Sioux Valley Health Plan http://
www. siouxvalley. org 2002
Serving: Central, Eastern South Dakota and
counties surrounding the Rapid City area.
Enrollment in this Plan is
limited. You must live in our Geographic service area to enroll. See pages 6-7
for requirements.
Sioux Valley Health Plan and Sioux Valley Health Plan
of Minnesota Commercial HMO products received NCQA New Health Plan Accreditation
on July 28, 2000 effective through July 28, 2003.
NCQA's New Health Plan Accreditation Program applies to health plans that are
less than two years old. The program is distinct from
NCQA's MCO
Accreditation Program.
Enrollment codes for this Plan:
AU1 Self Only AU2 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 73-814
For changes in benefits
see page 8.
A Health Maintenance Organization with a point of service product 1
1 Page 2 3
2002 Sioux Valley Health Plan 2 Table of Contents
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..........................................................................................................................................................................
6
Section 2. We are a new
plan.................................................................................................................................................................
8
Section 3. How you get care
.................................................................................................................................................................
9
Identification
cards................................................................................................................................................................
9
Where you get covered
care..................................................................................................................................................
9
. Plan
providers............................................................................................................................................................
9
. Plan
facilities.............................................................................................................................................................
9
What you must do to get covered
care..................................................................................................................................
9
. Primary care
..............................................................................................................................................................
9
. Specialty care
............................................................................................................................................................
9
. Hospital
care............................................................................................................................................................
10
Circumstances beyond our
control......................................................................................................................................
10
Services requiring our prior
approval..................................................................................................................................
10
Section 4. Your costs for
covered services
..........................................................................................................................................
13
.
Copayments.............................................................................................................................................................
13
. Deductible
...............................................................................................................................................................
13
.
Coinsurance.............................................................................................................................................................
13
Your out-of-pocket
maximum.............................................................................................................................................
13
Section 5. Benefits
...............................................................................................................................................................................
14
Overview.............................................................................................................................................................................
14
(a) Medical services and supplies provided by physicians and other health
care professionals .................................... 15
(b) Surgical and anesthesia services provided by physicians and
other health care professionals................................. 23
(c) Services provided by a hospital or other facility, and
ambulance services
.............................................................. 26
(d) Emergency services/
accidents..................................................................................................................................
28
(e) Mental health and substance abuse
benefits.............................................................................................................
30
(f) Prescription drug
benefits.........................................................................................................................................
32
(g) Special features
.......................................................................................................................................................
34
. 24 Hour Nurse Line 2
2
Page 3 4
2002 Sioux Valley Health Plan 3 Table of Contents
. Services for deaf and hearing impaired
. High risk
pregnancies
. Centers of Excellence for transplants
(h) Dental benefits………………………………………………………………………………………………………… 35
(i) Point of service
product................................................................................................................................................
36
Section 6. General exclusions --things we don't
cover........................................................................................................................
39
Section 7. Filing a claim for covered services
.....................................................................................................................................
40
Section 8. The disputed claims process
...............................................................................................................................................
41
Section 9. Coordinating benefits with other
coverage
........................................................................................................................
43
When you have…
. Other
health
coverage..............................................................................................................................................
43
. Original
Medicare....................................................................................................................................................
43
. Medicare managed care plan
..................................................................................................................................
45
TRICARE/ Workers' Compensation/ Medicaid
...................................................................................................................
45
Other Government
agencies................................................................................................................................................
46
When others are responsible for
injuries.............................................................................................................................
46
Section 10. Definitions of
terms we use in this
brochure......................................................................................................................
47
Section 11. FEHB facts
........................................................................................................................................................................
49
Coverage
information........................................................................................................................................................
49
. No pre-existing condition
limitation.....................................................................................................................
49
. Where you get information about enrolling in the FEHB Program
...................................................................... 49
.
Types of coverage available for you and your
family...........................................................................................
49
. When benefits and premiums
start........................................................................................................................
49
. Your medical and claims records are
confidential................................................................................................
50
. When you retire
....................................................................................................................................................
50
When you lose benefits
.....................................................................................................................................................
50
. When FEHB coverage
ends..................................................................................................................................
50
. Spouse equity coverage
........................................................................................................................................
50
. Temporary Continuation of Coverage
(TCC).......................................................................................................
50
. Converting to individual
coverage........................................................................................................................
51
. Getting a Certificate of Group Health Plan Coverage
..........................................................................................
51
Long term care insurance is coming later in 2002
................................................................................................................................
52
Index…………
.....................................................................................................................................................................................
53
Summary of
benefits.............................................................................................................................................................................
54
Rates
.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Sioux Valley Health Plan 4 Introduction/ Plain Language
Introduction
Sioux Valley Health Plan PO Box 91110
Sioux
Falls, SD 57109-1110
This brochure describes the benefits of Sioux Valley
Health Plan under our contract (CS 2443) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This brochure
is the official statement of benefits.
No oral statement can modify or
otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits that were available before
January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
. Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we"
means Sioux Valley Health
Plan.
. We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel
Management. If we use
others, we tell you what they mean first.
. Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you compare plans.
If you have comments or suggestions about
how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E Street,
NW Washington, DC 20415-3650.
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:
. Call the provider and
ask for an explanation. There may be an error. .
If the provider does not
resolve the matter, call us at 605/ 328-6800 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
Stop health care fraud! 4
4 Page 5 6
2002 Sioux Valley
Health Plan 5 Introduction/ Plain Language
Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate anyone who
uses an ID card if the
person tries to obtain services for someone who is
not an eligible family member, or is no longer enrolled in the Plan and tries to
obtain benefits. Your agency may also take
administrative action against
you. 5
5 Page 6 7
2002 Sioux Valley Health Plan 6 Section 1
Section 1.
Facts about this HMO plan
This Plan is a health maintenance organization
(HMO). To receive in-network benefit coverage, the Plan requires you to see
specific physicians, hospitals, and other providers that contract with us. These
Plan providers coordinate your health care services. You are
encouraged to
select a Sioux Valley Health Plan participating Primary Care Provider (PCP) to
provide and coordinate your healthcare services. However, the Plan does not
require that you select a PCP or that a PCP refer you for specialty care. You
can self-refer
yourself to a Sioux Valley Health Plan participating
specialty provider at any time.
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 copayments or coinsurance or deductible (if
applicable).
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may
get information about us, our networks, providers, and facilities. OPM's FEHB
website (www. opm. gov/ insure) lists the specific types of information that
we must
make available to you. Some of the required information is listed
below.
. Years in existence
. Profit status
If you want more
information about us, call 1-800/ 752-5863, or write to Sioux Valley Health
Plan, PO Box 91110, Sioux Falls, SD 57109-1110. You may also contact us by fax
at 605/ 328-6812 or visit our website at www. siouxvalley. org.
Service Area
To enroll in this Plan, you must live in our Service
Area. This is where our providers practice. Our service area is: Aurora, Beadle,
Bennett, Bon Homme, Brookings, Brown, Brule, Buffalo, Butte, Campbell, Charles
Mix, Clark, Clay, Codington, Davison, Day ,
Deuel, Douglas, Edmunds, Faulk,
Grant, Gregory, Hamlin, Hand, Hanson, Hughes, Hutchinson, Hyde, Jerauld,
Kingsbury, Lake, Lawrence, Lincoln, Lyman, Marshall, McCook, McPherson, Meade,
Miner, Minnehaha, Moody, Potter, Roberts, Sanborn, Spink,
Stanley, Sully,
Todd, Tripp, Turner, Union, Walworht, and Yankton.
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. 6
6 Page
7 8
2002 Sioux Valley Health Plan 7
Section 1
If you or a covered family member move outside of our
service area, you can enroll in another plan. If your dependents live out of the
area (for example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO
that has agreements
with affiliates in other areas. If you or a family member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page 8
9
2002 Sioux Valley Health Plan 8 Section 2
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. 8
8 Page 9 10
2002 Sioux Valley Health Plan 9 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it whenever you receive services from a
Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive
your ID card, use your copy of the Health Benefits Election Form, SF-2809, your
health benefits
enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30
days after the effective date of your enrollment, or if you need replacement
cards, call us at 1-800/ 752-5863.
Where you get covered care 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. You may
also have to file your own claims.
. Plan providers Plan providers are physicians and other health care
professionals in our service area that
we contract with to provide covered
services to our members. We credential Plan providers according to the NCQA
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
are encouraged, but not required, to select a primary care physician. This
decision is
important since your primary care physician provides or arranges
for most of your health care. Primary care physicians are included in the Plan
provider directory. You may
choose the physician who best meets your needs.
