Health Net of Arizona,
Inc. http:// www. health. net
2004
Serving: Cochise, Gila, Maricopa, Pima, Pinal and Santa Cruz counties
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.
Enrollment codes for this Plan:
A71 Self Only
A72 Self and Family
RI 73-283
For changes
in benefits
see page 9.
A Health Maintenance Organization
1.
1
Page 2
3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits (FEHB) Program plan brochure. The brochure describes the
benefits this plan offers you for 2004. Because benefits vary from year to year, you should review your plan's brochure every Open
Season � especially Section 2, which explains how the plan changed.
It takes a lot of information to help a consumer make wise healthcare decisions. The information in this brochure, our FEHB Guide,
and our web-based resources, make it easier than ever to get information about plans, to compare benefits and to read customer service
satisfaction ratings for the national and local plans that may be of interest. Just click on www. opm. gov/ insure!
The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector competition to
keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in 1960, is sound and has stood the
test of time. It enjoys one of the highest levels of customer satisfaction of any healthcare program in the country.
I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health benefits. We demand
cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies and departments to pay the full FEHB
health benefit premium for their employees called to active duty in the Reserve and National Guard so they can continue FEHB
coverage for themselves and their families. Our carriers have also responded to my request to help our members to be prepared by
making additional supplies of medications available for emergencies as well as call-up situations and you can help by getting an
Emergency Preparedness Guide at www. opm. gov. OPM's HealthierFeds campaign is another way the carriers are working with us to
ensure Federal employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain
healthcare costs and keep premiums down by living a healthy life style.
Open Season is your opportunity to review your choices and to become an educated consumer to meet your healthcare needs. Use this
brochure, the FEHB Guide, and the web resources to make your choice an informed one. Finally, if you know someone interested in
Federal employment, refer them to www. usajobs. opm. gov.
Sincerely,
Kay Coles James
Director
2.
2
Page 3
4
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 United States 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 health care 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.
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.
3.
3
Page 4
5
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
United States 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
United States 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 are effective April 14, 2003.
4.
4
Page 5
6
2004 Health Net of Arizona, Inc. 2 Table of Contents
Table of Contents
Introduction�������������������������............................................................................................... 5
Plain Language ................................................................................................................................................................................................ 5
Stop Health Care Fraud!.................................................................................................................................................................................. 5
Preventing medical mistakes........................................................................................................................................................................... 6
Section 1. Facts about this HMO plan........................................................................................................................................................... 8
How we pay providers .................................................................................................................................................................. 8
Your Rights ................................................................................................................................................................................... 8
Service Area.................................................................................................................................................................................. 8
Section 2. How we change for 2004.............................................................................................................................................................. 9
Program-wide changes.................................................................................................................................................................. 9
Changes to this Plan...................................................................................................................................................................... 9
Section 3. How you get care ....................................................................................................................................................................... 10
Identification cards ..................................................................................................................................................................... 10
Where you get covered care ....................................................................................................................................................... 10
Plan providers....................................................................................................................................................................... 10
Plan facilities ........................................................................................................................................................................ 10
What you must do to get covered care ....................................................................................................................................... 10
Primary care.......................................................................................................................................................................... 10
Specialty care........................................................................................................................................................................ 10
Hospital care......................................................................................................................................................................... 11
Circumstances beyond our control............................................................................................................................................. 12
Services requiring our prior approval ........................................................................................................................................ 12
Section 4. Your costs for covered services.................................................................................................................................................. 13
Copayments .......................................................................................................................................................................... 13
Deductible............................................................................................................................................................................. 13
Coinsurance .......................................................................................................................................................................... 13
Your catastrophic protection out-of-pocket maximum ............................................................................................................. 13
Section 5. Benefits........................................................................................................................................................................................ 14
Overview ..................................................................................................................................................................................... 14
(a) Medical services and supplies provided by physicians and other health care professionals ........................................ 15
(b) Surgical and anesthesia services provided by physicians and other health care professionals .................................... 27
(c) Services provided by a hospital or other facility, and ambulance services ................................................................... 32
(d) Emergency services/ accidents......................................................................................................................................... 35
(e) Mental health and substance abuse benefits ................................................................................................................... 37
(f) Prescription drug benefits................................................................................................................................................ 39
5.
5
Page 6
7
2004 Health Net of Arizona, Inc. 3 Table of Contents
(g) Special features ............................................................................................................................................................... 42
Flexible benefits option
Services for deaf and hearing impaired
Centers of excellence
High risk pregnancies
Case Management programs
(h) Dental benefits ................................................................................................................................................................ 43
(i) Non-FEHB benefits available to Plan members............................................................................................................. 44
Section 6. General exclusions --things we don't cover .............................................................................................................................. 45
Section 7. Filing a claim for covered services ............................................................................................................................................ 46
Section 8. The disputed claims process....................................................................................................................................................... 47
Section 9. Coordinating benefits with other coverage ............................................................................................................................... 49
When you have other health coverage ....................................................................................................................................... 49
What is Medicare?............................................................................................................................................................... 49
Should I enroll in Medicare?............................................................................................................................................... 49
Medicare + Choice. ............................................................................................................................................................. 52
TRICARE and CHAMPVA................................................................................................................................................ 52
Workers' Compensation ...................................................................................................................................................... 52
Medicaid ............................................................................................................................................................................. 53
Other Government agencies................................................................................................................................................ 53
When others are responsible for injuries ............................................................................................................................ 53
Section 10. Definitions of terms we use in this brochure ............................................................................................................................ 54
Section 11. FEHB facts ................................................................................................................................................................................ 56
Coverage information ............................................................................................................................................................... 56
No pre-existing condition limitation................................................................................................................................. 56
Where you can get information about enrolling in the FEHB Program.......................................................................... 56
Types of coverage available for you and your family...................................................................................................... 56
Children's Equity Act........................................................................................................................................................ 56
When benefits and premiums start.................................................................................................................................... 57
When you retire ................................................................................................................................................................. 57
When you lose benefits............................................................................................................................................................. 57
When FEHB coverage ends .............................................................................................................................................. 57
Spouse equity coverage..................................................................................................................................................... 57
Temporary Continuation of Coverage (TCC) .................................................................................................................. 58
Converting to individual coverage.................................................................................................................................... 58
Getting a Certificate of Group Health Plan Coverage ..................................................................................................... 58
Two new Federal Programs complement FEHB benefits������������.����.�������������... 59
The Federal Flexible Spending Account Program � FSAFEDS����.������������������.... 59
The Federal Long Term Care Insurance Program ..................................................................................................................... 62
6.
