible
Out of Network 20% after deductible
Not covered: non-emergency travel,
unless approved and arranged by AHP All charges
Avera Health Plans 2002 33 Section 5( d) 33
33 Page 34 35
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.
. The calendar year deductible or, for facility care, the
inpatient deductible apply to almost all benefits in this Section. We
added
"No Deductible" to show when a deductible does not apply. . The calendar year
deductible is $350 per person and $700 per family for In Network Services. For
Out of Network Services
the calendar year deductible is $1,500 per person and $3,000 per family. The
calendar year deductible applies to almost all benefits in this Section.
.
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 After the calendar year deductible…
Mental
health and substance abuse benefits You Pay
All diagnostic and treatment
services recommended by a Plan provider and contained in a treatment plan that
we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
. Inpatient Mental Health Services from a licensed or certified provider are
provided as described under Inpatient Hospital Benefits in Section C. In
Network: $250 copay, No deductible
Out of Network 40% after deductible plus any difference between
our
allowable charge and the provider's actual charge.
. Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers. .
Medication management
In Network: $35 copay. No deductible
Out of Network 40% after deductible plus any difference between
our
allowable charge and the provider's actual charge.
Avera Health Plans 2002 34 Section 5( f) 34
34 Page 35 36
Mental health and substance abuse benefits
(continued) You Pay . Diagnostic tests In Network:
$20% after deductible
Out of Network 40% after deductible plus any difference between
our
allowable charge and the provider's actual charge.
. Services provided by a hospital or other facility .
Services in
approved alternative care setting such as partial hospitalization, half-way
house, residential treatment, full-day hospitalization, facility
based intensive outpatient treatment.
In Network: $250 Copay, No deductible
Out of Network 40% after deductible
plus any difference between
our allowable charge and the provider's actual
charge.
Chemical Dependency Outpatient Treatment from a licensed or certified
provider. In Network: 20% after deductible
Out of Network 40% after
deductible plus any difference between
our allowable charge and the
provider's actual charge.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all the authorization processes found on
pages 10 and 11.
Avera Health Plans 2002 35 Section 5( f) 35
35 Page 36 37
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 charge beginning
on the next page.
. All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
. 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.
. The calendar year deductible does not apply to benefits in this section.
. Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works.
Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you
should be aware of. These include:
. Who can write your prescription?
A licensed physician must write the prescription.
. Where can you
obtain prescribed drugs? You must fill the prescription at a plan pharmacy
or by mail for a
maintenance medication. . We use a formulary. We
cover nonformulary drugs prescribed by a Plan doctor. If your physician
believes a name brand product is necessary or there is no generic available,
your physician may prescribe a name brand drug from a formulary list. This list
of name brand drugs is a preferred list of drugs that we
selected to meet
patient needs at a lower cost. To order a prescription drug brochure, call (888)
322-2115. . These are the dispensing limitations. Prescription drugs are
dispensed in a 30-day supply, or less, if less is
needed. A 90-day supply of
maintenance drugs may be obtained through mail order. 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, you have to pay the higher copay for the brand name
drug.
. Why use generic drugs? Generic drugs offer a safe and
economic way to meet your prescription drug needs.
The generic name of a
drug is its chemical name; the name brand is the name under which the
manufacturer advertises and sells a drug. Under federal law, generic and name
brand drugs must meet the same standards
for safety, purity, strength, and effectiveness. A generic prescription costs
you – and us – less than a name brand prescription.
. When you have to
file a claim. Read section 7 regarding the procedure for filing a pharmacy
claim.
Avera Health Plans 2002 36 Section 5( f) 36
36 Page 37 38
Covered medications and supplies You Pay We
cover the following medications and supplies prescribed by a
Plan physician
and obtained from a Plan pharmacy or through our mail order program:
. Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those listed as Not
covered.
. Drugs for sexual dysfunction
Note: Quantity limitations may apply. .
Contraceptive drugs and devices (IUDs and implantable birth control
devices, e. g., Norplant and Depro-Provera)
In Network: (30 day supply) Generic $10 Copay
Formulary/ Preferred $20
Copay Non-Formulary $35 Copay
In Network: (90 day supply-mail order) Generic $20 Copay
Formulary/
Preferred $40 Copay Non-Formulary $70 Copay
Out of Network All Charges
Diabetic supplies and insulin
. A 30-day supply of diabetic needles,
syringes, wipes, strips, and pump
supplies; and . Either a 30-day supply or
one 10-ml bottle, whichever is greater,
of injectable insulin.