. Primary care Your primary care physician can be a family
practitioner, internist, pediatrician, general practitioner or OB/ GYN. Your
primary care physician will provide most of your health
care, or give you a
referral to see a specialist.
If you want to change primary care physicians
or if your primary care physician leaves the Plan, call us. We will help you
select a new one.
. Specialty care Your primary care physician may refer you to a
specialist for needed care. However, you may also self– refer to Plan specialist
providers. No referral is necessary.
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, you may directly access the
specialist for needed services.
. If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment
you need. If he or
she decides to refer you to a specialist, ask if you can
see your current specialist. If your current specialist does not participate
with us, you must receive treatment from a
specialist who does. Generally,
we will not pay at the in-network benefit level if you choose to see a
specialist who does not participate with our Plan.
What you must do to get covered care 9
9
Page 10 11
2002
Sioux Valley Health Plan 10 Section 3
. If you are seeing a
specialist and your specialist leaves the Plan, call your primary care
physician, who will arrange for you to see another specialist. You may receive
services from your current specialist until we can make arrangements for you
to see someone else.
. If you have a chronic or disabling condition and lose access to your
specialist because we:
. terminate our contract with your specialist for
other than cause; or
. drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
. reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your
new
plan.
If you are in the second or third trimester of pregnancy and
you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until
the end of your postpartum care, even
if it is beyond the 90 days.
. Hospital care Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of
facility.
If you are in
the hospital when your enrollment in our Plan begins, call our Member Service
department immediately at 605/ 328-6800 or 1-800/ 752-5863 (TYY 605/ 328-6869).
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.
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 prior approval. You or your
physician must obtain prior approval for the following services:
. Acute
Inpatient Hospital Services; .
Maternity, Pregnancy, and Newborn Care; .
Inpatient Physician Services and Consultations;
. Outpatient Surgery not performed in a Physician's office; .
Home Health
Care and home IV therapy services;
Services requiring our prior approval 10
10
Page 11 12
2002
Sioux Valley Health Plan 11 Section 3
. Skilled Nursing facility
and sub-acute care; .
Non-Emergency Ambulance and Other Transportation
Services; . Mental Health Services;
. Chemical Dependency Services; .
Alcohol Treatment; . Growth Hormone
Therapy;
. Sexual Dysfunction Drug; .
Durable Medical Equipment and Prosthetic
Device rentals or purchases over $200; . Outpatient Rehabilitative Therapy;
. Organ transplant services; .
Referrals to Non-Participating Providers
which are recommended by Participating Providers, unless services are a result
of a lack of appropriate access to Participating
Providers, or unless you choose to accept Point of Service benefits.
A
request for prior approval is required at least three (3) business days prior to
the receipt of the Health Care Services listed above. Failure to do so will
result in payment of benefits at the Out of Network Coverage level. In the event
that health care
services need to be provided within less than three (3) business days,
Members should contact the Health Services Department at 605/ 328-6807 or 1-800/
805-7938 to request an expedited review.
Prior approval is not required for Emergency Conditions. However, the Plan
must be notified of an admission as soon as reasonably possible, and no later
than forty-eight (48) hours after physically or mentally able to do so.
Additionally, because of
the inability to predict admission, obstetrical
admissions shall be authorized when the pregnancy is confirmed. The exception is
that of an elective C-section, which must be authorized as an elective
admission.
Prior approval Process
All requests for elective inpatient
hospitalizations are to be made by the Physicians office at least three (3) days
prior to the scheduled admission. Sioux Valley Health Plan's Health Services
Department is available between the hours of 8: 00a. m. and
5: 00p. m. Central Time, Monday through Friday, by calling the Plan's
toll-free number 1-800/ 805-7938.
The Health Services Department will review the Member profile information
against standard criteria. A determination will be made by the Health Services
Department within two (2) business days of the initial notification. The
determination shall either
be authorization of the requested service or
additional review by the Health Plan Medical Director.
If the determination is to authorize the requested service, the attending
practitioner and those Providers involved in the provision of the service shall
be notified of the decision by telephone within one (1) business day of
the initial determination.
When the service is approved, the Health Services
Department will assign an authorization/ certification number. Written
notification shall be sent to the attending practitioner, those Providers
involved in the provision of the service and the Member
within three (3)
business days of the date of authorization.
When the request requires further review because a denial is being
recommended by the Health Services staff, an intensified review will be
performed by the Medical Director. If additional documentation is required, the
Member, his or her
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 within two (2) business
days after the initial determination or, if
additional information is
necessary, within two (2) business days from the receipt of all necessary
documentation. If information is not submitted within thirty (30) days, the
Utilization Management (UM) record is closed and services will be
denied.
The attending practitioner, those Providers involved in the provision of the
service and the Member shall be notified of the decision by telephone within
twenty-four (24) hours of the determination. Those Providers involved in
the provision of the
service and the Member shall be provided with written
notification of the decision within two (2) business days of the date of
the determination.
If the decision is to deny a hospital or surgical facility admission or other
service, it is the plan's policy to notify the attending physician and hospital
of the determination by telephone and in writing within one (1) business day of
the determination. The
Member and those Providers who are involved in the
provision of the service shall be informed of the reasons for the denial and 11
11 Page 12 13
2002 Sioux Valley Health Plan 12 Section 3
the Plan's appeal procedures. In addition, upon request, the Plan will
provide the attending Physician and or Provider with the criteria used to
determine the necessity, appropriateness, and efficacy of the health care
service. 12
12 Page
13 14
2002 Sioux Valley Health Plan
13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
.
Copayments A copayment is a fixed amount of money you pay to provider,
facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per visit and when you go in the hospital, you pay $100 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. Deductibles only apply when
you use our Point of Services (POS) benefits.
The calendar year deductible
for POS benefits is $500 per individual. 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 reaches $1,000.
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 certain in-network
and all out-of-network care. Coinsurance
doesn't begin until you meet your deductible for out-of-network care (there is
no deductible for in-network care).
Example: In our Plan, you pay 40% of our allowance for medical office visits
when you receive services from a Non-Participating Provider or you pay 20% of
our negotiated fee
for durable medical equipment and orthopedic appliances
received by in-network providers.
After your in-network copayments total $1500 per person or $3000 per family
enrollment in any calendar year, you do not have to pay any more for covered
services. However,
copayments for the following services do not count toward
your out-of-pocket maximum, and you must continue to pay copayments for these
services:
. Prescription drugs; and .
Physician office visits. . Be sure to keep
accurate records of your copayments, deductibles and coinsurance
since you are responsible for informing us when you reach the maximum.
Your catastrophic protection out-of-pocket maximum for
deductibles,
coinsurance, and copayments 13
13 Page 14 15
2002 Sioux
Valley Health Plan 14 Section 5
Section 5. Benefits – OVERVIEW
(See page 8 for how our benefits changed this year and page 15 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 1-800/ 752-5863
(TYY at 605/ 328-6869). (a) Medical services and supplies provided by physicians
and other health care
professionals................................................... …15-22
. Diagnostic and treatment services . Lab, X-ray, and other diagnostic tests
. Preventive care, adult . Preventive care, children
. Maternity care .
Family planning
. Infertility services .
Allergy care
. Treatment
therapies . Physical, cardiac and occupational therapies
. Speech therapy . Hearing services (testing, treatment, and supplies)
.
Vision services (testing, treatment, and supplies) . Foot care
. Orthopedic
and prosthetic devices . Durable medical equipment (DME)
. Home health
services .
Chiropractic
. Alternative treatments . Educational classes
and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................................ 23-25
.
Surgical procedures . Reconstructive surgery . Oral and maxillofacial surgery .
Organ/ tissue transplants
. Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services
..............................................................................
26-27
. Inpatient hospital .
Outpatient hospital or ambulatory surgical
center . Extended care benefits/ skilled nursing care facility benefits .
Hospice care . Ambulance
(d) Emergency services/ accidents
.................................................................................................................................................
28-29 . Medical emergency . Ambulance
(e) Mental health and substance abuse
benefits
............................................................................................................................
30-31
(f) Prescription drug benefits
........................................................................................................................................................
32-33
(g) Special features
.............................................................................................................................................................................
34 . 24 Hour Nurse Line
. Services for deaf and hearing impaired
. High risk pregnancies
.
Centers of Excellence for transplants
(h) Dental benefits
...............................................................................................................................................................................
25
(i) Point of service benefits
............................................................................................................................................................
.36-38
Summary of benefits
.............................................................................................................................................................................