6
Page 7
8
2004 Health Net of Arizona, Inc. 4 Table of Contents
Index........................................................................................................................................................................................................... 63
Summary of benefits...................................................................................................................................................................................... 64
Rates................................................................................................................................................................................................. Back cover
7.
7
Page 8
9
2004 Health of Arizona, Inc. 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Health Net of Arizona, Inc. under our contract (CS 2121) with the United States Office of
Personnel Management, as authorized by the Federal Employees Health Benefits law. The address for Health Net of Arizona,
Inc. administrative offices is:
Health Net of Arizona, Inc.
950 N. Finance Center Drive
Tucson, Arizona 85710-1362
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 in 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, 2004, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and changes are
summarized on page 9. 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 Health Net of Arizona, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States
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 http:// www. opm. gov/ insure
or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the
Office of Personnel Management, Insurance Services Program, Program Planning & Evaluation Group, 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.
8.
8
Page 9
10
2004 Health of Arizona, Inc. 6 Introduction/ Plain Language/ Advisory
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 800/ 289-2818 and explain the situation.
If we do not resolve the issue:
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, with
your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under
Temporary Continuation of Coverage.
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.
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes
in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome,
medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even
additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own
health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
Ask questions and make sure you understand the answers. Choose a doctor with whom you feel comfortable talking.
Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take.
Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines. Tell them about any drug allergies you have.
Ask about side effects and what to avoid while taking the medicine. Read the label when you get your medicine, including all warnings.
Make sure your medicine is what the doctor ordered and know how to use it. Ask the pharmacist about your medicine if it looks different than you expected.
3. Get the results of any test or procedure.
Ask when and how you will get the results of test or procedures. Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
Call your doctor and ask for your results. Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
CALL --THE HEALTH CARE FRAUD HOTLINE
202-418-3300
OR WRITE TO:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415-1100
9.
9
Page 10
11
2004 Health of Arizona, Inc. 7 Introduction/ Plain Language/ Advisory
Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.
Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery.
Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. Ask your doctor, "Who will manage my care when I am in the hospital?"
Ask your surgeon: Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.
Want more information on patient safety?
www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide-ranging
list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers
and improve the quality of care you receive.
www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and
your family.
www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is dedicated to
improving communication about the safe, appropriate use of medicines.
www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals
working to improve patient safety.
www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent
mistakes in the nation's healthcare delivery system.
10.
10
Page 11
12
2004 Health Net of Arizona, Inc. 8 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,
coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot
change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for your copayments or coinsurance
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 Web site (http:// 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.
Health Net of Arizona, Inc. complies with the State of Arizona statutes and is licensed to operate an HMO in Arizona
Health Net of Arizona, Inc. has been in existence since 1981 (we were formerly Intergroup of Arizona, Inc.)
Health Net of Arizona, Inc. is a for-profit organization.
If you want more information about us, call 800/ 289-2818, or write to Health Net of Arizona, 950 N. Finance Center Drive, Tucson,
Arizona 85710-1362. You may also contact us by fax at 520/ 258-5176 or visit our Web site at www. health. net.
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:
Cochise, Gila, Maricopa, Pima, Pinal and Santa Cruz.
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.
11.
11
Page 12
13
2004 Health Net of Arizona, Inc. 9 Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change
benefits.
Program-wide changes
We added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible Spending Account Program -FSAFEDS and the Federal Long Term Care Insurance Program. See page 59 and 62.
We added information regarding Preventing medical mistakes. See page 6.
We added information regarding enrolling in Medicare. See page 49
We revised the Medicare Primary Payer Chart. See page 51.
Changes to this Plan
Your share of the non-Postal premium will increase by 11% for Self Only or 11% for Self and Family.
The primary care or specialist office visit copayment will increase from $10 per office visit to $15 per office visit.
The lab and x-ray and other diagnostic tests in a physician office or freestanding facility setting copayment of $10 has been eliminated.
The mail order prescription drug copayment will decrease from $30-$ 90-$ 125 (Generic / Brand name / Non-formulary) respectively to $25-$ 75-$ 112.50.
12.
12
Page 13
14
2004 Health Net of Arizona, Inc. 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800/ 289-2818 or write to us at
Attn: Health Net of Arizona, Inc. 950 N. Finance Center Drive, Tucson, Arizona 85710-
1362. You may also request replacement cards through our Web site at www. health. net.
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 Web site.
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 Web site.
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 can find a primary care physician
by looking in the provider directory, visiting our Web site or calling us at 800/ 289-2818.
Primary care Your primary care physician can be a Family Practice, General Practice, Internal Medicine 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 the primary care
physician after the consultation, unless your primary care physician authorized a certain
number of visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may see a Plan Provider for
obstetrician/ gynecologist, Plan chiropractor, Health Net Vision provider for routine eye
exam, Plan provider for mental health and substance abuse services and diabetic
members may see an opthamologist for an annual eye examination without a referral.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating your
What you must do
to get covered care
13.
13
Page 14
15
2004 Health Net of Arizona, Inc. 11 Section 3
treatment plan (the physician may have to get an authorization or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or
she decides to refer you to a specialist, ask if you can see your current specialist. If
your current specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see a specialist who does
not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive
services from your current specialist until we can make arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your new
plan.
