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Humana Health Plan of Texas
Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure. |
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Sincerely,
Kay Coles James
Director
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Humana Health Plan of Texas http:// www. humana. com
A Health Maintenance Organization
For changes in benefits
see page 8.
Enrollment codes for this Plan:
High Option
UR1 Self Only UR2 Self and Family
Standard Option
UR4 Self Only UR5 Self and Family
Special notice: Members currently enrolled in Plan Codes UR1 Self Only or UR2 Self and Family will remain in that Plan Code unless an Open Season change is requested.
2003
Serving: San Antonio area
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 7 for requirements.
RI 73-070
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UNITED STATES
OFFICE OF PERSONNEL MANAGEMENT
WASHINGTON, DC 20415-0001
OFFICE OF THE DIRECTOR
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its
enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to
determine the care options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality
and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer
choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to
explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to
prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM
initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress
and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to
investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size; the FEHB
Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit
packages and yet keep health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and
your family. We suggest you also visit our web site at www. opm. gov/ insure.
Sincerely,
Kay Cole James Director
CON 131-64-4 September 1993
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Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative), .
To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
. To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and .
Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
. To communicate with your FEHB health plan when you or someone you have authorized to act on your
behalf asks for our assistance regarding a benefit or customer service issue. . To review, make a decision, or litigate your disputed claim.
. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
. For Government healthcare oversight activities (such as fraud and abuse investigations), .
For research studies that meet all privacy law requirements (such as for medical research or education), and . To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
. See and get a copy of your personal medical information held by OPM. .
Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information. . Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing
will not cover your personal medical information that was given to you or your personal representative, any information that you authorized OPM to release, or that was given out for law enforcement purposes or to
pay for your health care or a disputed claim.
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. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending
materials to a P. O. Box instead of your home address). . Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be
able to agree to your request if the information is used to conduct operations in the manner described above. . Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003.
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2003 Humana Health Plan of Texas, Inc. 2 Table of Contents
Table of Contents
Introduction .................................................................................................................................................................. 4
Plain Language .............................................................................................................................................................. 4
Stop Health Care Fraud! ............................................................................................................................................ 4-5
Section 1. Facts about this HMO plan ...................................................................................................................... 6-7
How we pay providers ................................................................................................................................. 6
Who provides my health care?..................................................................................................................... 6
Your Rights.................................................................................................................................................. 6
Service Area ................................................................................................................................................ 7
Section 2. How we change for 2003.. ............................................................... 8
Program-wide changes................................................................................................................................. 8
Changes to this Plan..................................................................................................................................... 8
Section 3. How you get care ... ............................................................................................................... 9-11
Identification cards ...................................................................................................................................... 9
Where you get covered care......................................................................................................................... 9
. Plan providers ........................................................................................................................................ 9
. Plan facilities.......................................................................................................................................... 9
What you must do to get covered care......................................................................................................... 9
. Primary care........................................................................................................................................... 9
. Specialty care ................................................................................................................................... 9-10
. Hospital care ........................................................................................................................................ 10
Circumstances beyond our control............................................................................................................. 11
Services requiring our prior approval ........................................................................................................ 11
Section 4. Your costs for covered services ................................................................................................................. 12
. Copayments ......................................................................................................................................... 12
. Coinsurance ......................................................................................................................................... 12
Your catastrophic protection out-of-pocket maximum.............................................................................. 12
Section 5. Benefits......................................................... 13-40
Overview ................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals......... 14-22
(b) Surgical and anesthesia services provided by physicians and other health care professionals ..... 23-27
(c) Services provided by a hospital or other facility, and ambulance services................................... 28-30
(d) Emergency services/ accidents ...................................................................................................... 31-33
(e) Mental health and substance abuse benefits ................................................................................. 34-35
(f) Prescription drug benefits ............................................................................................................. 36-37
(g) Special features................................................................................................................................... 38
. Flexible benefits option
. Services for deaf and hearing impaired
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2003 Humana Health Plan of Texas, Inc. 3 Table of Contents
. High risk pregnancies
. Centers of excellence
. 24-hour nurse line
(h) Dental benefits.................................................................................................................................... 39
(i) Non-FEHB benefits available to Plan members ................................................................................. 40
Section 6. General exclusions things we don't cover ............................................................................................... 41
Section 7. Filing a claim for covered services ............................................................................................................ 42
Section 8. The disputed claims process ................................................................................................................ 43-44
Section 9. Coordinating benefits with other coverage .......................................................................................... 45-49
When you have other health coverage ....................................................................................................... 45
. What is Medicare?......................................................................................................................... 45-46
. Medicare managed care plans ............................................................................................................. 48
. TRICARE and CHAMPVA................................................................................................................ 48
. Workers' Compensation ...................................................................................................................... 49
. Medicaid.............................................................................................................................................. 49
. Other Government agencies ................................................................................................................ 49
. When others are responsible for injuries ............................................................................................. 49
Section 10. Definitions of terms we use in this brochure ....................................................................................... 50-51
Section 11. FEHB facts .......................................................................................................................................... 52-55
Coverage information ................................................................................................................................ 52
. No pre-existing condition limitation.................................................................................................... 52
. Where you get information about enrolling in the FEHB Program..................................................... 52
. Types of coverage available for you and your family ......................................................................... 52
. Children's Equity Act.................................................................................................................... 52-53
. When benefits and premiums start ...................................................................................................... 53
. When you retire ................................................................................................................................... 53
When you lose benefits.............................................................................................................................. 53
. When FEHB coverage ends................................................................................................................. 53
. Spouse equity coverage....................................................................................................................... 53
. Temporary Continuation of Coverage (TCC) ..................................................................................... 54
. Converting to individual coverage ...................................................................................................... 54
. Getting a Certificate of Group Health Plan Coverage ................................................................... 54-55
Long term care insurance is still available................................................................................................................... 56
Index............................................................................................................................................................................ 57
Summary of benefits.............................................................................................................................................. 59-60
Rates .............................................................................................................................................................. Back cover
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2003 Humana Health Plan of Texas, Inc. 4 Introduction/ Plain Language
Introduction
This brochure describes the benefits of Humana Health Plan of Texas, Inc., under our contract (CS 1895) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address
for Humana Health Plan of Texas, Inc. administrative offices is:
Humana Health Plan of Texas, Inc. 8431 Fredericksburg Rd.
San Antonio, Texas 78229
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
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, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language 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 Humana Health Plan of Texas, Inc.
. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefit 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 email OPM at fehbpwebcomments@ 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.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud -Here are some things you can do to prevent fraud:
. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except
to your doctor, other provider, or authorized plan or OPM representative.
. Let only the appropriate medical professionals review your medical record or recommend services.
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2003 Humana Health Plan of Texas, Inc. 5 Introduction/ Plain Language
. Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid.
. Carefully review explanations of benefits (EOBs) that you receive from us.
. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or
service.
. If you suspect that a provider 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 1-800/ 4HUMANA and explain the situation.
. If we do not resolve the issue:
CALL THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
OR WRITE TO:
The United States Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415
. Do not maintain as a family member on your policy:
. your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
. your child over age 22 unless he/ she is disabled and incapable of self support.
. If you have any questions about the eligibility of a dependent, check with your personnel office if you are
employed or with OPM is you are retired.
. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain
FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
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2003 Humana Health Plan of Texas, Inc. 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments and coinsurance described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments and
coinsurance.
Who provides my health care
Humana Health Plan of Texas offers members an extensive choice of primary care physicians. Humana contracts with both private office physicians and with physician networks. When choosing a physician from one of the
physician networks for your primary care needs, you should expect to receive all specialty care from providers affiliated with your primary care physician's network. Obstetricians and gynecologists must be selected from
providers affiliated with your primary care physician's network. If your physician's network cannot provide the services you need, your primary care physician will make arrangements for you to receive the care from an
appropriate provider. To find out if your primary care physician is affiliated with a certain network, check the provider directory or call the Plan before you make your selection.
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.
. Medical case management is a special Humana program that coordinates the provision of care and the management of benefits in cases of catastrophic illness or injury, transplant management and disease management. The program
strives to ensure that patients receive the most appropriate, cost-effective care and also derive maximum advantage from plan benefits.
. Humana has adopted preventative care guidelines based on the United States Preventative Health Task Force and subscribes to their Healthy People 2000 goals. Our Patterns of Preventative Care (POPC) program monitors the
delivery of well care and uses an automated reminder system to help assure that our members schedule routine preventative services.
. Humana provides comprehensive disease management programs to plan members. Key to each program is ongoing education, communication and coordination. Each contracted vendor offers plan members access to a staff of highly
specialized nurses and doctors, experienced in the respective disease field. The programs focus on linking the plan member with a specialized nurse or interdisciplinary team to ensure an individualized care development approach.
These nurses work closely with the plan member, member's family, member's primary care physician (PCP) and other involved providers to provide information, education and assistance when needed.
. Nationally, Humana has been in the health care business since 1961. Locally, Humana has been in existence since 1986.
. Humana is a for profit corporation which is publicly traded on the New York Stock Exchange (NYSE).
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2003 Humana Health Plan of Texas, Inc. 7 Section 1
If you want more information about us, call 1-800/ 4HUMANA, or write to the Plan at P. O. Box 400040, San Antonio, Texas 78229. You may also contact us by fax at 210/ 615-3320 or visit our website at www. humana. com.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:
The Texas counties of Atascosa, Bexar, Blanco, Comal, Frio, Guadalupe, Karnes, Kendall, Medina and Wilson and Zip codes 78003 and 78063 in Bandera County.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office.
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2003 Humana Health Plan of Texas, Inc. 8 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
. A Notice of the Office of Personnel Management's Privacy Practices is included.
. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family
coverage.
. Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their
FEHB Program enrollment.
. Program information on Medicare is revised.
. By law, the DoD/ FEHB Demonstration projects ends on December 31, 2002.
Changes to this Plan
. A new Standard Option Plan is being offered.
. The 2002 UR1 and UR2 plans will become High Option.
. Your share of the High Option non-Postal premium will increase by 29.9% for Self Only and 42.4% for Self and
Family.
. You pay a $20 copay for a specialist visit.
. You pay a $20 copay for physical, occupational, speech and cardiac therapy.
. You pay a $100 copay per day for the first three days per inpatient admission.
. You pay $100 per visit for outpatient surgery; and $50 per visit for other outpatient hospital services.
. You pay $75 for emergency care, including doctor fees, at a hospital outpatient facility.
. Skilled nursing facility benefits were increased from 60 days per calendar year to 100 days per calendar year.
. You pay a $5 copay for Level 1 prescription drugs; a $20 copay for Level 2 drugs; a $40 copay for Level 3 drugs;
and 25% of the amount that the Plan pays for Level 4 drugs.
. The dollar limits have been removed from the hospice benefit.
. After your copayments or coinsurance total $2,500 per person or $5,000 per family enrollment in a calendar year,
you do not have to pay any more for covered services.
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2003 Humana Health Plan of Texas, Inc. 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at
1-800/ 4HUMANA or 1-800/ 448-6262 or write to us at P. O. Box 400040, San Antonio, Texas 78229. You may also request replacement cards
through our website at www. humana. com..
Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and/ or coinsurance, and you will not have to file claims.
. Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website at www. humana. com.
. 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 at www. humana. com.
What you must do to get covered care It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for
most of your health care. You may choose your primary care physician from our Provider Directory or our website, or you may call us for
assistance.
. Primary care Your primary care physician can be a family practitioner, internist or
pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
. Specialty care Your primary care physician will refer you to a specialist for needed care.
When you receive a referral from your primary care physician, you must return to your primary care physician after the consultation, unless your
primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or
authorize follow-up care. Do not go to the specialist for your return visit unless your primary care physician gives you a referral. However, you
may see the following providers without a referral:
. Mental health providers
. Vision care providers
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2003 Humana Health Plan of Texas, Inc. 10 Section 3
. OB/ GYN providers
. Another doctor your primary care physician has designated to provide
patient care when he or she is not available.
Here are other things you should know about specialty care:
. If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for
a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval beforehand).
. If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to
a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive
treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
. If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.
. If you have a chronic or disabling condition and lose access to your
specialist because we:
. terminate our contract with your specialist for other than cause; or
. drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
. reduce our service area and you enroll in another FEHB Plan;
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the
program, contact your new plan.
If you are in the third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90 days.
. Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800/ 4HUMANA. 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.
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2003 Humana Health Plan of Texas, Inc. 11 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to refer you for most services. prior approval For certain services, however, your physician must obtain approval from
us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.
We call this review and approval process precertification. Your physician must obtain precertification for the following services:
. Growth hormone therapy .
Organ/ Tissue transplants . Gastric bypass
. All durable medical equipment (DME) over $750 .
Acute inpatient rehabilitation services . Home health care services
. Genetic testing .
Infertility services . Pain Management services
. PET and SPECT scans .
Sclerotherapy . Occupational and Physical therapies
. Prescription drugs requiring prior authorization
Your physician must obtain our approval before sending you to a hospital, referring you to a specialist, or recommending follow-up care
from a specialist.
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2003 Humana Health Plan of Texas, Inc. 12 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 the provider,
facility, pharmacy etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10 per office visit and $20 per specialist office visit on the
High Option plan.
. Deductible We do not have a deductible.
. Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care.
Example: In our Plan, you pay 50% of our allowance for infertility services.
Your catastrophic protection out-of-pocket maximum for
copayments and coinsurance After your copayments or coinsurance total $2,500 per person or $5,000 per family enrollment in any calendar year, you do not have to pay any
more for covered services. However, copayments for the following services do not count toward your catastrophic protection out-of-pocket
maximum, and you must continue to pay copayments for these services:
. Prescription drugs
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.
15.
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Page 16
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2003 Humana Health Plan of Texas, Inc. 13 Section 5
Section 5. Benefits OVERVIEW (See page 8 for how our benefits changed this year and pages 59-60 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 sections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-800/ 4HUMANA or at our website at www. humana. com.
(a) Medical services and supplies provided by physicians and other health care professionals .......................... 14-22
. 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, occupational and cardiac 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....................... 23-27
. Surgical procedures
. Reconstructive surgery
. Oral and maxillofacial surgery
. Organ/ tissue transplants
. Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................... 28-30
. Inpatient hospital
. Outpatient hospital or ambulatory surgical
center
. Extended care benefits/ skilled nursing care
facility benefits .