55 14
14 Page 15
16
2002 Sioux Valley Health Plan 15 Section
5( a)
Section 5 (a). Medical services and supplies provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care.
. We have no
calendar year deductible for In Network services.
. Be sure to read Section
4, Your costs for covered services, for valuable information about how
cost
sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians, nurse practitioners, and
physician's assistants
. In physician's office .
In an urgent care center . Office medical
consultations
. Second surgical opinions
$10 per visit
Professional services of physicians, nurse practitioners, and physician's
assistants
. During a hospital stay
. In a skilled nursing facility
Nothing
Home visits Nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap
tests
. Pathology
. X-rays
. Non-routine Mammograms
. CAT Scans/
MRI
. Ultrasound
. Electrocardiogram and EEG
Nothing 15
15 Page
16 17
2002 Sioux Valley Health Plan
16 Section 5( a)
Preventive care, adult You Pay
Routine screenings, such as:
. Total Blood Cholesterol – once every
three years
. Colorectal Cancer Screening, including:
. Fecal occult
blood test
. Sigmoidoscopy, screening – every five years starting at age 50
. Prostate Specific Antigen (PSA test) – one annually for men age 40 and
older
. Colonoscopy – once every 5 years
Nothing
Routine pap test
NOTE: The office visit is covered if pap test is
received on the same day; see Diagnosis and Treatment, above.
Nothing
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
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges.
Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster
– once every 10 years, ages19 and
over (except as provided for under
Childhood immunizations)
. Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing
Preventive care, children
. Childhood immunizations recommended by
the American Academy
of Pediatrics Nothing
. Well-child care charges for routine examinations, immunizations and
care (up to age 22)
. Examinations, such as:
. Eye exams through age 17 to determine the need
for vision correction.
. Ear exams through age 17 to determine the need for hearing correction
.
Examinations done on the day of immunizations (up to age 22)
$10 per visit 16
16 Page
17 18
2002 Sioux Valley Health Plan
17 Section 5( a)
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 need to
pre-approve your normal delivery due to the inability to
predict admission,
obstetrical admissions shall be authorized when the pregnancy is confirmed.
C-sections must be pre-approved as an
elective admission. See page 11 for the pre-approval process.
. 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).
NOTE: We encourage all members to participate in the Plan's Healthy Pregnancy
Program; see Special Features Section.
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex. All
charges.
Family planning
A broad range of voluntary family
planning services, limited to:
. Voluntary Sterilization
. Surgically
implanted contraceptives
. Injectable contraceptive drugs (such as Depo
provera)
. Intrauterine devices (IUDs)
. Diaphragms
NOTE: We cover
oral contraceptives under the prescription drug benefit.
$10 per visit
20% of charges per inpatient admission
$25 per
outpatient surgery
Not covered: reversal of voluntary surgical sterilization, genetic
counseling or testing. All charges. 17
17
Page 18 19
2002
Sioux Valley Health Plan 18 Section 5( a)
Infertility services
You Pay Diagnosis and treatment of infertility, such as:
Artificial
insemination: . Intravaginal insemination (IVI)
. Intracervical
insemination (ICI) .
Intrauterine insemination (IUI)
$10 per visit 20% of charges per inpatient admission
$25 per outpatient
surgery
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
All charges.
Allergy care . Testing and treatment
. Allergy injection $10 per
visit
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization. All charges.
Treatment therapies . Chemotherapy and radiation therapy
NOTE: High dose chemotherapy in association with autologous bone marrow
transplants are limited to those transplants listed under Organ/ Tissue
Transplants on page 25. . Respiratory and inhalation therapy
. Dialysis
– Hemodialysis and peritoneal dialysis .
Intravenous (IV)/ Infusion Therapy
– Home IV and antibiotic therapy . Growth hormone therapy (GHT)
NOTE: Growth hormone is covered under the medical benefit.
NOTE: We will
only cover GHT when we pre-authorize the treatment. Call 1-800/ 752-5863 for
prior approval. We will ask you to submit information that
establishes that
the GHT is medically necessary. Ask us to authorize GHT before you begin
treatment; otherwise, we will only cover GHT services from
the date you
submit the information. If you do not ask or if we determine GHT is not
medically necessary, we will not cover the GHT or related services and
supplies. See Services requiring our prior approval in Section 3.
$10 per visit 18
18 Page
19 20
2002 Sioux Valley Health Plan
19 Section 5( a)
Physical, cardiac and occupational therapies
You Pay Coverage up to 2 consecutive months per condition for the services
of each of
the following: . qualified physical therapists
. occupational
therapists .
Cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction.
NOTE: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to illness or injury.
$10 per outpatient visit Nothing per visit during covered inpatient
admission
. Not covered: .
long-term rehabilitative therapy .
exercise programs All charges.
Speech therapy Coverage up to 2 consecutive months per condition by
speech therapists $10 per outpatient visit Nothing per visit during covered
inpatient admission
Not covered: . Long term therapy All charges.
Hearing services (testing, treatment, and supplies) . First hearing
aid( s) (unilateral or bilateral, one time only), and testing and
fitting of
hearing aid( s) when necessitated by accidental injury only. NOTE: Hearing
services must be received within 6 months of injury.
. Hearing testing for
children through age 17 (see Preventive care, children)
$10 per visit
Not covered: . all other hearing testing
. all other
hearing aids .
all other hearing supplies and services
All charges.
Vision services (testing, treatment, and supplies) Eyeglasses or one
pair of contact lenses to correct an impairment directly
caused by
accidental ocular injury or intraocular surgery (such as for cataracts) $10 per
visit Eye exam to determine the need for vision correction for children through
age
17 (see Preventive care, children) $10 per visit
Foot care Routine foot care when you are under active treatment for a
metabolic or
peripheral vascular disease, such as diabetes. See orthopedic
and prosthetic devices for information on podiatric shoe inserts. $10 per visit
Not covered: . Cutting, trimming or removal of corns, calluses, or
the free edge of
toenails, and similar routine treatment of conditions of
the foot, except as stated above
. Treatment of weak, strained or
flat feet or bunions or spurs; and of any
instability, imbalance or
subluxation of the foot (unless the treatment is by open cutting surgery).
All charges. 19
19 Page 20 21
2002 Sioux
Valley Health Plan 20 Section 5( a)
Orthopedic and prosthetic
devices . Artificial limbs and eyes; stump hose
. Externally worn breast
prostheses and surgical bras, including necessary
replacements, following a
mastectomy . Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear
implants, and surgically implanted breast implant following mastectomy. NOTE:
See 5( b) for coverage of the surgery to insert the device.
. Corrective
orthopedic appliances for non-dental treatment of
temporomandibular joint
(TMJ) pain dysfunction syndrome.
20% of charges
Not covered: . orthopedic and corrective shoes
. arch
supports .
foot orthotics . heel pads and heel cups
. lumbosacral supports .
corsets, trusses, elastic stockings,
support hose, and other supportive devices
. prosthetic replacements provided less than 3 years after the last one we
provided.
All charges. 20
20 Page 21 22
2002 Sioux
Valley Health Plan 21 Section 5( a)
Durable medical equipment
(DME) You Pay
Rental or purchase, at our option, including repairs
(repairs are limited to $750 allowable charges per year) and adjustments, of
durable medical equipment
prescribed by your Plan physician, such as oxygen and dialysis equipment.
Under this benefit, we also cover:
. standard hospital beds; .
standard
wheelchairs; . crutches;
. walkers; .
canes; . diabetes supplies including blood glucose monitors
and insulin pumps;
. spacers .
initial casts, braces, and/ or slings provided on day of
treatment; . air compressor
. pressure pads, mattresses, and decubitus care equipment; .
apnea
monitor; . sleeve compression;
. home intravenous therapy supplies; .
commodes; . compression hose
NOTE: We will cover motorized wheelchairs and electric beds up to, but not to
exceed, the cost of standard wheelchairs or standard hospital beds. Call us at
605/ 328-6807 or toll free at 1-800/ 805-7938 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider to rent
or sell you durable medical equipment at discounted rates and will tell you
more about this service when you call.
20% of charges
Not covered: . The remaining charges of a motorized wheelchair
after the Plan
contributes the cost of a standard wheelchair to the purchase
. Medical supplies/ equipment that can be purchased over-the-counter
. Environmental control equipment .
Household equipment/
fixtures . Convenience items
. Self-help items .
Educational equipment
All charges.
Home health services . Home health care ordered by a Plan physician
and provided by a registered
nurse (R. N.), licensed practical nurse (L. P.