If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
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
Contact Center immediately at 800/ 289-2818. 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. If your plan
terminates participation in the FEHB Program in whole or in part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such case,
the hospitalized family member's benefits under the new plan begin on the effective date
of enrollment.
14.
14
Page 15
16
2004 Health Net of Arizona, Inc. 12 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.
Your primary care physician has authority to refer you for most services. For certain
services, however, your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally
accepted medical practice.
We call this review and approval process�. Prior Authorization. Your physician must
obtain prior authorization for the following services: hospital stays, certain surgeries,
outpatient imaging and testing services, home health care, certain medications and organ
transplants.
When your primary care physician feels that you may need such a service, he or she will
submit a request for an authorization to Health Net. Once we receive the request, our
medical staff will review it. They review the treatment plan, covered benefits, medical
history and national treatment standards.
If a request is denied, it will automatically proceed to one of our doctors for review. He
or she will either support the decision for denial or approve the care requested. If a case
involves new medical technology, our doctors may review current medical literature
and/ or consult with medical experts. Our doctors will use this information to decide if the
care requested is appropriate.
Remember, your primary care physician must coordinate your medical care. If you need
specialty care, your primary care physician will determine the most appropriate specialist
based on your medical condition. If you go to a specialist or receive a service without
prior authorization (except for emergencies, OB/ GYN visits, chiropractic care, outpatient
mental health and/ or substance abuse, and diabetic members may see a plan
opthamologist for an annual eye exam), the services you receive will not be covered by
this Plan.
Services requiring our
prior approval
15.
15
Page 16
17
2004 Health Net of Arizona, Inc. 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $15 per
office visit and when you go in the hospital, you pay $100 per day up to 5 days per
admission.
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 or surgically
implanted devices.
After your copayments total $2,000.00 per person or $4,000.00 per family enrollment in
any calendar year, you do not have to pay any more for covered services. However,
copayments and/ or coinsurance for the following services do not count toward your
catastrophic protection out-of-pocket maximum, and you must continue to pay
copayments and/ or coinsurance for these services:
Prescription drugs Infertility services
Be sure to keep accurate records of your copayments and/ or coinsurance since you are
responsible for informing us when you reach the maximum.
Your catastrophic protection
out-of-pocket maximum for
deductibles, coinsurance, and
copayments
16.
16
Page 17
18
2004 Health Net of Arizona, Inc. 14 Section 5
Section 5. Benefits � OVERVIEW
(See page 9 for how our benefits changed this year and page 64 for a benefits summary.)
Note: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of
each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the following subsections. To obtain
claim forms, claims filing advice, or more information about our benefits, contact us at 800/ 289-2818 or at our Web site at
http:// www. health. net
.
(a) Medical services and supplies provided by physicians and other health care professionals ............................................................ 15-26
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies) Foot care
Orthopedic and prosthetic devices Durable medical equipment (DME)
Home health services Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health care professionals...................................................... 27-31
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................................................... 32-34
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/ accidents .......................................................................................................................................................... 35-36
Medical emergency Ambulance
(e) Mental health and substance abuse benefits..................................................................................................................................... 37-38
(f) Prescription drug benefits ................................................................................................................................................................. 39-41
(g) Special features ...................................................................................................................................................................................... 42
Flexible benefits option
Services for deaf and hearing impaired
Centers of excellence
High risk pregnancies
Case management programs
(h) Dental benefits ....................................................................................................................................................................................... 43
(i) Non-FEHB benefits available to Plan members .................................................................................................................................. 44
Summary of benefits...................................................................................................................................................................................... 64
17.
17
Page 18
19
2004 Health Net of Arizona, Inc. 15 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second surgical opinion
$15 per office visit
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Included in the facility copayment
At home $15 per visit
Not covered: hearing exams to determine extent of hearing loss, if you
are over age 18.
All charges.
18.
18
Page 19
20
2004 Health Net of Arizona, Inc. 16 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
No charge for laboratory, X-ray and other
diagnostic tests at the physician's office or
freestanding facility.
If you receive these services at an
outpatient hospital setting a $10 copay per
visit will apply.
Outpatient imaging and testing, such as:
CAT/ Scans MRI
MRAs
Stress tests
PET/ SPECT scans
$100 per visit at the physician's office,
freestanding facility or at an outpatient
hospital setting
Preventive care, adult
Routine screenings, such as: Total Blood Cholesterol � once every three
years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening � every five years starting at age 50
$15 per office visit
Routine Prostate Specific Antigen (PSA) test � one annually for men age 40
and older
$15 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment..
$15 per office visit
Routine mammogram �covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year At age 65 and older, one every two consecutive calendar years
No charge for laboratory, X-ray and other
diagnostic tests at the physician's office or
freestanding facility.
If you receive these services at an
outpatient hospital setting a $10 copay per
visit will apply.
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges.
Preventive care -Adult -continued on next page
19.
19
Page 20
21
2004 Health Net of Arizona, Inc. 17 Section 5( a)
Preventive care, adult (continued) You pay
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster � once every 10 years, ages19 and over (except as provided for under Childhood immunizations)
Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over or for high risk members under age 65.
Nothing when performed by non-physician
personnel or an affiliated flu shot clinic sponsored
by your primary care physician or Health Net of
Arizona, Inc.
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics $15 per office visit
Well-child care charges for routine examinations, immunizations and care (up to age 22)
Examinations, such as: --Eye exams through age 17 to determine the need for vision
correction.
--Ear exams through age 17 to determine the need for hearing
correction
--Examinations done on the day of immunizations ( up to age 22)
$15 per office visit
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 12 for other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$15 per office visit, nothing for prenatal
and postnatal care after the initial diagnosis
of pregnancy. $50 outpatient copayment
will apply for services rendered in an
outpatient hospital setting. Inpatient
hospital copayment will apply for Delivery.
Maternity care -continued on next page
20.