Hospice care .
Ambulance
(d) Emergency services/ accidents ........................................................................................................................ 31-33
. Medical emergency . Ambulance
(e) Mental health and substance abuse benefits ................................................................................................... 34-35
(f) Prescription drug benefits............................................................................................................................... 36-37
(g) Special features..................................................................................................................................................... 38
. Flexible benefits option .
24-hour nurse line . Services for deaf and hearing impaired
. High risk pregnancies .
Centers of excellence
(h) Dental benefits...................................................................................................................................................... 39
(i) Non-FEHB benefits available to Plan members ................................................................................................... 40
Summary of benefits.............................................................................................................................................. 59-60
16.
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2003 Humana Health Plan of Texas, Inc. 14 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.
. 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 Standard Option High Option
Professional services of physicians
. In physician's office
. In an urgent care center
. Office medical consultations
. Second surgical opinion
$15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care physician
$20 per office visit to a specialist
. During a hospital stay
. In a skilled nursing facility
Nothing Nothing
Professional services of physicians
. At home
$15 per house call by your primary care physician $10 per house call by your primary care physician
Lab, x-ray and other diagnostic tests
Such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
. Non-routine Mammograms
. CAT Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG
Nothing if you receive these services during your
office visit; otherwise,
$15 per office visit to your primary care physician
$25 per office visit to a specialist
Nothing if you receive these services during your
office visit; otherwise,
$10 per office visit to your primary care physician
$20 per office visit to a specialist
17.
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Page 18
19
2003 Humana Health Plan of Texas, Inc. 15 Section 5( a)
Preventive care, adult You pay -Standard Option You pay High Option
Routine screenings, such as:
. A fasting lipoprotein profile (total
cholesterol , LDL, HDL and triglycerides) once every five years for adults 20 or
over; and.
. Colorectal Cancer Screening, including
Fecal occult blood test: . Sigmoidoscopy screening every five
years starting at age 50; or
. Colonoscopy once every ten years at
age 50; or
. Double contrast barium enema
(DCBE) once every five to ten years at age 50.
. Chlamydial infection screening
. Routine Prostate Specific Antigen (PSA)
test one annually for men age 40 and older
. Routine pap test one annually
Note: The office visit is covered if pap test is received on the same day; see Diagnostic
and treatment services, above.
$15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care physician
$20 per office visit to a specialist
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
. When prescribed by the doctor as
medically necessary to diagnose or treat illness.
$15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care physician
$20 per office visit to a specialist
Not covered: Physical exams and immunizations required for obtaining or
continuing employment or insurance, attending schools or camp, or travel.
All charges 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 vaccines, annually
. Pneumococcal vaccine, age 65 and over,
or in the presence of high risk, chronic conditions.
$15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care physician
$20 per office visit to a specialist
18.
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Page 19
20
2003 Humana Health Plan of Texas, Inc. 16 Section 5( a)
Preventive care, children You pay -Standard Option You pay High Option
. Childhood immunizations recommended
by the American Academy of Pediatrics Nothing Nothing
. Well-child care charges for routine
examinations, immunizations and care (through 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 (through age 22)
$15 per office visit to your primary care
physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
Maternity care
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
Note: Here are some things to keep in mind:
. 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).
$15 for initial office visit only to your
primary care physician
$25 for initial office visit to a specialist
No copay for other prenatal and postnatal
visits
$10 for initial office visit only to your
primary care physician
$20 for initial office visit to a specialist
No copay for other prenatal and postnatal
visits
Not covered: Routine sonograms to determine fetal age, size, or sex. All charges All charges
19.
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Page 20
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2003 Humana Health Plan of Texas, Inc. 17 Section 5( a)
Family planning You pay Standard Option You pay High Option
A range of voluntary family planning services, limited to:
. Voluntary sterilization -See Surgical
procedures, Section 5( b)
. Surgically implanted contraceptives
(such as Norplant)
. Injectable contraceptive drugs (such as
Depo provera)
. Intrauterine devices (IUDs)
. Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit. See Section 5 (f).
$15 per office visit to your primary care
physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
Not covered: Reversal of voluntary surgical sterilization All charges All charges
Infertility services
Diagnosis and treatment of infertility, such as:
. Artificial insemination: .
intravaginal insemination (IVI) . intracervical insemination (ICI)
. intrauterine insemination (IUI)
. Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral fertility
drugs under the prescription drug benefit. See Section 5 (f).
50% of all charges 50% of all charges
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 All charges
Allergy care
. Testing and treatment, including test and
treatment materials $15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
20.
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Page 21
22
2003 Humana Health Plan of Texas, Inc. 18 Section 5( a)
Allergy care (continued) You pay Standard Option You pay High Option
. Allergy serum
. Allergy injections
Nothing Nothing
Not covered: Provocative food testing and sublingual allergy desensitization All charges All charges
Treatment therapies
. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow
transplants is limited to those transplants listed under Organ/ Tissue Transplants on
page 26.
. Respiratory and inhalation therapy
. Dialysis hemodialysis and peritoneal
dialysis
$15 per office visit to your primary care
physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
. Intravenous (IV)/ Infusion Therapy
Home IV and antibiotic therapy Nothing Nothing
. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We will only cover Growth Hormone Therapy if the treatment is precertified and
there is a laboratory confirmed diagnosis of Growth Hormone Deficiency. You will
need to call the precertification telephone number on the back of your medical ID
(identification) card. We will also ask that your physician submit information that
establishes that the GHT is medically necessary. GHT must be authorized before
you begin treatment.
See Services requiring our prior approval in Section 3.
$15 per office visit to your primary care
physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
21.
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Page 22
23
2003 Humana Health Plan of Texas, Inc. 19 Section 5( a)
Physical, occupational and cardiac therapies You pay Standard Option You pay High Option
. Physical and occupational therapy.
provided by:
. qualified physical therapists and .
occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total
or partial loss of bodily function due to illness or injury. Occupational therapy is
limited to services that assist the member to achieve and maintain self-care and
improved functioning in other activities of daily living.
$25 per office visit;
$25 per outpatient visit; and
Nothing per visit during covered inpatient
admission
$20 per office visit;
$20 per outpatient visit; and
Nothing per visit during covered inpatient
admission
. Inpatient cardiac rehabilitation
following a heart transplant, bypass surgery or a myocardial infarction, is
provided for up to 30 sessions.
Nothing Nothing
. Outpatient cardiac rehabilitation
following a heart transplant, bypass surgery or a myocardial infarction, is
provided for up to 30 sessions.
$25 per office visit $20 per office visit
Not covered:
. Long-term rehabilitative therapy
. Exercise programs
All charges All charges
Speech therapy
. Speech therapy provided by speech
therapists $25 per office visit; $25 per outpatient visit;
and
Nothing per visit during covered inpatient
admission
$20 per office visit;
$20 per outpatient visit; and
Nothing per visit during covered inpatient
admission
22.
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Page 23
24
2003 Humana Health Plan of Texas, Inc. 20 Section 5( a)
Hearing services (testing, treatment, and supplies) You payStandardOption You payHighOption
. Hearing testing for children through age
17 (see Preventive care, children) $15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
Not covered:
. All other hearing testing
. Hearing aids, testing and examinations
for them
All charges All charges
Vision services (testing, treatment, and supplies)
. Diagnosis and treatment of diseases of the
eye.