N.), licensed vocational nurse (L. V. N.), or home health aide.
. Services
include oxygen therapy, intravenous therapy and medications.
Nothing 21
21 Page
22 23
2002 Sioux Valley Health Plan
22 Section 5( a)
Home health services (continued) You pay
Not covered:
. Nursing care requested by, or for the convenience of, the
patient or the
patient's family; . Home care primarily for personal
assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.
All charges.
Chiropractic . Manipulation of the spine and extremities.
.
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application. NOTE: Office visits are
limited to 20 visits per calendar year.
$10 per visit
Not covered: Vitamins, minerals, therabands, cervical pillows and traction
services. All charges.
Alternative treatments Acupuncture by a
doctor of medicine or osteopathy for anesthesia pain relief.
Not covered: . naturopathic services
. hypnotherapy .
biofeedback
$10 per visit
All charges.
Educational classes and programs
Coverage is limited to: . Smoking
Cessation – Up to $100 for one smoking cessation program per
member per lifetime, including all related expenses such as drugs . Diabetes
self-management
Nothing 22
22 Page 23 24
2002 Sioux
Valley Health Plan 23 Section 5( b)
Section 5 (b). Surgical
and anesthesia services provided by physicians and other health care
professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits: .
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are
payable only when we determine they
are medically necessary. . Plan physicians must provide or arrange your care.
. We have no calendar year deductible for In Network services. .
Be sure
to read Section 4, Your costs for covered services for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.
. The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical
care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.). .
YOU OR YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES.
Please refer to the precertification information shown in Section 3 to be
sure which services require precertification and identify which surgeries
require precertification.
I M
P O
R T
A N
T
Benefit Description You pay Surgical procedures
A comprehensive
range of services, such as: . Operative procedures
. Treatment of fractures,
including casting .
Normal pre-and post-operative care by the surgeon .
Correction of amblyopia and strabismus
. Endoscopy procedures .
Biopsy procedures . Removal of tumors and cysts
. Correction of congenital anomalies (see reconstructive surgery) .
Surgical treatment of morbid obesity --a condition in which an individual
weighs 100 pounds or 100% over his or her normal weight according to
current underwriting standards; eligible members must be age 18 or over. .
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information. . Voluntary
sterilization
. Treatment of burns
NOTE: Generally, we pay for internal
prostheses (devices) according to where the procedure is done. For example, we
pay Hospital benefits for a pacemaker
and Surgery benefits for insertion of
the pacemaker.
$10 per office visit $100 per inpatient surgery or service
$25 per
outpatient surgery or service
Not covered: . Reversal of voluntary sterilization
.
Routine treatment of conditions of the foot; see Foot care.
All charges.
23
23 Page 24
25
2002 Sioux Valley Health Plan 24 Section
5( b)
Reconstructive surgery You pay . Surgery to correct a
functional defect
. Surgery to correct a condition caused by injury or
illness if:
-the condition produced a major effect on the member's
appearance and -the condition can reasonably be expected to be corrected by such
surgery
. Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate;
birth marks; webbed fingers; and webbed toes. . All stages of breast
reconstruction surgery following a mastectomy, such
as: -surgery to produce
a symmetrical appearance on the other breast;
-treatment of any physical
complications, such as lymphedemas; -breast prostheses and surgical bras and
replacements (see Prosthetic
devices) NOTE: If you need a mastectomy,
you may choose to have the procedure
performed on an inpatient basis and
remain in the hospital up to 48 hours after the procedure.
$10 per office visit $100 per inpatient surgery or service
$25 per
outpatient surgery or service
Not covered: . Cosmetic surgery – any surgical procedure (or any
portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury.
.
Surgeries related to sex transformation
All charges.
Oral and maxillofacial surgery Oral surgical procedures, limited to:
. Reduction of fractures of the jaws or facial bones; .
Surgical
correction of cleft lip, cleft palate or severe functional malocclusion;
. Removal of stones from salivary ducts; .
Excision of leukoplakia or
malignancies; . Excision of cysts and incision of abscesses when done as
independent
procedures; and . Other surgical procedures that do not involve the teeth or
their supporting
structures.
$10 per office visit $100 per inpatient surgery or service
$25 per
outpatient surgery or service
Not covered: . Oral implants and transplants
.
Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone)
All charges. 24
24 Page 25 26
2002 Sioux
Valley Health Plan 25 Section 5( b)
Organ/ tissue transplants
You pay Limited to:
. Cornea .
Heart . Heart/ lung
. Kidney .
Kidney/ Pancreas . Liver
. Lung: Single –Double .
Pancreas . Allogeneic (donor) bone marrow
transplants
. Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma; advanced non-Hodgkin's
lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma; epithelial
ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian
germ cell tumors . Intestinal transplants (small intestine) and the small
intestine with the liver
or small intestine with multiple organs such as the
liver, stomach, and pancreas
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved clinical
trial at a Plan-designated center of excellence and if approved by the
Plan's medical director in accordance with the Plan's protocols.
NOTE: We
cover related medical and hospital expenses of the donor when we cover the
recipient. All transplants must be provided at Plan participating
Center of
Excellence facilities.
Nothing
Not covered: . Donor screening tests and donor search expenses,
except those performed
for the actual donor . Implants of artificial
organs
. Transplants not listed as covered
All charges.
Anesthesia Professional services provided in –
. Hospital
(inpatient) Nothing
Professional services provided in – . Hospital outpatient department
.
Skilled nursing facility .
Ambulatory surgical center . Office
Nothing 25
25 Page
26 27
2002 Sioux Valley Health Plan
26 Section 5( c)
.
Section 5 (c). Services provided by a
hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits: .
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this
brochure and are payable only when we determine they
are medically necessary. . Plan physicians must provide or arrange your care and
you must be hospitalized in a Plan facility.
. Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
. The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or
ambulance service for your surgery or care.
Any costs associated with the professional charge (i. e., physicians, etc.) are
covered in Sections 5( a) or (b).
. YOU OR YOUR PHYSICIAN MUST GET PRECERTIFICATION OF NON-EMERGENCY
HOSPITAL STAYS. Please refer to Section 3 to be sure which services require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay Inpatient hospital
Room and board,
such as . ward, semiprivate, or intensive care accommodations;
. general
nursing care; and .
meals and special diets
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
$100 per admission
Other hospital services and supplies, such as: . Operating, recovery,
maternity, and other treatment rooms
. Prescribed drugs and medicines .
Diagnostic laboratory tests and X-rays . Administration of blood and blood
products
. Blood or blood plasma, if not donated or replaced .
Dressings, splints,
casts, and sterile tray services . Medical supplies and equipment, including
oxygen
. Anesthetics, including nurse anesthetist services .
Take-home items .
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home
Nothing
Not covered: . Custodial care
. Non-covered facilities,
such as nursing homes, schools .
Personal comfort items, such as
telephone, television, barber services, guest meals and beds
. Private nursing care
All charges. 26
26 Page 27 28
2002 Sioux
Valley Health Plan 27 Section 5( c)
Outpatient hospital or
ambulatory surgical center You pay . Operating, recovery, and other
treatment rooms
. Prescribed drugs and medicines .
Diagnostic laboratory
tests, X-rays, and pathology services . Administration of blood, blood plasma,
and other biologicals
. Blood and blood plasma, if not donated or replaced .
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.
Outpatient hospital services: . Diagnostic laboratory tests, X-rays, and
pathology services
. Pre-surgical testing
$25 per visit
Nothing
Not covered: blood and blood derivatives
not replaced by the member All charges.
Extended care
benefits/ skilled nursing care facility benefits
All necessary services ordered by a Plan doctor are covered, including: .
Unlimited days
. bed, board, and general nursing care .
drugs,
biologicals, supplies, and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a Plan doctor
. Care must be received from a state licensed nursing facility.
$100 per admission
Not covered: custodial care All charges.
Hospice care
.
Admission to a hospice facility, hospital, or skilled nursing facility for
room and board, supplies and services for pain management and other acute/
chronic symptom management
. Part-time or intermittent nursing care by an RN, LPN, LVN or home
health aide for patient care for up to 8 hours a day . Social services
. Psychological and dietary counseling .
Physical or occupational therapy
. Consultation and case management services by a participating practitioner
. Medical supplies and drugs prescribed by a participating practitioner
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance . Local professional ground and/ or air ambulance
service when medically
necessary and plan approved hospital transfers.
Nothing 27
27 Page
28 29
2002 Sioux Valley Health Plan
28 Section 5( d)
Section 5 (d). Emergency services/ accidents
I
M P
O R
T A
N T
Here are some important things to keep in mind about these benefits: . Please
remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure.