Note: Each of the following shall constitute a
separate prescription "supply" for copay purposes, and together they constitute
the maximum amount of
diabetic treatment that may be dispensed at any one
time:
In Network: (30 day supply) Generic $10 Copay
Formulary/ Preferred $20
Copay Non-Formulary $35 Copay
In Network: (90 day supply-mail order) Generic $20 Copay
Formulary/
Preferred $40 Copay Non-Formulary $70 Copay
Out of Network All Charges
Avera Health Plans 2002 37 Section 5( f) 37
37 Page 38 39
Covered medications and supplies (continued) You
Pay Birth Control Drugs and Devices including, but not limited to:
.
IUDS
. Implantable birth control devices, e. g., Norplant and Depo-Provera
In Network: (30 day supply) Generic $10 Copay
Formulary/ Preferred $20
Copay Non-Formulary $35 Copay
In Network: (90 day supply-mail order) Generic $20 Copay
Formulary/
Preferred $40 Copay Non-Formulary $70 Copay
Out of Network All Charges
Not covered:
. Drugs and supplies for cosmetic purposes
. Drugs to enhance athletic performance
. Fertility drugs
. Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
. Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
. Nonprescription medicines
All charges
Avera Health Plans 2002 38 Section 5( f) 38
38 Page 39 40
Section 5 (g) Special Features
Feature
Description
Employee Assistance Program Employee Assistance Program for individual
and family problems that have a negative impact upon personal or work life.
Benefits include up to three counseling sessions with a behavioral health
professional per contract year, access to behavioral health professionals with a
wide range
of expertise in family, couples, individual, and substance abuse
related services, and access to toll-free Referral Service line 24 hours/ 7days
a week.
Avera Health Plans 2002 39 Section 5( g) 39
39 Page 40 41
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. . The calendar year deductible is $350
per person and $700 per family for In Network Services. For Out
of Network Services the calendar year deductible is $1,500 per person and
$3,000 per family. The calendar year deductible applies to almost all benefits
in this Section.
. We cover hospitalization for dental procedures only when a nondental
physical impairment exisits which makes
hospitalization necessary to
safeguard the health of the patient; we do not cover the dental procedure unless
it is described below.
. Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works.
Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair (but not replace) sound natural teeth.
The need for these services must
result from an accidental injury.
In Network:
$35 per visit to a
specialist 20% after deductible for other covered
services
Out of Network: 40% after deductible plus any difference
between our allowable charge and the provider's actual charge.
Dental benefits
We have no other dental benefits.
Avera Health Plans 2002 40 Section 5( h) 40
40 Page 41 42
Section 5 (i). Point of service benefits
Point of Service (POS) Benefits
Facts about this Plan's POS option
At your option you may choose to obtain benefits covered by this Plan from
non-Plan doctors and hospitals whenever you need care,
except for the
benefits listed below under "What is not covered." Benefits not covered under
Point of Service must either be received from or arranged by Plan doctors to be
covered. When you obtain covered non-emergency medical treatment from a non-Plan
doctor
without a referral from a Plan doctor, you are subject to the
deductibles, coinsurance and maximum benefit stated below.
What is covered
Most of the covered services described in Section 5 allow you to choose a
non-participating provider, except those listed in "What is
not covered".
When you choose non-participating providers, covered services provided by those
providers are covered at the "out of network" level as described in Section 5.
All covered services provided by participating or in-network providers are
covered at the in-network
benefit level.
Services do not need to be
obtained within the Plan service area to be eligible for coverage under POS.
Precertification Services received out-of-network are subject to the same
precertification or prior approval requirements as described in Section 3.
You do not need to obtain a referral from a Plan doctor prior to seeking a
non-Plan doctor, but you or the non-plan doctor must obtain prior approval
before receiving any of the procedures listed in Section 3 as requiring prior
approval. Failure to obtain prior approval
may result in benefits being
denied, however, we will not deny coverage solely on the basis of lack of
precertification to the extent that the health care services would have been
covered had precertification been obtained.