. Annual eye refractions (to provide a
written lens prescription for eyeglasses)
. Eye exam to determine the need for vision
correction for children through age 17 (see Preventive care, children)
. One pair of eyeglasses or contact lenses to
correct an impairment directly caused by accidental ocular injury or intraocular
surgery (such as for cataracts)
$15 per office visit to your primary care
physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
Not covered:
. Eyeglasses or contact lenses and, after
age 17, examinations for them, except as shown above
. Eye exercises and orthoptics
. Radial keratotomy and other refractive
surgery
All charges All charges
23.
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Page 24
25
2003 Humana Health Plan of Texas, Inc. 21 Section 5( a)
Foot care You pay Standard Option You pay High Option
Routine foot care when you are under active treatment for a metabolic or peripheral
vascular disease, such as diabetes.
See Orthopedic and prosthetic devices for information on podiatric shoe inserts.
$15 per office visit to your primary care
physician
$25 per office visit to a specialist
$10 per office visit to your primary care
physician
$20 per office visit to a specialist
Not covered:
. Cutting, trimming or removal of corns,
calluses, or the free edge of toenails, and similar routine treatment of conditions of
the foot, unless primary medical condition requires such care
. 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 All charges
Orthopedic and prosthetic devices
. Artificial limbs
. Foot orthotics
. Orthopedic devices such as braces
. Externally worn breast prostheses and
surgical bras, including necessary replacements, following a mastectomy
. Internal prosthetic devices, such as
artificial joints and pacemakers. 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.
Nothing Nothing
Not covered:
. Orthopedic and corrective shoes
. Arch supports
. Heel pads and heel cups
. Lumbosacral supports
. Corsets, trusses, elastic stockings,
support hose, and other supportive devices
. Prosthetic replacements except as
required by growth or change in medical condition
All charges All charges
24.
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Page 25
26
2003 Humana Health Plan of Texas, Inc. 22 Section 5( a)
Durable medical equipment (DME) You payStandardOption You payHighOption
Rental or purchase, at our option, including repair and adjustment, of durable medical
equipment prescribed by your Plan physician, such as oxygen and dialysis equipment.
Under this benefit, we also cover:
. Hospital beds
. Wheelchairs
. Crutches
. Walkers
. Insulin pumps
Nothing Nothing
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 includes intravenous therapy and
medications.
Nothing Nothing
Not covered:
. Nursing care requested by, or for the
convenience of, the patient or the patient's family
. Home care primarily for personal
assistance that does not include a medical component and is not diagnostic,
therapeutic, or rehabilitative
All charges All charges
Chiropractic
No benefit All charges All charges
Alternative treatments
No benefit All charges All charges
Educational classes and programs
Coverage is limited to:
. Smoking cessation Up to $100 for one
smoking cessation program per member per lifetime. Nothing Nothing
. Diabetic self management training $15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care physician
$20 per office visit to a specialist
25.
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Page 26
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2003 Humana Health Plan of Texas, Inc. 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.
. 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 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 Standard Option High Option
A comprehensive range of services, such as:
. Operative procedures
. Treatment of fractures, including casting
. Normal pre-and post-operative care by
the surgeon
. 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 (e. g., Tubal
ligation, Vasectomy)
. Treatment of burns
Nothing Nothing
Not covered:
. Reversal of voluntary sterilization
All charges All charges
26.
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2003 Humana Health Plan of Texas, Inc. 24 Section 5( b)
Reconstructive surgery You pay Standard Option You pay High Option
. 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 that is a significant deviation from the common
form or norm. Examples of congenital anomalies are: protruding ear
deformities; cleft lip; cleft palate; birth marks; webbed fingers and webbed toes.
. All stages of breast reconstruction
surgery following a mastectomy, such as: . surgery to produce a symmetrical
appearance on the other breast; . treatment of any physical
complications, such as lymphedemas; . breast prostheses and surgical bras
and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure performed on
an inpatient basis and remain in the hospital up to 48 hours after the procedure.
Nothing Nothing
Not covered:
. Cosmetic surgery any surgical
procedure (or any portion of a procedure) performed primarily to
improve physical appearance through change in bodily form, except repair of
accidental injury
. Surgeries related to sex transformation
All charges All charges
27.
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Page 28
29
2003 Humana Health Plan of Texas, Inc. 25 Section 5( b)
Oral and maxillofacial surgery You pay Standard Option You pay High Option
Oral surgical procedures, limited to:
. Reduction of fractures of the jaws or
facial bones;
. Surgical correction of congenital defects
such as cleft lip or 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;
. Diagnosis and treatment specifically
directed toward medical and functional disorders of the temporomandibular joint
(TMJ); and
. Other surgical procedures that do not
involve the teeth or their supporting structures.
Nothing Nothing
Not covered:
. Procedures that involve the teeth or their
supporting structures (such as the periodontal membrane, gingiva, and
alveolar bone)
. Oral implants and transplants
All charges All charges
28.
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Page 29
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2003 Humana Health Plan of Texas, Inc. 26 Section 5( b)
Organ/ tissue transplants You pay Standard Option You pay High Option
Limited to:
. Cornea
. Heart
. Lung: Single-Double
. Heart/ Lung
. Kidney
. Kidney/ Pancreas
. Liver
. 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; Wiskott-Aldrich syndrome; severe
combined immunodeficiency syndrome; aplastic anemia; ewings sarcoma; 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
. Autologous tandem transplants as
accepted treatment for testicular and other germ cell tumors
Humana has a National Transplant Network with over 35 facilities within 20 states.
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 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 precertified.
Nothing 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 All charges
29.
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2003 Humana Health Plan of Texas, Inc. 27 Section 5( b)
Anesthesia You pay Standard Option You pay High Option
Professional services provided in
. Hospital (inpatient)
. Hospital outpatient department
. Skilled nursing facility
. Ambulatory surgical center
. Office
Nothing Nothing
30.
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2003 Humana Health Plan of Texas, Inc. 28 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
. Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
. Be sure to read Section 4, Your costs for covered services for valuable
information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
. The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i. e.,
physicians, etc.) are covered in Section 5( a) or (b).
. YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital Standard Option High Option
Room and board, such as
. Semiprivate, intensive care or cardiac
care accommodations;
. General nursing care;
. Private accommodations when a Plan
doctor determines it is medically necessary;
. Private duty nursing when Plan doctor
determines it is medically necessary; 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.
$250 per day for the first three days per admission $100 per day for the first three days per admission
Inpatient hospital services continued on next page
31.
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Page 32
33
2003 Humana Health Plan of Texas, Inc. 29 Section 5( c)
Inpatient hospital (continued) You pay Standard Option You pay High Option
Other hospital services and supplies, such as:
. Operating, recovery, maternity, and other
treatment rooms
. Administration of blood or blood
components
. Prescribed drugs and medicines
. Diagnostic laboratory tests and x-rays
. 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 Nothing
Not covered:
. Cost of blood and blood components if
replaced
. Custodial care
. Non-covered facilities, such as nursing
homes
. Personal comfort items, such as
telephone, television, barber services, guest meals and beds
All charges All charges
Outpatient hospital or ambulatory surgical center
Outpatient surgery
. Operating, recovery, and other treatment
rooms
. Prescribed drugs and medicines
. Laboratory tests, x-rays, and pathology
services
. Administration of blood, blood plasma,
and other biologicals
. Blood and blood components if not
replaced
. Dressings, casts, and sterile tray services
. Medical supplies, including oxygen
. Anesthetics and anesthesia service
$200 copay per visit $100 copay per visit
Outpatient hospital or ambulatory surgical center continued on next page
32.