. We have no calendar year deductible for In
Network services. .
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T What is a medical emergency?
A
medical emergency is the sudden and unexpected onset of a condition or an injury
that you believe endangers your life or could result in serious injury or
disability, and requires immediate medical or surgical care. Some problems are
emergencies because, if
not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are emergencies
because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden inability to
breathe. There are many
other acute conditions that we may determine are medical emergencies – what they
all have in common is the need for quick action.
What to do in case of emergency: In the event of an Emergency Medical
Condition, go to the closest emergency room, or call 911 for assistance. Sioux
Valley Health
Plan will cover Emergency Services whether you are in or out
of the Service Area. Sioux Valley Health Plan offers world-wide emergency
coverage. Prior approval for treatment of Emergency Medical Conditions is not
required. You should have someone
telephone Sioux Valley Health Plan at
1-800/ 805-7938 (TYY 605/ 328-6869) as soon as reasonably possible. Emergency
services are covered inpatient or outpatient services that are furnished by any
Provider qualified to furnish such
services; and needed to evaluate or
stabilize an Emergency Medical Condition.
Emergencies within our service
area: If you have an Emergency Medical Condition within the Service Area,
you should contact your PCP and the Plan after an emergency so that we can
arrange for your follow-up care.
Emergencies outside our service area: If you have an Emergency Medical
Condition while out of the Service Area, we prefer that you return to the
Service Area to receive care through Plan Participating Providers after you have
been treated for your condition.
However, services will be covered out of
the Service Area as long as the care required continues to meet the definition
for either Emergency Services or Urgently Needed Services.
Whether you are inside or outside of the Plan's service area, a $50 copay
for Emergency or Urgent services applies. However, this copay is waived if you
are admitted to a hospital within 30 days for the same diagnosis.
Post-Stabilization Care We also provide coverage for services needed to
ensure that you remain stabilized (or, in certain instances, to improve or
resolve
your condition) if: . We provide prior approval for such services;
or
. The services were not pre-approved by us, but were administered within
1 hour of a request from the Provider for prior
approval of additional
post-stabilization care; or . We do not respond within one (1) hour to a request
for prior approval from a Non-Contracting Medical Provider or Facility (or
Sioux Valley Health Plan could not be contacted for prior approval).
Coverage for Post-Stabilization Care is effective until: . You are
discharged; or
. A Contracting Medical Provider with privileges at the
hospital in which you are treated arrives and assumes responsibility for
your care; or . The Non-Contracting Medical Provider and Sioux Valley Health
Plan agree to other arrangements; or
. A Contracting Medical Provider assumes responsibility for your care through
transfer.
Remember, if you receive services from Non-Contracting Medical
Providers without Prior approval, except for Emergency Services, Urgently Needed
Services, or out-of-area renal dialysis, Sioux Valley Health Plan will pay for
those services at the 28
28 Page 29 30
2002 Sioux
Valley Health Plan 29 Section 5( d)
Out-of-Network benefit
level.
Refunds for Emergency, Urgently Needed, or Out-of-Area Dialysis
Services Paid by Members: Providers should submit bills to Sioux Valley
Health Plan for payment. However, if you paid for any Emergency Services,
Urgently
Needed Services, or Out-of-Area Renal Dialysis services obtained
from Non-Contracting Medical Providers, you should submit your bills to Sioux
Valley Health Plan for payment. Bills should be submitted to the following
address:
Sioux Valley Health Plan, PO Box 91110, Sioux Falls, SD 57109-1110
If you have questions about any bills, contact the SVHP Member Service
Department at 1-800/ 752-5863 or 605/ 328-6800. The
TTY # is 605/ 328-6869.
(The hours of operation for these numbers are 8: 00a. m. until 5: 00p. m.
Central Standard Time, Monday through Friday.)
Benefit Description You pay Emergency within our service area
.
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
$50 per visit, waived if admitted
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area . Emergency care at a doctor's
office
. Emergency care at an urgent care center .
Emergency care as an
outpatient or inpatient at a hospital, including doctors' services
$50 per visit, waived if admitted
Not covered: . Elective care or non-emergency care
. Emergency
care provided outside the service area if the need for care
could have been
foreseen before leaving the service area . Medical and hospital costs resulting
from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance Professional ground ambulance, air ambulance, or regularly
scheduled flight on
a commercial airline when service is medically
necessary. See 5( c) for non-emergency service. Nothing 29
29 Page 30 31
2002 Sioux Valley Health Plan 30 Section 5(
e)
Section 5 (e). Mental health and substance abuse benefits I
M
P
O R
T A
N T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for similar benefits for other
illnesses
and conditions. Here are some important things to keep in mind about these
benefits:
. All benefits are subject to the definitions, limitations,
and exclusions in this brochure. .
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
. YOU MUST GET PRIOR APPROVAL OF THESE SERVICES. See the instructions
after the benefits
description below.
I M
P O
R T
A N
T Benefit Description You Pay
Mental health and substance abuse benefits All diagnostic and
treatment services recommended by a Plan provider and
contained in a
treatment plan that we approve. The treatment plan may include services, drugs,
and supplies described elsewhere in this brochure.
NOTE: Plan benefits are
payable only when we determine the care is clinically appropriate to treat your
condition and only when you receive the care as part
of a treatment plan
that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
. Outpatient Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers.
. Medication management. $10 per visit
. Diagnostic tests Nothing
. Services provided by a hospital or other facility $100 per inpatient
admission
Not covered: Services we have not approved. All charges. 30
30 Page 31 32
2002 Sioux Valley Health Plan 31 Section 5(
e)
Prior approval To be eligible to receive these benefits you
must obtain a treatment plan and follow all the following
authorization
processes:
All requests for elective inpatient hospitalizations are to be
made by the Physicians office at least three (3) days prior to the scheduled
admission. Sioux Valley Health Plan's Health Services Department is available
between the hours of 8: 00a. m. and
5: 00p. m. Central Time, Monday through
Friday, by calling the Plan's toll-free number 1-800/ 805-7938.
The Health
Services Department will review the Member profile information against standard
criteria. A determination will be made by the Health Services Department within
two (2) business days of the initial notification. The determination shall
either be
authorization of the requested service or additional review by the
Health Plan Medical Director.
If the determination is to authorize the requested service, the attending
practitioner and those Providers involved in the provision of the service shall
be notified of the decision by telephone within one (1) business day of
the initial determination. When the service
is approved, the Health Services
Department will assign an authorization/ certification number. Written
notification shall be sent to the attending practitioner, those Providers
involved in the provision of the service and the Member within three (3)
business days of
the date of authorization.
When the request
requires further review because a denial is being recommended by the Health
Services staff, an intensified review will be performed by the Medical Director.
If additional documentation is required, the Member, his or her 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 within two (2) business days after the initial
determination or, if additional information is
necessary, within two (2)
business days from the receipt of all necessary documentation. If
information is not submitted within thirty (30) days, the Utilization Management
(UM) record is closed and services will be denied. The attending practitioner,
those
Providers involved in the provision of the service and the Member
shall be notified of the decision by telephone within twenty-four (24) hours
of the determination. Those Providers involved in the provision of the
service and the Member shall be provided with
written notification of the
decision within two (2) business days of the date of the determination.
If the decision is to deny a hospital or surgical facility admission or
other service, it is the plan's policy to notify the attending physician and
hospital of the determination by telephone and in writing within one (1)
business day of the determination. The
Member and those Providers who are
involved in the provision of the service shall be informed of the reasons for
the denial and the Plan's appeal procedures. In addition, upon request, the Plan
will provide the attending Physician and or Provider with the criteria
used
to determine the necessity, appropriateness, and efficacy of the health care
service.
Limitation We may limit your benefits if you do not obtain a
treatment plan. 31
31 Page
32 33
2002 Sioux Valley Health Plan
32 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits: .
We cover prescribed drugs and medications, as described in the chart beginning
on the next page.
. All benefits are subject to the definitions, limitations
and exclusions in this brochure and are payable
only when we determine they
are medically necessary.
. We have no calendar year deductible for In Network services.
. 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, Nurse Practitioner, or Physician's Assistant must
write
the prescription. . Where you can obtain them. You may fill the
prescription at a pharmacy, a non-network pharmacy, or by mail.