20
Page 21
22
2004 Health Net of Arizona, Inc. 18 Section 5( a)
Maternity care (continued) You Pay
Not covered: Routine sonograms, amniocenteses, ultrasound or any
other procedure to determine fetal age, size or sex; non-medically
necessary circumcision after the newborn period.
All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs) (limited to one non-medically necessary removal in any 3 consecutive year period).
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.
$15 per office visit if you receive these
services during your office visit.
$50 copay per visit if you receive these
services in an outpatient hospital setting.
Surgically implanted contraceptives (such as Norplant) 50% for surgically implanted contraceptives limited to one implant in any
3 consecutive year period. No charge for
removal, limited to one non-medically
necessary removal in any 3 consecutive
year period.
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, diagnostic testing to establish paternity of a child and
genetic testing.
All charges.
Infertility services
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
50% of all covered services
Infertility services -continued on next page
21.
21
Page 22
23
2004 Health Net of Arizona, Inc. 19 Section 5( a)
Infertility services (continued) You Pay
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
Fertility drugs
All charges.
Allergy care
Testing and treatment
Allergy injection
$15 per office visit; nothing for allergy
injections performed by non-physician
personnel
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization, skin titration (Rinkel Method), cytotoxicity testing
(Bryans Test). RAST testing, MAST testing, urine autoinjection
All charges.
22.
22
Page 23
24
2004 Health Net of Arizona, Inc. 20 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 30.
Respiratory and inhalation therapy
Dialysis � hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy � Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: � We will only cover GHT when we preauthorize the treatment.
Call 800/ 863-7847 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment; otherwise, we will
only cover GHT services from the date you submit the information. If
you do not ask or if we determine GHT is not medically necessary, we
will not cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.
$15 per office visit in provider office or
$50 per visit if provided in outpatient
hospital setting.
Dialysis � Hemodialysis and peritoneal dialysis
Note: A maximum of 6 out-of-area dialysis treatments per year are
provided when Prior Authorization has been obtained from Health Net of
Arizona, Inc.
$15 per visit in the provider office or
outpatient hospital setting.
Not covered: Experimental, investigational or alternative therapies All charges.
23.
23
Page 24
25
2004 Health Net of Arizona, Inc. 21 Section 5( a)
60 visits for the services of each of the following:
Qualified physical therapists and
Occupational therapists.
Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to
illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60
sessions per Plan year.
Not covered:
long-term rehabilitative therapy
exercise programs
Therapies provided for the purposes of maintaining physical condition
Speech therapy
60 visits per plan year
Hearing services (testing, treatment, and supplies)
First hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care, children)
$15 per office visit
Not covered:
all other hearing testing, including hearing exams to determine the extent of hearing loss if you are over age 18
hearing aids, testing and examinations for them
All charges.
Physical and occupational therapies
24.
24
Page 25
26
2004 Health Net of Arizona, Inc. 22 Section 5( a)
One eye exam for refraction every 24 months
Note: Eye examinations for refraction is administered by Health Net
Vision. Call 800/ 443-4994.
Nothing
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts surgery, treatment of keratoconus, aphakia or
corneal transplants) � limited to a frame allowance of up to $75
$15 per office visit
Eye exam to determine the need for vision correction for children
through age 17 (see Preventive care, children)
$15 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics and other vision training
Radial keratotoym, lasik and any other refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.
Note: See orthopedic and prosthetic devices for information on
podiatric shoe inserts.
$15 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,
except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery).
All charges.
Vision services (testing, treatment, and supplies) You pay
25.
25
Page 26
27
2004 Health Net of Arizona, Inc. 23 Section 5( a)
Artificial limbs and eyes; including the initial purchase and subsequent purchases due to physical growth. Coverage is limited
to limbs that are necessary because of an illness, injury or surgery
causing anatomical functional impairment, or from a congenital
defect.
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See 5( b)
for coverage of the surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
Prosthetic devices when determined to be medically necessary and
result from an illness, injury or surgery causing anatomical functional
impairment, or from a congenital defect. Coverage includes the fitting
and purchase of a standard model. Replacement is covered only if
determined to be medically necessary and results from a change in your
physical condition.
Nothing
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices
repair and/ or replacements of parts or devices worn out due to misuse or abuse
Model upgrades, deluxe, or specialized equipment
Over-the-counter items
All charges.
Orthopedic and prosthetic devices You pay
26.
26
Page 27
28
2004 Health Net of Arizona, Inc. 24 Section 5( a)
Durable medical equipment (DME) You pay
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;
Standard size wheelchairs � one per lifetime;
Crutches, canes;
walkers;
Plan approved standard blood glucose monitors;
insulin pumps;
Plan approved peak flow monitors;
Medical supplies determined by Health Net to be medically necessary to operate and/ or maintain a covered prosthesis or item of Durable
Medical Equipment, subject to the following exclusions and
limitations.
Nothing
Not covered:
Motorized electric or specialized wheel chairs
ThAIRpy� vest, except when Health Net medical criteria is met, as determined by the Plan
Scooters or other power operated vehicles
More than one device to provide essentially the same functional assistance
Deluxe, specialized or customized equipment, model upgrades
Transcutaneious Electrical Nerve Stimulation (TEMS) units
Repair of replacement of equipment or parts due to misuse and/ or abuse
Prophylactic braces
Braces used primarily for sport activities
Foot orthotics which are not an integral part of a leg brace
All charges.
27.
27
Page 28
29
2004 Health Net of Arizona, Inc. 25 Section 5( a)
Home health services You pay
Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
nursing care requested by, or for the convenience of, the patient or the patient's family;
home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.
Housekeeping services
Services of a person who resides in the patient's home
Custodial care, rest cures, respite cures
Services performed by the patient's family member
All charges.
Chiropractic
Up to 12 visits per year for manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
$15 per office visit
28.