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Page 33
34
2003 Humana Health Plan of Texas, Inc. 30 Section 5( c)
Outpatient hospital or ambulatory surgical center (continued) You pay Standard Option You pay High Option
Pre-surgical testing Nothing Nothing
Other hospital outpatient services
Note: We cover hospital services and supplies related to dental procedures when
necessitated by a non-dental physical impairment. We do not cover the dental
procedures.
$100 copay per visit $50 copay per visit
Not covered: Blood and blood derivatives if replaced by the member All charges All charges
Extended care benefits/ skilled nursing care facility benefits
Extended care benefit:
Up to 100 days per calendar year, including . bed and board
. general nursing care .
drugs, biologicals, supplies and equipment provided by the facility.
Note: Coverage is provided when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as determined by a
Plan doctor and approved by the Plan.
Nothing Nothing
Not covered: Custodial care, rest cures, domiciliary or convalescent care All charges All charges
Hospice care
Supportive and palliative care for a terminally ill member is covered in the
home or hospice facility. Bereavement counseling is also covered.
Note: These services are provided under the direction of a Plan doctor who certifies that
the patient is in the terminal stages of illness, with a life expectancy of approximately six
months or less.
Nothing Nothing
Not covered: Independent nursing, homemaker services All charges All charges
Ambulance
. Local professional ambulance service
when ordered or authorized by a Plan doctor Nothing Nothing
33.
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2003 Humana Health Plan of Texas, Inc. 31 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 and are payable only when we determine they are medically necessary.
. Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical
care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have
in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local
emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family
member must notify the Plan within 48 hours unless it was not reasonably possible to do so. It is your responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you
are hospitalized in a non-Plan facility and a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan
doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
Emergency services/ accidents continued on next page
34.
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2003 Humana Health Plan of Texas, Inc. 32 Section 5( d)
Benefit Description You pay
Emergency within our service area Standard Option High Option
. Emergency care as an outpatient at a
hospital, including doctor's services
If the emergency results in admission to a hospital, the emergency care copay is
waived.
$75 per visit $75 per visit
. Emergency care at a doctor's office or
urgent care center $15 per office visit to your primary care physician
$25 per office visit to a specialist
$10 per office visit to your primary care physician
$20 per office visit to a specialist
Not covered: Elective care or non-emergency care All charges All charges
Emergency outside our service area
. Emergency care as an outpatient at a
hospital, including doctor's services
If the emergency results in admission to a hospital, the emergency care copay is
waived.
$75 per visit $75 per visit
. Emergency care at an urgent care center or
at a doctor's office $15 per office visit to a primary care physician
$25 per office visit to a specialist
$10 per office visit to a primary care physician
$20 per office visit to a specialist
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 All charges
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2003 Humana Health Plan of Texas, Inc. 33 Section 5( d)
Ambulance You pay Standard Option You pay High Option
. Professional ambulance service when
ordered or authorized by a Plan doctor. See 5( c) for non-emergency service.
Note: Air ambulance is covered only when point of pick-up is inaccessible by land
vehicle; or great distances or other obstacles are involved in getting a patient
to the nearest hospital with appropriate facilities when prompt admission is
essential
Nothing Nothing
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2003 Humana Health Plan of Texas, Inc. 34 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:
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.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Description You pay
Mental health and substance abuse benefits Standard Option High Option
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan may include
services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive the care as part of a
treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illnesses or conditions.
Your cost sharing responsibilities are no
greater than for other illnesses or conditions.
. Professional services, including
individual or group therapy by providers such as psychiatrists, psychologists, or
clinical social workers
. Medication management
$25 per office visit $20 per office visit
. Diagnostic tests Nothing if you receive
these services during your office visit; otherwise,
$25 per office visit to a specialist
Nothing if you receive these services during your
office visit; otherwise,
$20 per office visit to a specialist
. Services provided by a hospital or other
facility $250 per day for the first three days per admission $100 per day for the first three days per admission
Mental health and substance abuse benefits continued on next page
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2003 Humana Health Plan of Texas, Inc. 35 Section 5( e)
Mental health and substance abuse benefits (continued) You pay Standard Option You pay High Option
. Services in approved alternative care
settings such as partial hospitalization, half-way house, residential treatment,
full-day hospitalization, facility based intensive outpatient treatment
. NOTE: Some services are considered to
be partial hospitalization. Two partial days will be considered one confinement
day.
$100 copay for outpatient services $50 copay for outpatient services
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the treatment
plan's clinical appropriateness. OPM will generally not order us to pay or provide
one clinically appropriate treatment plan in favor of another.
All charges All charges
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes.
Please contact Magellan Behavioral Health at 1-800-473-2422 to obtain Mental Health/ Substance Abuse treatment services.
Limitation We may limit your benefits if you do not obtain a treatment plan.
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2003 Humana Health Plan of Texas, Inc. 36 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
. All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically necessary.
. Be sure to read Section 4, Your costs for covered services for valuable
information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
. Who can write your prescription. A plan physician or licensed dentist must write the prescription.
. Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a prescribed
maintenance medication. Maintenance medications are drugs that are generally prescribed for the treatment of long term chronic sicknesses or injuries.
. The Rx4 Plan allows members access to any drug that is used to treat a condition the medical plan covers.
Thousands of drugs have been placed in levels based on their a) efficacy, b) safety, c) possible side effects, d) drug interactions, and e) cost compared to similar drugs. The levels are no longer based on a Drug List or
formulary. New drugs are continually reviewed for level placement, dispensing limits and prior authorization requirements that represent the current clinical judgment of our Pharmacy and Therapeutics Committee.
Level One contains the lowest copayment for low cost generic and brand-name drugs.
Level Two copays are higher than Level One this level covers higher cost generic and brand-name drugs.
Level Three is made up of higher cost drugs, mostly brand names. These drugs may have generic or brand-name options on Levels One or Two.
Level Four includes high technology drugs that are often newly approved by the U. S. Food and Drug Administration.
Rx4's specific copayment amounts for the first three levels eliminate unexpected charges at the pharmacy, which means you won't have to calculate cost differentials when you choose brand-name drugs over generic
equivalents. You can visit our web site at www. humana. com to check the copayment for your prescription drug coverage before you get your prescription filled. You can also find out more about possible drug
alternatives and the locations of participating pharmacies.
With Rx4 the member takes on more of the cost share for the drug. In return, members receive access to more drugs to treat their conditions and have more choices, along with their physicians, to decide which drug
to take. Members receive letters offering guidance in changing medications to those with a lower copayment. We use internal data to identify members for whom a less expensive prescription drug option may be
available. We communicate the information to the member to enable them, along with their physician, to make an informed choice regarding prescription drug copayment options.
. These are the dispensing limits. Prescription drugs dispensed at a Plan pharmacy will be dispensed for up
to a 30-day supply. You may receive up to a 90-day supply of a prescribed maintenance medication through our mail-order program.