We pay a
higher level of benefits when you use a network pharmacy. . We use a
formulary. However, we have an open formulary. 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 605/
328-6800. . These are the dispensing limitations. Prescriptions can be
filled for up to a 30 day supply per copayment. Those
prescription drug
classes identified as maintenance medications will be made available for up to a
90-day supply. However, three copayments will apply. A generic equivalent will
be dispensed if it is available, unless your
physician specifically requires
a name brand. If you receive a name brand drug when a Federally-approved generic
drug is available, and your physician has not specified Dispense as Written for
the name brand drug, you have to
pay the difference in cost between the name
brand drug and the generic. Additionally, if there is no generic equivalent, you
will still be required to pay the brand name copayment.
. Why use generic
drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical
equivalent of a
corresponding brand name drug. Under federal law, generic
and name brand drugs must meet the same standards for safety, purity, strength,
and effectiveness. Generic drugs are less expensive than brand name drugs;
therefore,
you may reduce your out-of-pocket costs by choosing to use a generic drug. .
When you have to file a claim. Please submit all claims directly to us
at: Sioux Valley Health Plan, PO Box
91110, Sioux Falls, SD 57109-1110.
Claim forms are available at your request. You may, however, submit your
itemized prescription receipt with date, supply, drug name, and all necessary
member information in lieu of a claim
form.
Benefit Description You pay
Covered medications and supplies We cover the following medications
and supplies prescribed by a Plan
physician and obtained from a Plan
pharmacy: . Drugs and medicines that by Federal law of the United States require
a
physician's prescription for their purchase, except those listed as Not
covered.
. Insulin .
Glucose test strips . Disposable needles and
syringes for the administration of covered
medications . Drugs for sexual dysfunction (see Prior approval section on
pages 10-12)
. Contraceptive drugs and devices
$ 10 per generic drug $ 20 per brand name drug
NOTE: If there is no
generic equivalent available, you will still have to pay the brand name copay.
32
32 Page 33 34
2002 Sioux Valley Health Plan 33 Section 5(
f)
Covered medications and supplies (continued) You Pay Not
covered:
. Drugs and supplies for cosmetic purposes including
appetite suppressants .
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
.
Orthomolecular therapy .
B-12 injections
All charges. 33
33 Page 34 35
2002 Sioux
Valley Health Plan 34 Section 5( g)
Section 5 (g). Special
Features Feature Description
24 hour nurse line For any of your health
concerns, 24 hours a day, 7 days a week, you may call Healthformation at 605/
333-4444 and talk with a registered nurse who will discuss
treatment options
and answer your health questions. Services for deaf and hearing
impaired
For individuals needing assistance, please contact the Plan TTY line at 605/
328-6869. High risk pregnancies Individuals may contact the Healthy
Pregnancy Program at 1-800/ 752-5863 to enroll.
Centers of excellence for transplants The Plan utilizes the LifeTrac
Centers of Excellent Network for transplant services. Please contact the Plan at
605/ 328-6807 for any information needed. 34
34
Page 35 36
2002
Sioux Valley Health Plan 35 Section 5( h)
Section 5 (h).
Dental benefits I
M P
O R
T A
N T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan dentists must provide or arrange your care. . We have no calendar year
deductible for in network coverage.
. We cover hospitalization for dental procedures only when a nondental
physical impairment exists which makes hospitalization necessary to safeguard
the health of the patient; we do not cover the dental
procedure unless it is
described below.
. Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay We cover restorative services and
supplies necessary to promptly repair (but
not replace) sound natural teeth.
The need for these services must result from an accidental injury. $10 per visit
$25 per outpatient surgery $100 per inpatient stay
Dental Benefits . Dental service required for cancer that damages
sound natural teeth.
. Associated radiology services .
TMJ Dental
Services
$10 per visit $25 per outpatient surgery
$100 per inpatient stay
We
have no other dental benefits 35
35 Page 36 37
2002 Sioux
Valley Health Plan 36 Section 5( i)
Section 5 (i). Point of
service 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: $500 per person and $1,000 per family.
. 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
Point of Service (POS) Benefits
Facts about this Plan's POS option You may choose to obtain benefits
covered by this Plan's POS options 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 POS 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
authorization from the
Plan, you are subject to the deductibles, coinsurance and maximum benefit stated
below.
What is covered
. Medical Office Visits
. Preventive Health Services including Well Baby and Well Child Care (up to 6
years old), routine periodic preventive health
exams, immunizations, allergy
testing and treatment, and allergy serum
. Emergency Services
. X-Ray and Laboratory Services
. Acute
Inpatient Hospital Services
. Maternity, Pregnancy and Newborn Care
.
Inpatient Physician Services and Consultations
. Outpatient Hospital
Services
. Outpatient Surgery
. Home Health Care
. Skilled Nursing
Facility Service
. Mental Health Services
. Inpatient Chemical
Dependency Services
. Inpatient Alcohol Treatment
. Durable Medical
Equipment and Prosthetic Devices (prior approval required for rentals or
purchases over $200).
. Orthopedic Appliances
. Outpatient
Rehabilitative Therapy
. Oral Surgery and Other Dental Services 36
36 Page 37 38
2002 Sioux Valley Health Plan 37 Section 5(
i)
What is Not Covered . Tobacco Treatment;
. Chiropractic
Services; .
Transplants at Non-Participating Center of Excellence
Facilities; . Custodial care; and
. All other services not listed in the "What is covered" Section above.
You pay 40% of the allowed benefit after paying the deductible and any
charges greater than the allowed benefit.
All participating providers are
paid at the In-Network Benefit level and only the out-of-network doctor and/ or
facility charges are paid at the Out-of-Network POS level. Services obtained
within or outside of the service area by non-Plan Participating
Providers
are eligible for coverage under POS.
Outpatient substance abuse benefits
You pay 70% of our allowed
benefit and any charges above the allowed $30 benefit, after the deductible for
all covered chemical dependency and alcohol treatment services.
Transplant services at designated transplant facilities
You pay a
nominal charge per course of treatment.
Ambulance and other transportation services
You pay 20% of our
allowed benefit and any charges above the allowed benefit, after the deductible,
for all covered services. Prior approval is only required for non-emergency
transportation.
Deductible
The deductible is the amount that a Member must pay at
the time services are received before the Plan will pay for such services. The
deductible for Point of Service benefits is $500 for the individual and $1, 000
for the family
Coinsurance Coinsurance is the percentage of charges to be paid by a
Member for services at the time such services are rendered. The Plans
coinsurance for Point of Service benefits is 60%; you pay 40%, except for
ambulance and other transportation services and outpatient substance abuse
services which have a different coinsurance. The fee schedule is set at the 90th
percentile of the standard Usual and
Customary Rate (UCR) allowance for our
region. You will be liable for your coinsurance percentage plus any charges in
excess of the UCR allowance.
Maximum benefit There is no lifetime maximum benefit under the POS
plan.
Out-of-pocket maximum The catastrophic limit on Member's
out-of-pocket Point of Service expenses per calendar year is $10, 000 for the
individual and
$10,000 for the family (this does not apply to transplant
services). Member's out-of-pocket expenses under POS qualify for the Plan's
out-of-pocket maximum.
Hospital/ extended care The Plan will pay a participating hospital in
full even though the POS benefit (and non-Plan doctor) are being used. The
hospital
charge, sometimes called facility charge, does not cover any
charges for doctors' services.
Emergency benefits True emergency care is always payable as an in-Plan
benefit; there is a $50 copay but the copay is waived if admitted to a hospital.
37
37 Page 38 39
2002 Sioux Valley Health Plan 38 Section 5(
i)
Outpatient substance abuse benefits For chemical dependency
services, the POS benefit pays 30% of eligible reasonable and customary charges
up to a $30 limit; you pay
70%. Also, for alcohol treatment, the POS benefit
pays 30% of eligible reasonable and customary charges up to a $30 limit; you pay
70%.
How to obtain benefits To access POS benefits you may see the
physician or obtain services at the facility of your choice. Benefits will be
paid at 60% after
the Out-of-Network deductible is met; you pay 40%, except
for ambulance and other transportation services and outpatient substance abuse
services which have a different coinsurance. The Plan will need a claim from the
member, including a CPT code, date of
service, diagnosis code, name of
doctor or hospital, member's birthdate and identification number. Submit your
claims to:
Sioux Valley Health Plan PO Box 91110
Sioux Falls, SD
57109-1110 38
38 Page
39 40
2002 Sioux Valley Health Plan
39 Section 6
Section 6. General exclusions --things we don't
cover
The exclusions in this section apply to all benefits. Although we
may list a specific service as a benefit, we will not cover it unless your Plan
doctor determines it is medically necessary to prevent, diagnose, or treat your
illness,
disease, injury, or condition and we agree, as discussed under
What Services Require Our Prior Approval on page 10.