Deductible The Plan deductible for Point of Service benefits is $1,500 for an
individual and $3,000 for a family.
Coinsurance The coinsurance requirement
for covered Point of Service benefits is 40% of the Plan's allowable charge to
be paid by you, and 60%
to be paid by the Plan, after the deductible. You
will also be responsible for any difference between our allowable charge and the
non-participating provider's actual charge.
Maximum benefit The catastrophic maximums you will have to pay for Point of
Service care is $10,000 for an individual or a family. Out of pocket
expenses under POS do not qualify for the Plan's in-network catastrophic
maximum.
Hospital/ extended care When you use a non-participating hospital
it is an out of network service, however, if you use a participating hospital
you will receive
in network benefits even if non-plan doctors are being
used.
Emergency benefits True emergency care is always payable as an in-Plan
benefit.
What is not covered The following covered services do not have Point of
Service coverage:
. Adult Preventive Care .
Children Preventive Care .
Vision Examination for eyeglasses or contact lenses
. Chiropractic Services .
Organ/ Tissue Transplants . Prescription Drugs
Avera Health Plans 2002 41 Section 5( i) 41
41 Page 42 43
How to obtain benefits You may access covered Point of
Service benefits directly. You may also contact us and ask us to consider
In-Network benefits for
out of network services that are medically necessary
and not available within the Plan's network by calling Medical Management at
1-888-605-1331.
Avera Health Plans 2002 42 Section 5( i) 42
42 Page 43 44
Section 6. General exclusions --things we don't
cover
The exclusions in this section apply to all benefits. Although
we may list a specific service as a benefit, we will not cover it unless your
Plan doctor determines it is medically necessary to prevent, diagnose, or treat
your illness, disease, injury,
or condition.
We do not cover the
following:
. Care by non-Plan providers except for authorized referrals or
emergencies (see Emergency Benefits);
. Services, drugs, or supplies you
receive while you are not enrolled in this Plan;
. Services, drugs, or
supplies that are not medically necessary;
. Services, drugs, or supplies
not required according to accepted standards of medical, dental, or psychiatric
practice;
. Experimental or investigational procedures, treatments, drugs or
devices;
. Services, drugs, or supplies related to abortions, except when
the life of the mother would be endangered if the fetus
were carried to term
or when the pregnancy is the result of an act of rape or incest;
. Services, drugs, or supplies related to sex transformations; or
.
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program.
Avera Health Plans 2002 43 Section 6 43
43 Page 44 45
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical 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 and also to get a copy of the claim form, call us at
(888) 322-2115.
When you must file a claim --such as for out-of-area care --submit it on a
HCFA-1500 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: Avera Health Plans 3900 West Avera Drive, Suite 200
Sioux Falls, SD 57108-5721
Prescription drugs Network pharmacies will usually submit your claims
electronically for you. If you need to submit a claim on your own, contact
Customer Service at (888) 322-2115 to obtain a
claim form.
When you file
a claim form, you must include a receipt from the pharmacy showing the
following:
. Name of the drug;
. Amount Dispensed;
. Price you paid for the
drug.
Submit your claims to: Avera Health Plans 3900 West Avera Drive,
Suite 200
Sioux Falls, SD 57108-5721
Avera Health Plans 2002 44 Section 7 44
44 Page 45 46
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.
Avera Health Plans 2002 45 Section 7 45
45 Page 46 47
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for services,
drugs, or supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: Avera Health Plans Attn:
Appeals Coordinator
3900 West Avera Drive, Suite 200 Sioux Falls, SD
57108-5721
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
. 90 days after the date of our letter
upholding our initial decision; or
. 120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
. 120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 2, 1900 E Street, NW, Washington, DC 20415-3620.
Avera Health Plans 2002 46 Section 8 46
46 Page 47 48
The Disputed Claims process (Continued)
Send OPM the following information:
. A statement about why you
believe our decision was wrong, based on specific benefit provisions in this
brochure;
. Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and
explanation of
benefits (EOB) forms;
. Copies of all letters you sent to us about the claim;
. Copies of all
letters we sent to you about the claim; and
. Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific
written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision,
your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in
which you received the disputed services, drugs, or supplies or from the year in
which you were denied 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 (888) 605-1331 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 2 at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time.
Avera Health Plans 2002 47 Section 8 47
47 Page 48 49
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.