28
Page 29
30
2004 Health Net of Arizona, Inc. 26 Section 5( a)
Alternative treatments You pay
Not covered:
Acupuncture services
Acupressure services
Naturopathic services
Hypnotherapy
Behavior training
Educational, recreational, art, dance sex, sleep or music therapies
Biofeedback, except for the treatment of urinary incontinence
Other forms of holistic or alternative therapies
All charges.
Educational classes and programs
Coverage is limited to classes offered by or through Health Net's Health
Education department. Recent classes and seminars include:
Smoking Cessation � Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.
Diabetes self-management
Lamaze
A nominal fee may be required for
classroom materials
29.
29
Page 30
31
2004 Health Net of Arizona, Inc. 27 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure which services require prior
authorization and identify which surgeries require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) � Orthopedic and prosthetic devices for device coverage information
$15 per office visit or $50 per outpatient
hospital visit
Surgical procedures -continued on next page
30.
30
Page 31
32
2004 Health Net of Arizona, Inc. 28 Section 5( b)
Surgical procedures (continued) You pay
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$15 per office visit or $50 per outpatient
hospital visit
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance of breasts;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
$15 per office visit or $50 per outpatient
hospital visit
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
31.
31
Page 32
33
2004 Health Net of Arizona, Inc. 29 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.
$15 per office visit or $50 per outpatient
hospital visit
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
Routine or general care of teeth or dental structures
Extractions or impacted or abscessed teeth
Dental splints, dental implants, dental prostheses or dentures
Accidental injury to the teeth or gums caused by chewing
All charges.
32.
32
Page 33
34
2004 Health Net of Arizona, Inc. 30 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single �Double
Pancreas
Allogeneic (donor) bone marrow transplants Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
Donor searches limited to $5,000 per organ per lifetime
FDA approved Ventricular Assist Device only when bridges to transplant.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in a National Cancer
Institute-or National Institutes of Health-approved clinical trial at a
Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor
when we cover the recipient.
Place of service copayment applies
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.
33.
33
Page 34
35
2004 Health Net of Arizona, Inc. 31 Section 5( b)
Professional services provided in �
Hospital (inpatient)
Nothing
Professional services provided in �
Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office
Nothing
Anesthesia You pay
34.
34
Page 35
36
2004 Health Net of Arizona, Inc. 32 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility,
and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge
(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION STAYS. Please refer to Section 3 to be sure which services require prior authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board, such as
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.
$100 per day up to 5 days per admission
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Medical supplies and medical equipment, including oxygen
Anesthetics, including nurse anesthetist services
$100 per day up to 5 days per admission
Inpatient hospital -continued on next page.
35.
35
Page 36
37
2004 Health Net of Arizona, Inc. 33 Section 5( c)
Inpatient hospital (continued) You pay
Not covered:
Custodial care
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services, guest meals, travel expenses, take-home supplies and beds
Collection and/ or storage of blood products for any unscheduled or non-covered medical procedure
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Dressings, casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: � We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.
$50 per visit
Not covered: blood and blood derivatives not replaced by the member All charges.
Extended care benefits/ skilled nursing care facility benefits
Skilled nursing facility (SNF):
Coverage is provided when a full-time skilled nursing care is medically
necessary and confinement in a SNF is medically appropriate as
determined by a plan doctor and approved by Health Net. Covered
services include:
Bed, board and general nursing care
Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the SNF when prescribed by a plan doctor.
$100 per day up to 5 days per admission
Not covered: custodial care, domiciliary care or convalescent care All charges.
36.
36
Page 37
38
2004 Health Net of Arizona, Inc. 34 Section 5( c)
Hospice care You pay
Members who are diagnosed as having an illness giving them a life
expectancy of 6 months or less may request Hospice care. All Hospice
care must be provided by a licensed participating Hospice and include
inpatient and outpatient care related to the condition.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically appropriate
Air ambulance when prior authorized or if the member's condition is an emergency and the location of the accidental injury and/ or
illness is inaccessible by ground vehicles or transport by ground
ambulance would be detrimental to the member's health.
Nothing
37.
37
Page 38
39
2004 Health Net of Arizona, Inc. 35 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.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies � what
they all have in common is the need for quick action.
What to do in case of emergency:
If you are faced with medical emergency, call 911 or go to the nearest emergency room.
Please notify your primary care physician within 48 hours following emergency services, or as soon as reasonably possible
to do so.
Emergency services do not include the use of a hospital emergency room or other emergency medical facility for routine
medical care, or follow-up or continuing care unless prior authorization has been given by your primary care physician or
Health Net.
Emergencies within our service area: call 911 or go to the nearest emergency room
Emergencies outside our service area: call 911 or go to the nearest emergency room
38.
38
Page 39
40
2004 Health Net of Arizona, Inc. 36 Section 5( d)
Benefit Description You pay
Emergency within or outside our service area
Emergency care at a doctor's office $15 per visit
Emergency care at an urgent care center $50 per visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $100 per visit (waived if admitted; $100 per day up to 5 days per admission inpatient
hospital admission applies
Not covered:
Elective care or non-emergency care, continuing, routine or follow-up care without prior authorization
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically appropriate and in an
emergency situation. Air ambulance when prior authorized or if the
member's condition is an emergency and the location of the accidental
injury and/ or illness is inaccessible by ground vehicles or transport by
group ambulance would be detrimental to the member's health
See 5( c) for non-emergency service.
Nothing
39.
39
Page 40
41
2004 Health Net of Arizona, Inc. 37 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 PRIOR AUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illnesses or
conditions.
Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
Medication management
$15 per visit
Mental health and substance abuse benefits -continued on next page
40.
40
Page 41
42
2004 Health Net of Arizona, Inc. 38 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnostic tests $15 per visit
Services provided by a hospital or other facility
Services in approved alternative care settings such as half-way house,
residential treatment or full-day hospitalization
$100 per day up to 5 days per admission
Services in approved alternative care settings such as partial hospitalization or facility based intensive outpatient treatment $50 per visit
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes:
To access Mental Health and/ or Substance Abuse benefits, you must contact MHN
Health Services at 800/ 977-0281. Services are covered as necessary for the diagnosis
and treatment of acute conditions and as outlined below.