We do not cover
the following:
. 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; and
.
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program. 39
39 Page
40 41
2002 Sioux Valley Health Plan
40 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies, you will not
have to file claims. Just present your identification card and pay your
copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, hospital and drug benefits
In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims
questions and assistance, call Member Services at
605/ 328-6800 or toll free
at 1-800/ 752-5863 (TYY 605/ 328-6869).
When you must file a claim --such as
for out-of-area care --submit it on the HCFA-1500 or a claim form that includes
the information shown below. Bills and receipts should be itemized and show:
. Covered member's name and ID number;
. Name and address of the
physician or facility that provided the service or supply;
. Dates you
received the services or supplies;
. Diagnosis;
. Type of each service
or supply;
. The charge for each service or supply;
. A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice (MSN); and
. Receipts, if you paid for your services.
Submit your claims to:
Sioux Valley Health Plan PO Box 91110
Sioux Falls, SD 57109-1110
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. 40
40 Page
41 42
2002 Sioux Valley Health Plan
41 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for services,
drugs, or supplies – including a request for prior approval:
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
Send your request to us at: Sioux Valley Health Plan, PO Box
91110, Sioux Falls, SD 57109-1110;
(b) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(c) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
. 90 days after the date of our letter
upholding our initial decision; or
. 120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
. 120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. 41
41 Page 42 43
2002 Sioux Valley Health Plan 42 Section 8
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 prior approval/ prior approval, then call us at 605/ 328-6807 and we will
expedite our review; or
(b) We denied your initial request for care or prior
approval/ prior approval, then:
. If we expedite our review and maintain our
denial, we will inform OPM so that they can give your claim
expedited
treatment too, or
. You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m. eastern
time. 42
42
Page 43 44
2002
Sioux Valley Health Plan 43 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health care expenses
without regard to fault. This is called "double coverage."
When you have
double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary
payer. We,
like other insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to
our regular
benefit. We will not pay more than our allowance.
. What is Medicare? Medicare is a Health Insurance Program for:
.
People 65 years of age and older.
. Some people with disabilities, under 65
years of age.
. People with End-Stage Renal Disease (permanent kidney
failure requiring
dialysis or a transplant).
Medicare has two parts:
. Part A (Hospital Insurance). Most people do not
have to pay for Part A. If
you or your spouse worked for at least 10 years
in Medicare-covered employment, you should be able to qualify for premium-free
Part A
insurance. (Someone who was a Federal employee on January 1, 1983 or since
automatically qualifies.) Otherwise, if you are age 65 or older, you
may be
able to buy it. Contact 1-800/ MEDICARE for more information.
. Part B
(Medical Insurance). Most people pay monthly for Part B.
Generally, Part B
premiums are withheld from your monthly Social Security check or your retirement
check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various health
plan choices available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits with Medicare, depending on the
type of Medicare managed care plan you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the
United States. It is the way everyone used to get Medicare benefits and is the
way most people get their Medicare Part A and Part B benefits now. You may
go to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care.
We will
not waive any of our copayments, coinsurance, and deductibles.
. The Original Medicare Plan
(Part A or Part B) 43
43 Page 44 45
2002 Sioux Valley Health Plan 44 Section 9
The following chart illustrates whether the Original Medicare Plan or
this Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you tell us
if you or a
covered family member has Medicare coverage so we can administer
these requirements correctly.
Primary Payer Chart
Then the primary
payer is… A. When either you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a)
The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that
you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an
annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
Please note, if your
Plan physician does not participate in Medicare, you will have to file a claim
with Medicare. 44
44 Page
45 46
2002 Sioux Valley Health Plan
45 Section 9
Claims process when you have the Original
Medicare Plan --You probably will never have to file a claim form when you
have both our Plan and the
Original Medicare Plan.
. When we are the
primary payer, we process the claim first.
. When Original Medicare is the primary payer, Medicare processes your
claim first. In most cases, your claims will be coordinated automatically
and we will pay the balance of covered charges. You will not need to do
anything. To find out if you need to do something about filing your claims,
call us at 605/ 328-6800 or 1-800/ 752-5863.
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.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If
. If you do not enroll in
Medicare Part A or Part B 45
45 Page 46 47
2002 Sioux Valley Health Plan 46 Section 9
both TRICARE and this Plan cover you, we pay first. See your TRICARE
Health Benefits Advisor if you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
. you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State
agency determines they must provide; or
. OWCP or a similar agency pays
for through a third party injury settlement or
other similar proceeding that
is based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our provider.
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.
The Plan will provide health care services to the Member for the illness or
injury, just as it would in any other case. However, if the Member accepts the
services from the Plan, this acceptance constitutes the Member's consent to
the subrogation provisions discussed above.
Member's Responsibilities The Member must take such action, furnish
such information and assistance, and execute such instruments as the Plan may
require to facilitate enforcement of its
rights under this provision. The
Member shall take no action prejudicing the rights and interests of the Plan
under this provision. Any Member who fails to
cooperate in the Plan's
administration of this subrogation provision shall be responsible for the Usual
and Reasonable Charges for services subject to this
Part and any legal costs
incurred by the Plan to enforce its rights under this Part. 46
46 Page 47 48
2002 Sioux Valley Health Plan 47 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 13, Section 4.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 13, Section 4.
Covered services
Care we provide benefits for, as described in this brochure.
Custodial care Care in which room, board, and other personal
assistance services are provided, generally on a long-term basis and which does
not include a medical component.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for those services.
See page 13, Section 4.
Any healthcare services where the Healthcare service in question is either:
1) 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 2)
requires approval by any governmental authority and
such approval has not been granted prior to the service being rendered.
Medical necessity Health care services that are appropriate, in terms
or type, frequency, level, setting, and duration, to the Members diagnosis or
condition, and diagnostic
testing and preventative services. Medically
necessary care must: . Be consistent with generally accepted standards of
medical practice as
recognized by the plan, 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 Member's health; or
. Prevent deterioration of the Member's condition;
or .
Prevent the reasonably likely onset of a health problem or detect an
incipient problem; or
. Not considered experimental or invesitgative.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in different
ways. We determine our allowance as follows: For
in-network coverage the allowance is based on a percent of discounted charges
that the Plan has
negotiated with Participating Providers; in-network
providers accept the plan allowance as payment in full. For out-of-network
providers the allowance is
based on a percent of eligible reasonable and
customary charges.
Us/ We Us and we refer to Sioux Valley Health Plan
Experimental or investigational services 47
47 Page 48 49
2002 Sioux Valley Health Plan 48 Section 10
Utilization Management A set of formal techniques designed to
monitor the use of, or evaluate the clinical necessity, appropriateness,
efficacy, or efficiency of, health care
services, procedures, or facilities.
You You refers to the enrollee and each covered family member. 48
48 Page 49 50
2002 Sioux Valley Health Plan 49 Section 11
Section 11.
FEHB facts
No pre-existing condition We will not refuse to cover the
treatment of a condition that you had limitation before you enrolled in
this Plan solely because you had the condition before you
enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing
or about enrolling in the retirement office can answer your questions,
and give you a Guide to Federal
FEHBP Program Employees 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. 49
49
Page 50 51
2002
Sioux Valley Health Plan 50 Section 11
Your medical and claims
records are confidential We will keep your medical and claims information
confidential. Only 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.
. records are confidential
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
. When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
. Your enrollment ends, unless you cancel your enrollment, or
. You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
. Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you may
be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary Continuation of Coverage and Former
Spouse Enrollees, or
other information about your coverage choices.
. Temporary continuation of coverage (TCC) If you leave Federal
service, or if you lose coverage because you no longer
qualify as a family
member, you may be eligible for Temporary Continuation of Coverage (TCC). For
example, you can receive TCC if you are not able to
continue your FEHB
enrollment after you retire, if you lose your job, if you are a covered
dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary
Continuation of Coverage and Former Spouse Enrollees, from
your employing 50
50 Page
51 52
2002 Sioux Valley Health Plan 51 Section 11
or retirement
office or from www. opm. gov/ insure. It
explains what you have to do to enroll.
. Converting to You may
convert to a non-FEHB individual policy if: individual coverage
.