. The Original Medicare Plan
(Part A or Part B)
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. This
includes following procedures
for precertifying procedures and treatments.
(Primary payer chart begins on next page.)
Avera Health Plans 2002 48 Section 9 48
48 Page 49 50
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 anactiveemployeewith
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you..)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are
unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare.
Avera Health Plans 2002 49 Section 9 49
49 Page 50 51
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 (888) 322-2115.
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, coinsurance,
or deductibles for your FEHB coverage.
This Plan and another plan's
Medicare managed care plan: You may enroll in another plan's Medicare
managed care plan and also remain enrolled in our FEHB plan.
We will still
provide benefits when your Medicare managed care plan is primary, even out of
the managed care plan's network and/ or service area (if you use our Plan
providers), but we will not waive any of our copayments, coinsurance, or
deductibles. If you enroll in a Medicare managed care plan, tell us. We will
need to know whether you
are in the Original Medicare Plan or in a Medicare
managed care plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your Medicare managed care plan premium.) For information
on suspending your FEHB
enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare Part B
and, if you can't
get premium-free Part A, we will not ask you to enroll in
it.
. If you do not enroll in
Medicare Part A or Part B
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.
Avera Health Plans 2002 50 Section 9 50
50 Page 51 52
Workers' Compensation We do not cover services
that:
. you need because of a workplace-related illness or injury that the
Office of Workers'
Compensation Programs (OWCP) or a similar Federal or
State agency determines they must provide; or
. OWCP or a similar agency pays for through a third party injury settlement
or other
similar proceeding that is based on a claim you filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries for injuries or illness 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.
Avera Health Plans 2002 51 Section 9 51
51 Page 52 53
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 pg. 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See pg. 12.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Patient care that is not medically required but is necessary when the
patient is unable to perform self-care. Custodial care may involve medical or
non-medical services that do
not seek to cure, but are provided during
periods when the patient's medical condition is not changing. Custodial care
services such as assistance in the activities of daily living,
normally do
not require ongoing administration by medical personnel.
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 pg. 12.
Durable Medical Equipment Equipment prescribed by an attending
physician which is medically necessary, not primarily and customarily used for
non-medical purposes, designed for prolonged use,
and for a specific
therapeutic purpose in the treatment of an illness or injury.
Experimental or Any health care service which: Investigational
services . is not recognized in accordance with generally accepted medical
standards as being
safe and effective for treatment of the condition in
question, regardless of whether the service is authorized by law or used in
testing or other studies; or
. requires approval by any governmental
authority and such approval has not been
granted prior to the service being
performed.
Medical necessity Covered health care services required to preserve
and maintain your health status in accordance with the accepted standards of
medical practice in the medical community in
the area where services are
rendered. Services or treatments are considered Medically Necessary and
appropriate if they could not have been omitted without adversely
affecting
the patient's condition or the quality of medical care provided. Medically
necessary care must:
. be consistent with generally accepted practice
parameters as determined by health care
providers in the same or similar
general specialty as typically manages the condition, procedure, or treatment at
issue; and
. help restore or maintain the patient's health; or .
prevent
deterioration of the patient's condition; or . prevent the reasonably likely
onset of a health problem or detect a problem in the
beginning stages.
Plan allowance Plan Allowance means the amount that we use to
determine our payment and your coinsurance (if applicable) for covered services.
All covered services are subject to this
Plan Allowance definition. An
expense or service or a portion of an expense or service that is not covered by
us is not an allowable charge. Our participating providers accept
the plan
allowance as payment in full for covered services.
Avera Health Plans 2002 52 Section 10 52
52 Page 53 54
Us/ We Us and we refer to Avera Health Plans.
You You refers to the enrollee and each covered family member.
Avera Health Plans 2002 53 Section 10 53
53 Page 54 55
Section 11. FEHB facts
No pre-existing
condition We will not refuse to cover the treatment of a condition that you
had before you
limitation 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 about enrolling in the retirement office can answer your
questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
. When you may change your enrollment;
. How you can cover your family
members;
. What happens when you transfer to another Federal agency, go on
leave without pay,
enter military service, or retire;
. When your enrollment ends; and
. When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22, including any
foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a disabled
child 22 years
of age or older who is incapable of self-support.