Limitation We may limit your benefits if you do not obtain a treatment plan.
41.
41
Page 42
43
2004 Health Net of Arizona, Inc. 39 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain them. You may fill the prescription at a Plan pharmacy, or by mail for maintenance medication.
We use a formulary. (Preferred Drug List). Plan doctors in accordance with the Plan's Preferred Drug List prescribe drugs. Generic drugs are available at the lowest copayment level. Preferred brand name drugs are
available for a slightly higher copayment. Unless otherwise excluded, other FDA-approved brand name
drugs are available at the highest copayment level. The Preferred Drug List is update periodically throughout
the year. To order a current Preferred Drug List call 800/ 289-2818 or visit our Web site at http:// www. health. net.
These are the dispensing limitations. Prescription drugs obtained at a plan pharmacy will be dispensed for up to a 31-day supply. Mail order prescriptions are limited to Health Net's mail order provider and will be
dispensed for up to a 93-day supply. Some medications may be dispensed in quantities less than those stated
due to the prepackaging by the pharmaceutical manufacturer. Insulin, diabetic supplies and inhalers have
quantity per copayment limitations, as stated below. Refills are only covered when authorized by a plan
physician and/ or Health Net. You will be financially liable for the cost of medications obtained after you are
no longer eligible for coverage under the plan.
Members called to Active Duty or during a National Emergency. Members may contact our Customer Contact Center at 800/ 289-2818. Our Customer Contact Center will work with our Pharmacy Department to
authorize the medications and/ or supplies and which provider to obtain the services from.
Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer
advertises and sells a drug. Under federal law, generic and brand name drugs must meet the same standards
for safety, purity, strength, and effectiveness. A generic prescription costs you � and us � less than a name
brand prescriptions.
When you have to file a claim. If you are required to pay for a prescription in an out-of-area emergency situation, you must submit an itemized statement to Health Net of the charges you paid, along with a
completed claim form. Claim forms can be obtained by calling Health Net at 800/ 289-2818. Proof of
payment must accompany the request for reimbursement. Claims should be addressed to: Health Net of
Arizona, Attn: Pharmacy Department, 950 N. Finance Center Drive, Tucson, Arizona 85710-1362.
42.
42
Page 43
44
2004 Health Net of Arizona, Inc. 40 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those
listed as Not covered.
Insulin � limited to 2 vials per copayment
Disposable needles and syringes for the administration of covered medications � limited to 100 per copayment
Diabetic supplies, including lancets, glucose test strips, visual reading testing strips, and urine testing strips � limited to 100 per
copayment
Insulin cartridges for the legally blind � limited to the equivalent to 2 vials of insulin per copayment
Automatic lancing devices � limited to one every six months per copayment
Insulin aids (insulin pen) � limited to one every six months per copayment
Glucogon (requires prior authorization) � limited to one per copayment
Spacers and holding chambers for inhaled medications � limited to one per six months per copayment
Inhalers � up to 2 (nasal or oral), or up to a 31-day supply, whichever is less, per copayment
Drugs for sexual dysfunction require Prior authorization and have dispensing limitations. Contact plan for details.
Oral contraceptive drugs
Growth hormone
$10 per generic prescription or refill
obtained from a plan pharmacy
$30 per preferred brand name prescription
or refill obtained from a plan pharmacy
$45 per non-preferred brand name
prescription or refill obtained from a plan
pharmacy
$25 per generic prescription or refill
obtained through our mail order program
$75 per preferred brand name prescription
or refill obtained through our mail order
program
$112.50 per non-preferred brand name
prescription or refill obtained through our
mail order program
Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay.
Covered medications and supplies -continued on next page
43.
43
Page 44
45
2004 Health Net of Arizona, Inc. 41 Section 5( f)
Covered medications and supplies (continued) You pay
Self-injectable drugs require prior authorization (brand name copayment applied to insulin). $40 per prescription or refill, up to a 31-day supply. Quantity limitation may apply to
specific drugs.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
Vitamins (except prenatal), nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Anorexiants, appetite suppressants, diet aids, weight loss medications, and drugs used to treat obesity.
Any drug consumed at the place where it is dispensed or that is dispensed or administered by the physician
Drugs prescribed for non-covered services
Take home drugs; drugs prescribed for use after discharge from a hospital, nursing home, skilled nursing facility or other inpatient
facility must be obtained from a plan pharmacy
Replacement prescriptions
All charges.
44.
44
Page 45
46
2004 Health Net of Arizona, Inc. 42 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.
Services for deaf and
hearing impaired
We provide a TTY line for the deaf and hearing imposed 800/ 977-6757.
Centers of excellence We contract with many respected institutions in our regions, such as, University Medical Centers, Barrow's Neurological Institute, Maricopa County Burn Unit,
St. Joseph's Hospital and Phoenix Children's Hospital.
High risk pregnancies We contract with Matria Healthcare, Inc. This program is directed at high-risk pregnancies including pre-term labor, multiple gestations, tocolytic therapy,
hypertension, diabetes and hydration therapy. The goal is to achieve optimal
pregnancy prolongation by providing increased level of education and
surveillance.
Case Management
Programs
Alere Medical, Inc. -Congestive Heart Failure monitoring program. High acuity, Class 3-4 CHF members are eligible for this program. The goal is to
assure compliance with weight management, medications, diet and decrease
hospitalization and emergency room visits.
Renaissance � All End Stage Renal Disease (ESRD) and Chronic Kidney Disease (CKD) members are eligible for this program. Renaissance will strive
to reduce morbidity, mortality and improve quality of life.
Health Share � An online tool accessible from Health Net's internet Web site that assists members to identify participating hospitals with the highest quality
service for a particular procedure based on key factors such as mortality rate,
patient volume and outcomes.