Prescription drug benefits begin on the next page.
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41
2003 Humana Health Plan of Texas, Inc. 37 Section 5( f)
Benefit Description You pay
Covered medications and supplies Standard Option High Option
We cover the following medications and supplies prescribed by a licensed physician
and obtained from a Plan pharmacy or through our mail order program:
. Drugs and medicines that by Federal law of the United States require a physician's
prescription for their purchase, except those listed as Not covered
. Insulin .
Disposable needles and syringes for the administration of covered medications
. Diabetic supplies including testing agents, lancet devices, alcohol swabs,
glucose elevating agents, insulin delivery devices, and blood glucose monitors.
. Self administered injectable drugs .
Oral fertility drugs . Oral contraceptive drugs
. Formulas necessary for treatment of phenylketonuria or other inherited diseases
. Drugs for sexual dysfunction .
Growth hormones
Note: Drugs to treat sexual dysfunction are limited. Contact the Plan for dosage limits.
You pay the applicable drug copay up to the dosage limits, and all charges after that.
$10 for Level One drugs
$25 for Level Two drugs
$45 for Level Three drugs
25% of the amount that the plan pays to the
dispensing pharmacy for Level Four drugs
Out of pocket maximum for Level Four benefits is
$2,500 per member per calendar year
Three applicable copays for a 90-day supply of
prescribed maintenance drugs, when ordered
through our mail-order program.
$5 for Level One drugs
$20 for Level Two drugs
$40 for Level Three drugs
25% of the amount that the plan pays to the
dispensing pharmacy for Level Four drugs
Out of pocket maximum for Level Four benefits is
$2,500 per member per calendar year
Three applicable copays for a 90-day supply of
prescribed maintenance drugs, when ordered
through our mail-order program.
Not covered:
. Drugs available without a prescription,
or for which there is a non-prescription equivalent available
. Drugs and supplies for cosmetic
purposes (such as Rogaine)
. Vitamins, fluoride, nutrients and food
supplements even if a physician prescribes or administers them (except
for the type of formulas listed above as covered)
. Drugs obtained at a non-Plan pharmacy
except for out of area emergencies
. Drugs to enhance athletic performance
. Smoking cessation drugs and
medications, including nicotine patches
. Any drug used for the purpose of weight
control
. Medical supplies such as dressings and
antiseptics
All charges All charges
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2003 Humana Health Plan of Texas, Inc. 38 Section 5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
. We may identify medically appropriate alternatives to
traditional care and coordinate other benefits as a less costly alternative benefit.
. Alternative benefits are subject to our ongoing review.
. By approving an alternative benefit, we cannot guarantee
you will get it in the future.
. The decision to offer an alternative benefit is solely ours,
and we may withdraw it at any time and resume regular contract benefits.
. Our decision to offer or withdraw alternative benefits is not
subject to OPM review under the disputed claims process.
24-hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call HumanaFirst at 1-800-622-9529 and talk
with a registered nurse who will discuss treatment options and answer your health questions.
Services for deaf and hearing impaired Humana offers telecommunication devices for the deaf (TDD) and Teletype (TTY) phone lines for the hearing impaired. Call
1-800-432-7482 to access the service.
High risk pregnancies HumanaBeginnings is an outreach program that provides high-risk plan members support and educational materials so care
can be actively managed during pregnancy.
Centers of excellence Members can use any facility that is within Humana's contracted National Transplant Network. This network has
over 35 transplant facilities located in more than 20 states.
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43
2003 Humana Health Plan of Texas, Inc. 39 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 cover hospitalization for dental procedures only when a nondental
physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; see Section 5 (c) for inpatient
hospital benefits. 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 Standard Option You pay High Option
We cover restorative services and supplies necessary to promptly repair (but not
replace) sound natural teeth. The need for these services must result from an
accidental injury.
Nothing Nothing
Dental benefits
We have no other dental benefits
42.
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2003 Humana Health Plan of Texas, Inc. 40 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection
out-of-pocket maximums.
. You are eligible to receive savings on dental services when provided
by participating dentists.
. No additional premium required.
Complementary and Alternative Medicine (CAM) is a program offered to all Humana members, giving discounted access to supplemental health
services. Through the program members will receive a discount of up to 30% on services by participating providers in the American WholeHealth
Network.
Alternative medicine is known for its focus on being healthy and preventing problems, not just treating illness and injury. To learn more
about this program go to www. wholehealthmd. com/ Humana.
. Discounts (listed in the separate Plan description) for frames and lenses
(including contacts) at participating vision care providers.
. No additional premium required.
. Discounts available at participating providers for eye exams, frames
and lenses. (see separate plan description on how to locate a provider nearest you).
. Mail Order Contact Lens Replacement Program .
Vision Correction (LASIK or PRK) for less than $1,000 per eye. (see separate Plan description on how to receive the discount
. No additional premium required.
. Free hearing aid evaluations at participating hearing aid providers.
. Free follow-up visits and adjustments for hearing aid within 60 days at
participating hearing aid providers.
. Discounts (listed in the separate Plan description) for hearing aids.
. No additional premium required.
Contact us for additional information concerning specific benefits, exclusions, limitations, eligible providers and other provisions of each of the above coverages.
Medicare prepaid plan enrollment This plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare. As indicated on page 48, annuitants and former spouses with FEHB coverage and Medicare Part B
may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area. They may then later reenroll in the FEHB program. Most Federal annuitants have Medicare Part A. Those without
Medicare Part A may join this Medicare prepaid plan, but will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether the plan covers hospital benefits and, if so, what you
will have to pay. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan. Contact us at 888/ 642-2344 for information on the Medicare prepaid plan and the cost of
that enrollment.
Expanded dental benefits . DEN-983
Expanded vision care . VIS-903
Expanded hearing care . HER-903
. Vision One Discount Program
Complementary and Alternative Medicine
43.
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2003 Humana Health Plan of Texas, Inc. 41 Section 6
Section 6. General exclusions things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury or condition.
We do not cover the following:
. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency benefits);
. Services, drugs, or supplies you receive while you are not enrolled in this Plan;
. Services, drugs, or supplies that are not medically necessary;
. Services, drugs, or supplies not required according to accepted standards of medical, dental, or
psychiatric practice;
. Experimental or investigational procedures, treatments, drugs or devices;
. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered
if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest;
. Services, drugs, or supplies related to sex transformations;
. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
. Services, drugs, or supplies you receive without charge while in active military service.
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2003 Humana Health Plan of Texas, Inc. 42 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 or
coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians
must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 1-800/ 4HUMANA or 1-800/ 448-6262.
When you must file a claim such as for services you receive outside of the Plan's service area 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: Humana Health Plan of Texas P. O. Box 14603
Lexington, Kentucky 40512-4603
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.
45.
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2003 Humana Health Plan of Texas, Inc. 43 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Humana Health Plan of Texas, ATTN: Member Grievance & Appeals, 8431 Fredericksburg Road, Suite 200, San Antonio, TX 78229; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request go to step 3.
3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
. 90 days after the date of our letter upholding our initial decision; or
. 120 days after you first wrote to us if we did not answer that request in some way within 30 days; or
. 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
The disputed claims process Continued on next page
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2003 Humana Health Plan of Texas, Inc. 44 Section 8
Step Description
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 more than one claim, 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.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.
Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-800/ 4HUMANA and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
. If we expedite our review and maintain our denial, we will inform OPM so that they can give your
claim expedited treatment too, or
. You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m.
eastern time.
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2003 Humana Health Plan of Texas, Inc. 45 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under
another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for: . People 65 years of age and older.
. Some people with disabilities, under 65 years of age.
. People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant).
Medicare has two parts:
. Part A (Hospital Insurance). Most people do not have to pay for
Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.)
Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.
. Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare managed care plan is the term used to
describe the various health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on the type of Medicare managed care plan you have.
The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) is 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. 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.
48.
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2003 Humana Health Plan of Texas, Inc. 46 Section 9
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.
Your care must continue to be authorized by your Plan PCP.
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 then provide secondary benefits for covered charges. You
will not need to do anything. To find out if you need to do something to file your claims, contact us at 1-800/ 4HUMANA or at our web site:
www. humana. com.
We do not waive any costs if the Original Medicare Plan is your primary payer.
(Primary payer chart begins on next page.)
49.
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2003 Humana Health Plan of Texas, Inc. 47 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,
b) Or 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.
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2003 Humana Health Plan of Texas, Inc. 48 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from 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 cost-sharing 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 provider), but we will not waive any of our copayments or coinsurance. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare managed care plan so
we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage and 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 enroll in If you do not have one or both Parts of Medicare, you can still be covered
Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan
cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.)
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 under the program.
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2003 Humana Health Plan of Texas, Inc. 49 Section 9
Workers' Compensation We do not cover services that:
. you need because of a workplace-related illness or injury that the
Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or
. OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB 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 under the State program.
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for medical or hospital for injuries care for injuries or illness caused by another person, you must reimburse
us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our
subrogation procedures.
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2003 Humana Health Plan of Texas, Inc. 50 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and
ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Services provided to you such as assistance with dressing, bathing, preparation and feeding of special diets, walking, supervision of
medication which is ordinarily self-administered, getting in and out of bed, and maintaining continence which are not likely to improve your
condition. Custodial care that lasts 90 days or more is sometimes known as long term care.
Durable Medical Equipment (DME) Equipment recognized as such by Medicare Part B, that meets all of the
following criteria:
. it can stand repeated use; and
. it is primarily and customarily used to serve a medical purpose
rather than being primarily for comfort or convenience; and
. it is usually not useful to a person in the absence of sickness or
injury; and
. it is appropriate for home use; and
. it is related to the patient's physical disorder; and the equipment
must be used in the member's home.
Experimental or investigational services A drug, biological product, device, medical treatment, or procedure is
determined to be experimental or investigational if reliable evidence shows it meets one of the following criteria:
. when applied to the circumstances of a particular patient is the
subject of ongoing phase I, II or III clinical trials, or
. when applied to the circumstances of a particular patient is under
study with written protocol to determine maximum tolerated dose, toxicity, safety, efficacy, or efficacy in comparison to conventional
alternatives, or
. is being delivered or should be delivered subject to the approval and
supervision of an Institutional Review Board as required and defined by the USFDA or Department of Health and Human
Services
. is not generally accepted by the medical community
Reliable evidence means, but is not limited to, published reports and articles in authoritative medical scientific literature or regulations and
other official actions and publications issued by the USFDA or the Department of Health and Human Services.
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2003 Humana Health Plan of Texas, Inc. 51 Section 10
Medical necessity The determination as to whether a medical service is required to treat a condition, illness, or injury. In order to meet the standard of medical
necessity the service must be consistent with symptoms, diagnosis, or treatment; consistent with good medical practice; and the most
appropriate level of service that can be safely provided.
Morbid obesity Morbid or clinically severe obesity correlated with a Body Mass Index (BMI) of 40k/ m2 or with being 100 pounds over ideal body weight.
Oral surgery Procedures to correct diseases, injuries and defects of the jaw and mouth structures.
Participating provider A hospital, physician, or any other health services provider who has been designated to provide services to covered members under this plan.
Service area The geographic area where the participating provider services are available to covered members.
Transplant Services for pre-transplant; the transplant including any chemotherapy, associated services and post-discharge services, and treatment of
complications after transplant.
Us/ We Us and we refer to Humana Health Plan of Texas, Inc.
You You refers to the enrollee and each covered family member.
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2003 Humana Health Plan of Texas, Inc. 52 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials tell you:
. 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.
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and
Family coverage in the Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative
order requiring you to provide health benefits for your child( ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children
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2003 Humana Health Plan of Texas, Inc. 53 Section 11
live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows:
. If you have no FEHB coverage, your employing office will enroll you
for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.
. If you have a Self Only enrollment in a fee-for-service plan or in an
HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same
option of the same plan; or . If you are enrolled in an HMO that does not serve the area where the
children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and
cannot make any changes after retirement. Contact your employing office for further information.
When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start this Plan during Open Season, your coverage begins on the first day of
your first pay period tht 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.
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. This is the case even when the court has ordered your former spouse to supply
health coverage to you. But, you may be eligible for your own FEHB coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). 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
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2003 Humana Health Plan of Texas, Inc. 54 Section 11
Temporary Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices. You can also download
the guide from OPM's website, www. opm. gov/ insure.
. 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 or retirement office or from www. opm. gov/ insure.
It explains what you have to do to enroll.
. Converting to
individual coverage You may convert to a non-FEHB individual policy if:
. 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 The Health Insurance Portability and Accountability Act of 1996
Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protection 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
FEHBP web site (www. opm. gov/ insure/ health): refer to the "TCC and
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2003 Humana Health Plan of Texas, Inc. 55 Section 11
HIPAA" frequently asked questions. These highlight HIPAA rules, such as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information.
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2003 Humana Health Plan of Texas, Inc. 56 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
. You can protect yourself against the high cost of long term care by applying for insurance in the Federal
Long Term Care Insurance Program.
. Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002.
. If you're a Federal employee, you and your spouse need only answer a few questions about your health
during Open Season.
. If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open
Season, your premiums are based on your age at the time LTC Partners receives your application.
FEHB Doesn't Cover It
. Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care," long term
care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a severe cognitive impairment such as Alzheimer's disease.
You Can Also Apply Later, But
. Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance
Program Open Season ends, but they will have to answer more health-related questions.
. For annuitants and other qualified relatives, the number of health-related questions that you need to answer
is the same during and after the Open Season.
You Must Act to Receive an Application
. Unlike other benefit programs, YOU have to take action you won't receive an application automatically.
You must request one through the toll-free number or website listed below.
. Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting
available to employees and their spouses, and the July 1 "age freeze"!
Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application.