Your coverage under TCC or the spouse equity law ends (If you canceled
your
coverage or did not pay your premium, you cannot convert)
. You decided not to receive coverage under TCC or the spouse equity law;
or
. You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this
notice. However, if you are a family member who is losing coverage, the
employing or retirement office will not notify you. You must apply in
writing
to us within 31 days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we will
not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) is a
Federal
law that offers limited Federal protections for health coverage availability and
continuity to people who lose employer group coverage. If you
leave the FEHB
Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us. You can use
this
certificate when getting health insurance or other health care coverage. Your
new plan must reduce or eliminate waiting periods, limitations, or
exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program.
See also the FEHB web site
(www. opm. gov/ insure/ health); refer to the
"TCC and HIPAA" frequently asked 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 it has information about
Federal and State agencies you can
contact for more information. 51
51 Page 52 53
2002 Sioux Valley Health Plan 52
Long Term Care Insurance
Long Term Care Insurance Is Coming
Later in 2002!
The Office of Personnel Management (OPM) will sponsor a
high-quality long term care insurance program effective in October 2002. As part
of its educational effort, OPM asks you to consider these questions:
. It's
insurance to help pay for long term care services you may need if you
can't
take care of yourself because of an extended illness or injury, or an
age-related disease such as Alzheimer's.
. LTC insurance can provide broad, flexible benefits for nursing home care,
care in an assisted living facility, care in your home, adult day care,
hospice care, and more. LTC insurance can supplement care provided by family
members, reducing the burden you place on them
. Welcome to the club! .
76% of Americans believe they will never need long term care, but the facts
are that about half of them will. And it's not just the old folks. About 40%
of people needing long term care are under age 65. They may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis,
etc.
. We hope you will never need long term care, but everyone should have a
plan just in case. Many people now consider long term care insurance to be
vital to their financial and retirement 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!
. Long term care can easily exhaust your savings. Long term care insurance
can protect your savings.
. Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of
your FEHB brochure. Health plans don't cover custodial care or a stay
in an assisted living facility or a continuing need for a home health aide to
help you get in and out of bed and with other activities of daily living.
Limited stays in skilled nursing facilities can be covered in some
circumstances. . Medicare only covers skilled nursing home care (the highest
level of
nursing care) after a hospitalization for those who are blind, age
65 or older or fully disabled. It also has a 100 day limit.
. Medicaid
covers long term care for those who meet their state's poverty
guidelines,
but has restrictions on covered services and where they can be received. Long
term care insurance can provide choices of care and
preserve your independence.
. Employees will get more information
from their agencies during the LTC
open enrollment period in the late
summer/ early fall of 2002. . Retirees will receive information at home.
. Our toll-free teleservice center will begin in mid-2002. In the meantime,
you can learn more about the program on our web site at www. opm. gov/
insure/ ltc.
. Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
.
How are YOU planning to pay for the future custodial or chronic care you may
need? .
You should consider buying long-term care insurance.
What is long term care (LTC) insurance?
I'm healthy. I won't need long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for this new
insurance coverage?
How can I find out more about the program NOW? 52
52 Page 53 54
2002 Sioux Valley Health Plan 53 Index
Index Do not rely on this page; it is for your convenience and may
not show all pages where the terms appear.
Accidental injury 28 Allergy
tests 18
Alternative treatment 22 Allogenetic (donor) bone marrow transplant
25
Ambulance 27, 29 Anesthesia 25-27
Autologous bone marrow transplant
25 Biopsies 23
Birthing centers 17 Blood and blood plasma 26
Breast cancer screening 16 Casts 21
Catastrophic protection 13
Chemotherapy 18
Childbirth 17 Chiropractic 22
Cholesterol tests 16
Claims 40-42
Coinsurance 13,47 Colorectal cancer screening 16
Congenital
anomalies 23-24 Contraceptive devices and drugs 17, 32
Coordination of
benefits 43 Covered charges 9, 14-38
Covered providers 9, 14-38 Crutches 21
Deductible 13, 47 Definitions 47
Dental care 35 Diagnostic
services 15
Disputed claims review 41 Donor expenses (transplants) 25
Dressings 26 Durable medical equipment (DME) 21
Educational
classes and programs 22 Effective date of enrollment 49
Emergency 28
Experimental or investigational 39
Eyeglasses 19 Family planning 17
Fecal occult blood test 16 General Exclusions 39
Hearing
services 19 Home health services 21-22
Hospice care 27 Home nursing care
21-22
Hospital 26-27 Immunizations 16
Infertility 18 Inhospital
physician care 26-27
Inpatient Hospital Benefits 26-27 Insulin 32
Laboratory and pathological services 26 Magnetic Resonance
Imagings (MRIs) 15
Mail Order Prescription Drugs 32 Mammograms 16
Maternity Benefits 17
Medicaid 46 Medically necessary 47
Medicare 43-45 Mental Conditions/
Substance Abuse Benefits 30-31
Newborn care 17 Nursing Care 26-27
Nurse Anesthetist 26 Nurse Practitioner 32
Obstetrical care 17
Occupational therapy 19
Ocular injury 19 Office visits 15
Oral and
maxillofacial surgery 24 Orthopedic devices 20
Out-of-pocket expenses 13
Outpatient facility care 27
Pap test 16 Physical examination 16
Physical therapy 19 Physician 32
Physician's Assistant 32 Point of
service (POS) 36-38
Prior approval 10-12, 30-31, 37 Preventive care, adult
16
Preventive care, children 16 Prescription drugs 32-33
Preventive
services 16 Prostate cancer screening 16
Prosthetic devices 20 Psychologist
30
Radiation therapy 18 Renal dialysis 18
Room and board 26-27
Second surgical opinion 15
Skilled nursing facility care 27 Smoking
cessation 22
Speech therapy 19 Sterilization procedures 17, 23
Subrogation 46 Substance abuse 30-31
Surgery 23 . Anesthesia 25-27
.
Oral 24 . Outpatient 27
. Reconstructive 24 Temporary continuation of
coverage 50
Transplants 25, 34 Treatment Therapies 18
Vision
services 19 Well child care 16
Wheelchairs 21 Workers'
compensation 46
X-rays 15 53
53 Page 54 55
2002 Sioux
Valley Health Plan 54 Summary
Summary of benefits for the
Sioux Valley Health Plan 2002
. Do not rely on
this chart alone. All benefits are provided in full unless indicated and are
subject to the definitions, limitations,
and exclusions in this brochure. On
this page we summarize specific expenses we cover; for more detail, look inside.
. If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from the cover on your
enrollment form.
. We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office.................
Office visit copay: $10 per primary care visit; $10 per specialist visit 15
Services provided by a hospital:
.
Inpatient............................................................................................
. Outpatient
Surgery............................................................................
. Outpatient Hospital Services……………………………………….
. Outpatient
Rehabilitative Services (cardiac rehab, physical,
occupational, and speech
therapies)………………………………
$100 per admission
$25 per visit
Nothing
$10 per outpatient visit
26
27
27
19
Emergency benefits:
.
In-area..............................................................................................
. Out-of-area
......................................................................................
$50; waived if admitted
$50; waived if admitted
29
29
Mental health and substance abuse
treatment...................................... $100 per admission
$10 per
outpatient visit
30
Prescription drugs
.................................................................................
$ 10 per 30 day supply for generic medications
$ 20 per 30 day supply for
brand name medications
NOTE: If there is no generic equivalent available,
you will still have to pay the brand
name copay.
32
Dental Care
.......................................................................................
Benefits only for accidental injury, cancer that damages teeth and TMJ services.
$10 per visit
$25 per outpatient visit
$100 per inpatient stay
35
Vision Care
.......................................................................................
Eye exams for children up to age 17.
Eyeglasses or one pair of contact
lenses to correct an impairment directly caused by injury.
19 54
54 Page 55 56
2002 Sioux Valley Health Plan 55 Summary
Special features: 24 hour nurse line, Services for deaf and hearing
impaired, High risk pregnancies, Centers of Excellence for transplants 34
Point of Service benefits --Yes 36-38
Protection against catastrophic
costs (your out-of-pocket
maximum)......................................................... Nothing after
$1, 500/ Self Only or $3, 000/ Family enrollment per year
Any costs above reasonable and customary charges do not count toward this
protection.
13 55
55 Page
56 57
56
56
Page 57
2002 Sioux Valley Health Plan
56 Rates
2002 Rate Information for Sioux Valley Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and special FEHB guides are
published for
Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for
Postal Service Inspectors and Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization. Refer to the applicable
FEHB Guide .
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Central, Eastern South Dakota and counties surrounding the Rapid City area
Self Only AU1 $97.86 $56.16 $212.03 $121.69 $115.52 $38.50
Self and
Family AU2 $223.41 $106.21 $484.06 $230.12 $263.75 $65.87 57