Complex Case Management � Health Net's Case Managers work with our members to promote quality, cost-effective outcomes. The focus is on
members who require assistance throughout the continuum of care, such as
COPD, Asthma, Diabetes, Coronary Artery Disease (CAD) and those with
multiple co-morbidities. Members who are hospitalized with either acute
complex illness or trauma, or members with chronic disease states, are
screened for case management activity.
45.
45
Page 46
47
2004 Health Net of Arizona, Inc. 43 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year deductible.
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
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth, the jawbone and supporting tissues
(does not include injury caused by the act of chewing). The need for
these services must result from an accidental injury.
$15 per office visit in providers office or
$50 per visit if provided in outpatient
hospital setting
Dental benefits
We have no other dental benefits.
46.
46
Page 47
48
2004 Health Net of Arizona, Inc. 44 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.
Dental Coverage -Health Net of Arizona, Inc. is pleased to provide you and your enrolled family members with
access to dental care through Employers Dental Services (EDS) at no additional premium. Health Net FEHB
members are automatically enrolled in this program.
Highlights of the plan include:
Easy to Use Select any provider from the Employer's Dental Services network
Show your EDS identification card when you receive services View the EDS Network and New Patient provider availability online at
http:// www. mydentalplan. net
Low copayments for preventive and basic services
Discount on Orthodontics for Children and Adults Prescription Discount Program for dental medications
WellRewards Program � a discount program that rewards you for being a Health Net member. You'll save on a range
of products and services designed to help you stay healthy. Products and services available include:
Acupuncture Chiropractic Care Cosmetic Surgery Eyewear
Hearing aids Lasik & PRK surgery Massage therapy Nutrition counseling
Sleep Improvement Weight Management
If you would like more information regarding WellRewards, please call our Customer Contact Center at 1-800-289-
2818, or TTY 1-800-977-6567 for the hearing impaired, Monday through Friday, 7 a. m. to 6 p. m., excluding holidays.
Medicare+ Choice Enrollment
This Individual Plan offers Medicare beneficiaries the opportunity to enroll in a plan through Medicare or Health Net.
As indicated on page 49, annuitants and former spouses with FEHB coverage and Medicare Parts A and B eligibility
may elect to:
1. Stay on FEHB and not enroll in a Medicare+ Choice plan.
2. Stay on FEHB and enroll in a Medicare+ Choice plan if available in your service area.
3. Suspend their FEHB coverage and enroll in a Medicare+ Choice plan when available in their area. They
may later re-enroll if they choose
Contact your retirement system for information on your FEHB enrollment and changing to a Medicare+ Choice plan or
you may contact us at 800/ 977-7522, Monday through Friday 7: 00 a. m. to 6: 00 p. m. for more information. Hearing
impaired assistance Monday through Friday 7: 00 a. m. to 6: 00 p. m. TTY 800/ 977-6567.
47.
47
Page 48
49
2004 Health Net of Arizona, Inc. 45 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.
48.
48
Page 49
50
2004 Health Net of Arizona, Inc. 46 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 800/ 289-2818.
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: ACS/ Health Net, Inc, P. O. Box 14225, Lexington, KY 40512-
4225
Prescription drugs Follow the process as stated above, but send your request for reimbursement to the following address.
Submit your claims to: Health Net of Arizona, Inc. Attn: Pharmacy Department, 950
N. Finance Center Drive, Tucson, Arizona 85710-1362
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.
49.
49
Page 50
51
2004 Health Net of Arizona, Inc. 47 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: Health Net of Arizona, Inc., Attn: Commercial Appeals and Grievances Department, P. O.
Box 18015, Tucson, Arizona 85731-1362; 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: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group 3,
1900 E Street, NW, Washington, DC 20415-3630.
50.
50
Page 51
52
2004 Health Net of Arizona, Inc. 48 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.
Note: If you want OPM to review 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 800/ 289-2818 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 Insurance Group 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time.
51.
51
Page 52
53
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.
The decision to enroll in Medicare is yours. We encourage you to apply for
Medicare benefits 3 months before you turn age 65. It's easy. Just call the
Social Security Administration toll-free number 1-800-772-1213 to set up
an appointment to apply. If you do not apply for one or both Parts of
Medicare, you can still be covered under the FEHB Program.
If you can get premium-free Part A coverage, we advise you to enroll in it.
Most Federal employees and annuitants are entitled to Medicare Part A at
age 65 without cost. When you don't have to pay premiums for Medicare
Part A, it makes good sense to obtain the coverage. It can reduce your out-of-
pocket expenses as well as costs to the FEHB, which can help keep
FEHB premiums down.
Everyone is charged a premium for Medicare Part B coverage. The Social
Security Administration can provide you with premium and benefit
information. Review the information and decide if it makes sense for you
to buy the Medicare Part B coverage.
Section 9. Coordinating benefits with other coverage
Should I enroll in Medicare?
2004 Health Net of Arizona, Inc. 49 Section 8
52.
52
Page 53
54
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and
is the way most people get their Medicare Part A and Part B benefits now.
You may go to any doctor, specialist, or hospital that accepts Medicare.
The Original Medicare Plan pays its share and you pay your share. Some
things are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care.
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 claim 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 claim, call us at 800/ 289-2818.
We do not waive any costs if the Original Medicare Plan is your
primary payer.
(Primary payer chart begins on next page.)
The Original Medicare Plan (Part A or Part B)
2004 Health Net of Arizona, Inc. 50 Section 8
53.