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2003 Humana Health Plan of Texas, Inc. 57 Index
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Allergy tests................................ 17 Alternative treatment .................. 22
Allogeneic (donor) bone marrow transplant 26
Ambulance............................ 30, 33 Anesthesia............................. 27, 29
Autologous bone marrow transplant ............................. 26
Blood and blood plasma ............. 29 Breast cancer screening .............. 15
Casts ........................................... 29 Changes for 2003.......................... 8
Chemotherapy............................. 18 Childbirth.................................... 16
Chiropractic.. 22 Cholesterol tests.......................... 15
Claims......................................... 42 Coinsurance .......................... 12, 50
Colorectal cancer screening........ 15 Congenital anomalies ................. 24
Contraceptive devices and drugs ....................... 17, 37
Coordination of benefits ........ 45-49 Covered services......................... 50
Covered providers......... 6, 9, 10, 51 Crutches...................................... 22
Definitions ............................. 50-51 Dental care.................................. 39
Diagnostic services ......... 14, 29, 34 Dialysis ....................................... 18
Disputed claims review ......... 43-44 Donor expenses (transplants)...... 26
Dressings .................................... 29 Durable medical equipment
(DME) ........................... 22, 50 Effective date of enrollment ....... 53
Emergency............................. 31-32 Experimental or investigational .. 50
Eyeglasses................................... 20 Family planning.......................... 17
Fecal occult blood test ................ 15 Foot care ..................................... 21
General Exclusions..................... 41 Hearing services ......................... 20
Home health services............ 14, 22 Home nursing care...................... 22
Hospice care ............................... 30 Hospital ........................... 10, 28-30
Immunizations....................... 15-16
Infertility ..................................... 17 Inhospital physician care .14, 23-27
Inpatient Hospital Benefits..................... 10, 28-29
Insulin ......................................... 37 Laboratory and pathological
services .......................... 14, 29 Machine diagnostic
tests ............................... 14, 29 Magnetic Resonance Imagings
(MRIs) ................................. 14 Mail-order prescription
drugs .................................... 37 Mammograms ........................ 14-15
Maternity Benefits ...................... 16 Medicaid ..................................... 49
Medical necessity........................ 51 Medicare ................................ 45-48
Members ....................................... 6 Mental Conditions/ Substance
Abuse Benefits................ 34-35 Newborn care.............................. 16
Non-FEHB benefits .................... 40 Nurse
Licensed Practical Nurse .......... 22 Nurse Anesthetist...................... 29
Registered Nurse....................... 22 Obstetrical care........................... 16
Occupational therapy .................. 19 Office visits................................. 14
Oral and maxillofacial surgery ................................. 25
Orthopedic devices ..................... 21 Out-of-pocket expenses .............. 12
Outpatient facility care........... 29-30 Oxygen........................................ 29
Pap test .................................. 14-15 Physical examination ............. 15-16
Physical therapy.......................... 19 Physician.............................. 6, 9-10
Preventive care, adult.................. 15 Preventive care, children............. 16
Prescription drugs .................. 36-37 Preventive services ................ 15-16
Prior approval ............................. 11 Prostate cancer screening............ 15
Prosthetic devices ....................... 21
Psychologist ................................ 34 Radiation therapy........................ 18
Room and board.................... 28, 30 Second surgical opinion.............. 14
Skilled nursing facility care ........ 30 Speech therapy............................ 19
Splints ......................................... 29 Sterilization procedures ........ 17, 23
Subrogation................................. 49 Substance abuse ..................... 34-35
Surgery................................... 23-27 Anesthesia........................... 27
Oral ..................................... 25 Outpatient ........................... 29
Reconstructive .................... 24 Syringes ...................................... 37
Temporary Continuation of Coverage.......................... 54
Transplants............................ 26, 51 Treatment therapies.. 18
Vision services............................ 20 Well child care............................ 16
Wheelchairs ................................ 22 Workers' Compensation ............. 49
X-rays ................................... 14, 29
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2003 Humana Health Plan of Texas, Inc. 58
NOTES:
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2003 Humana Health Plan of Texas, Inc. 59 Summary
Summary of benefits for Humana Health Plan of Texas, Inc. 2003 Standard Option
. Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.
. If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.
. We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians: .
Diagnostic and treatment services provided in the office.......... Office visit copay: $15 primary care; $25 specialist 14
Services provided by a hospital: .
Inpatient.....................................................................................
. Outpatient --surgical.................................................................
. Outpatient non-surgical ..........................................................
$250 per day for the first three days per admission
$200 copay
$100 copay
28
29
30
Emergency benefits:
. In-and out-of-area (emergency room) ......................................
. In-and out-of-area (at a doctor's office or urgent care center).....
$75 per visit
$15 per visit to a primary care physician; $25 per visit to a
specialist
32
Mental health and substance abuse treatment............................... Regular cost sharing 34-35
Prescription drugs:
. Level One drugs ........................................................................
. Level Two drugs........................................................................
. Level Three drugs......................................................................
. Level Four drugs .......................................................................
. Maintenance drugs (90-day supply) when ordered through
our mail-order program .............................................................
$10 copay
$25 copay
$45 copay
25% of charges
3 applicable copays
37
Dental Care . Accidental injury benefit........................................................... Nothing
39
Vision Care (annual eye refractions to provide a written lens prescription for eyeglasses) .......................................................... $25 per visit 20
Special features: Flexible Benefits Option; TDD and TTY phone lines; HumanaBeginnings; National Transplant Network; and HumanaFirst 38
Protection against catastrophic costs (your out-of-pocket maximum)..................................................................................... Nothing after $2,500/ per person or $5,000/ per family enrollment per
year.
Some costs do not count toward this protection.
12
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2003 Humana Health Plan of Texas, Inc. 60 Summary
Summary of benefits for Humana Health Plan of Texas, Inc. 2003 High Option
. Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.
. If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.
. We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians: .
Diagnostic and treatment services provided in the office.......... Office visit copay: $10 primary care; $20 specialist 14
Services provided by a hospital: .
Inpatient.....................................................................................
. Outpatient --surgical.................................................................
. Outpatient non-surgical ..........................................................
$100 per day for the first three days per admission
$100 copay
$50 copay
28
29
30
Emergency benefits:
. In-and out-of-area (emergency room) ......................................
. In-and out-of-area (at a doctor's office or urgent care center).....
$75 per visit
$10 per visit to a primary care physician; $20 per visit to a
specialist
32
Mental health and substance abuse treatment............................... Regular cost sharing 34-35
Prescription drugs:
. Level One drugs ........................................................................
. Level Two drugs........................................................................
. Level Three drugs......................................................................
. Level Four drugs .......................................................................
. Maintenance drugs (90-day supply) when ordered through
our mail-order program .............................................................
$5 copay
$20 copay
$40 copay
25% of charges
3 applicable copays
37
Dental Care . Accidental injury benefit........................................................... Nothing
39
Vision Care (annual eye refractions to provide a written lens prescription for eyeglasses) .......................................................... $20 per visit 20
Special features: Flexible Benefits Option; TDD and TTY phone lines; HumanaBeginnings; National Transplant Network; and HumanaFirst 38
Protection against catastrophic costs (your out-of-pocket maximum)..................................................................................... Nothing after $2,500/ per person or $5,000/ per family enrollment per
year.
Some costs do not count toward this protection.
12
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2003 Humana Health Plan of Texas, Inc. 61 Rates
2003 Rate Information for Humana Health Plan of Texas
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 a
special FEHB guide is published 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
San Antonio Area
High Option Self Only UR1 $100.34 $33.44 $217.40 $72.46 $118.73 $15.05
High Option Self and Family UR2 $249.62 $94.24 $540.84 $204.19 $294.70 $49.16
Standard Option Self Only UR4 $80.66 $26.89 $174.77 $58.26 $95.45 $12.10
Standard Option Self and Family UR5 $207.34 $69.11 $449.24 $149.74 $245.35 $31.10
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