If you
have a Self Only enrollment, you may change to a Self and Family enrollment if
you marry, give birth, or add a child to your family. You may
change your
enrollment 31 days before to 60 days after that event. The Self and Family
enrollment begins on the first day of the pay period in which the child is
born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective on the first day of the pay
period that begins after your employing office receives your enrollment
form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us
immediately when you add or remove family members from your coverage
for any reason, including divorce, or when your child under age 22 marries or
turns
22.
If you or one of your family members is enrolled in one FEHB
plan, that person may not be enrolled in or covered as a family member by
another FEHB plan.
When benefits and The benefits in this brochure are effective on
January 1. If you joined this Plan premiums start during Open Season,
your coverage begins on the first day of your first pay
period that starts
on or after January 1. Annuitants' coverage and premiums begin on January 1. If
you joined at any other time during the year, your
employing office will
tell you the effective date of coverage.
Avera Health Plans 2002 54 Long Term Care Insurance 54
54 Page 55 56
Your medical and claims We will keep your
medical and claims information confidential. Only records are confidential
the following will have access to it:
. OPM, this Plan, and
subcontractors when they administer this contract;
. This Plan and
appropriate third parties, such as other insurance plans and the Office of
Workers' Compensation Programs (OWCP), when coordinating benefit payments
and subrogating claims;
. Law enforcement officials when investigating and/ or prosecuting alleged
civil
or criminal actions;
. OPM and the General Accounting Office when conducting audits;
.
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
. OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
. When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
. Your enrollment ends, unless you cancel your enrollment, or
. You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
. Spouse
equity If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get benefits under your former spouse's
enrollment. But, you may be eligible for your own FEHB coverage under the spouse
equity law. If you are
recently divorced or are anticipating a divorce, contact your ex-spouse's
employing or retirement office to get RI 70-5, the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former
Spouse Enrollees, or other information about your coverage choices.
. Temporary continuation of If you leave Federal service, or if you
lose coverage because you no longer qualify as a
of coverage (TCC)
family member, you may be eligible for Temporary Continuation of Coverage
(TCC). For example, you can receive TCC if you are not able to continue your
FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child
and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage
and Former Spouse Enrollees, from
your employing or retirement office or from www. opm. gov/ insure. It explains
what you have to do to enroll.
. Converting to You may convert to a non-FEHB individual policy if:
individual coverage
. Your coverage under TCC or the spouse
equity law ends (if you canceled your coverage or did not pay your premium, you
cannot convert);
. You decided not to receive coverage under TCC or the spouse equity law; or
Avera Health Plans 2002 55 Long Term Care Insurance 55
55 Page 56 57
. 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.
Getting a Certificate of Group Health Plan
Coverage
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 question. These highlight
HIPAA rules, such as the requirement that Federal
employees must exhaust
any TCC eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about
Federal and State agencies
you can contact for more information.
Avera Health Plans 2002 56 Long Term Care Insurance 56
56 Page 57 58
Long Term Care Insurance Is Coming Later in 2002!
. Many FEHB
enrollees think that their health plan and/ or Medicare will cover their
long-term care needs. Unfortunately, they are WRONG!
. How are YOU
planning to pay for the future custodial or chronic care you may need? .
You
should consider buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
. 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. What is long term care (LTC)
insurance?
. 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! I'm
healthy. I won't need
long term care. Or, will I? . 76% of Americans
believe they will never need long term care, but the facts are that about half
ofthem 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 planing.
. 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! Is long term care expensive?
. 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.
But won't my FEHB plan, Medicare or Medicaid cover
my long term care?
. Medicare only covers skilled nursing home care (the highest level of
nursing
care) after a hospitalization for those who are blind, age 65 or
older or fully disabled. It also has a 100 day limit.
. Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide choices of care and preserve
your independence. When will I get more information on how to apply
for this new
insurance coverage? . 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.
How can I find out more about the program NOW? 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.
.
Avera Health Plans 2002 57 Long Term Care Insurance 57
57 Page 58 59
Index Do not rely on this page; it is for your
convenience and may not show all pages where the terms appear.
Allergy
tests 18 Alternative treatment 23
Allogenec (donor) bone marrow
transplant 26 Ambulance 31,33
Anesthesia 27 Autologous bone marrow
transplant 26
Blood and blood plasma 29 Catastrophic
protection 42,60
Chemotherapy 18 Chiropractic 23
Claims 44
Coinsurance 52
Congenital defects 24,25 Coordination of benefits 48
Covered services 52 Crutches 22
Custodial Care 52 Deductible 12,
52
Definitions 52 Diabetes 23
Diagnostic services 15 Disputed claims
review 46
Donor expenses (transplants) 27 Durable medical equipment (DME)
22, 52
Educational classes and programs 23 Emergency 32
Experimental or investigational 43, 52 Eyeglasses 20
Family
planning 17 General Exclusions 43
Hearing services 16, 20 Home health services 22
Hospice care 30
Hospital 28
Immunizations 16 Infertility 17
Inhospital physician
care 14 Inpatient Hospital Benefits 28
Insulin 23, 37 Laboratory and
pathological
services 29 Magnetic Resonance Imagings
(MRIs) 15
Mail Order Prescription Drugs 36
Mammograms 15 Maternity Benefits 16
Medicaid 51 Medically necessity 52
Medicare 48 Mental Conditions/
Substance
Abuse Benefits 34-35 Newborn care 16
Occupational
therapy 19 Office visits 14
Oral and maxillofacial surgery 26 Orthopedic
devices 21
Out-of-pocket expenses 12 Outpatient facility care 29
Oxygen
22 Pap test 15
Physical examination 15-16 Physical therapy 19
Precertification 10, 24
Preventive care, adult 15
Preventive care, children 16 Prescription drugs
36-38
Prostate cancer screening 15 Prosthetic devices 21
Radiation
therapy 18 Renal dialysis 18
Skilled nursing facility care 27
Smoking cessation 23
Speech therapy 19 Sterilization procedures 17, 24
Subrogation 51 Substance abuse 34-35
Surgery 24 . Anesthesia 27
.
Oral 26 . Outpatient 29
. Reconstructive 25 Syringes 37
Temporary
continuation of coverage 55
Transplants 26 Vision services 16
Wheelchairs 22 Workers' compensation 51
X-rays 15, 29
Avera Health Plans 2002 58 Index 58
58 Page 59 60
Summary of benefits for the Avera Health Plans –
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.
. Below, an asterisk (*) means the item is subject to the 2002 calendar year
deductible.
Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office........... Office
visit copay: $10 primary care; $35 specialist 14
Services provided by a hospital:
.
Inpatient......................................................................................
. Outpatient*
.................................................................................
$250 per admission copay
20% of allowed charge after deductible 28 29
Emergency benefits:
.
In-area*.......................................................................................
. Out-of-area*
...............................................................................
20% of allowed charge after deductible
20% of allowed charge after deductible
32
33
Mental health and substance abuse treatment* ................................
Regular cost sharing. 34
Prescription drugs
............................................................................ $10
for a 30 day supply of generic drugs $20 for a 30 day supply of formulary drugs
$35 for a 30 day supply of non-formulary drugs
$20 for a 60 day mail order supply of generics $40 for a 60 day mail order
supply of formulary drugs
$60 for a 60 day mail order supply of
non-formulary drugs
37
Vision Care
......................................................................................
One routine vision exam per year with a participating provider (eyeglass exam
only) 20
Special features: Employee Assistance Program 39
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
Avera Health Plans 2002 59 Summary 59
59 Page 60
2002
Rate Information for Avera Health Plans
Non-Postal rates apply to most
non-Postal enrollees. If you are in a special enrollment category, refer to the
FEHB Guide for that category or contact the agency that maintains your health
benefits
enrollment.
Postal rates apply to career Postal Service
employees. Most employees should refer to the FEHB Guide for United States
Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB
guides are
published for Postal Service Nurses (see RI 70-2B); and for
Postal Service Inspectors and Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization. Refer to the applicable
FEHB Guide .
Type of
Enrollment Code
Non-Postal Premium
Biweekly Monthly
Gov't Your
Gov't Your Share Share Share Share
Postal Premium
Biweekly
USPS Your
Share Share
Self Only
Self & Family
AV1
AV2
$78.90 $26.30 $170.95
$56.98
$181.08 $60.36 $392.34 $130.78
$93.37 $11.83
$214.28 $27.16
2002 Avera Health Plans 60