53
Page 54
55
2004 Health Net of Arizona, Inc. 51 Section 9
Primary Payer Chart
The primary payer for the individual with Medicare is� A. When you -or your covered spouse -are age 65 or over and have Medicare and you�
Medicare This Plan
1) Are an active employee with the Federal government and�
You have FEHB coverage on your own or through your spouse who is also an active employee
You have FEHB coverage through your spouse who is an annuitant
2) Are an annuitant and�
You have FEHB coverage on your own or through your spouse who is also an annuitant You have FEHB coverage through your spouse who is an active employee
3) Are a reemployed annuitant with the Federal government and your position is excluded from the
FEHB (your employing office will know if this is the case) *
4) Are a reemployed annuitant with the Federal government and your position is not excluded from the
FEHB (your employing office will know if this is the case) and�
You have FEHB coverage on your own or through your spouse who is also an active employee You have FEHB coverage through your spouse who is an annuitant
5) 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) *
6) Are enrolled in Part B only, regardless of your employment status for Part
B services
for other
services
7) 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) **
B. When you or a covered family member�
1) Have Medicare solely based on end stage renal disease (ESRD) and�
It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and�
This Plan was the primary payer before eligibility due to ESRD for 30-month coordination period
Medicare was the primary payer before eligibility due to ESRD
C. When either you or your spouse are eligible for Medicare solely due to disability and you
1) Are an active employee with the Federal government and�
You have FEHB coverage on your own or through your spouse who is also an active employee You have FEHB coverage through your spouse who is an annuitant
2) Are an annuitant and�
You have FEHB coverage on your own or through your spouse who is also an annuitant
You have FEHB coverage through your spouse who is an active employee
D. Are covered under the FEHB Spouse Equity provision as a former spouse
* Unless you have FEHB coverage through your spouse who is an active employee
** Workers' Compensation is primary for claims related to your condition under Workers' Compensation
Medicare always makes the final determination as to whether they are the primary payer. The following chart illustrates whether
Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these
requirements correctly.
54.
54
Page 55
56
2004 Health Net of Arizona, Inc. 52 Section 9
Medicare + Choice If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare + Choice plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare +
Choice plans, you can only go to doctors, specialists, or hospitals that are
part of the plan. Medicare + Choice plans provide all the benefits that
Original Medicare covers. Some cover extras, like prescription drugs. To
learn more about enrolling in a Medicare + Choice plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at http:// www. medicare. gov.
If you enroll in a Medicare + Choice plan, the following options are
available to you:
This Plan and our Medicare + Choice plan: You may enroll in our
Medicare + Choice 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 + Choice plan: You may enroll in another plan's Medicare+ Choice plan and also remain enrolled in our
FEHB plan. We will still provide benefits when your Medicare+ Choice
plan is primary, even out of the Medicare+ Choice plan's network and/ or
service area (if you use our Plan providers), but we will not waive any of
our copayments or coinsurance. If you enroll in a Medicare + Choice plan,
tell us. We will need to know whether you are in the Original Medicare
Plan or in a Medicare + Choice plan so we can correctly coordinate benefits
with Medicare.
Suspended FEHB coverage to enroll in a Medicare + Choice plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare + Choice plan, eliminating your FEHB
premium. (OPM does not contribute to your Medicare+ Choice 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 + Choice plan's
service area.
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 a 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.
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
55.
55
Page 56
57
2004 Health Net of Arizona, Inc. 53 Section 9
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, or are responsible for your care 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 for injuries 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.
56.
56
Page 57
58
2004 Health Net of Arizona, Inc. 54 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same
year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 13.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Room and board, nursing care (except for skilled nursing care), and personal care designed to assist a member who has reached the maximum level of recovery
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See page 13.
Experimental or
investigational services Our parent company, Health Net, Inc (HNI), has a technology assessment policy committee whose sole function if to evaluate if a drug, device, medical treatment or
procedure is experimental or investigational. HNI bases its determination on one or more
of the following:
Is it broadly accepted in the medical community as standard, safe and effective for the illness or injury being related;
Is it approved for use by the appropriate governmental regulatory bodies, including the FDA;
It is attainable in the U. S. outside of a research institution program or protocol; Does it clearly improve the net health outcome as evaluated against non-experimental
or non-investigational health care services using credible and accepted
medical evidence.
Group health coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular organization or group that provides
payment for hospital, medical, or other health care services or supplies.
Medical necessity Services required to identify or treat an illness that is either diagnosed or reasonably suspected. Medically Necessary services must, in the judgement of Health Net:
1. be required to treat an illness or injury; and
2. be consistent and appropriate for the diagnosis and treatment of the Member's
condition; and
3. be in accordance with the standards of accepted principles of medical practice in the
United States; and
4. be performed at the most appropriate level of care for the Member as determined by
the Member's medical condition and not the Member's financial or family situations,
or the distance the Member lives from the Hospital, or any other non-medical factor;
and
5. not be for the convenience of the Member, nor the Member's family, support network,
Physician or another Health Professional; and
6. not be Experimental, Unproved or Investigational of furnished in connection with
medical or other research.
57.
57
Page 58
59
2004 Health Net of Arizona, Inc. 55 Section 10
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our
allowance as follows: our contracted amount.
Us/ We Us and we refer to Health Net of Arizona, Inc.
You You refers to the enrollee and each covered family member.
58.
58
Page 59
60
2004 Health Net of Arizona, Inc. 56 Section 11
Section 11. FEHB facts
Coverage information
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 http:// www. opm. gov/ insure.
Also, your employing or retirement office can answer your
about enrolling in the questions, and give you a Guide to Federal Employees Health Benefits Plans, brochures
FEHB Program 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 you, your spouse,
for you and your family 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 live or provide documentation
to your employing office that you have obtained other health benefits coverage for your
59.
59
Page 60
61
2004 Health Net of Arizona, Inc. 57 Section 11
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 cancel your coverage, change to
Self Only, or change to a plan that doesn't serve the area in which your children live as
long as the court/ administrative order is in effect. Contact your employing office for
further information.
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan
premiums start during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season
and you receive care between January 1 and the effective date of coverage under your
new plan or option, your claims will be paid according to the 2004 benefits of your old
plan or option. However, if your old plan left the FEHB Program at the end of the year,
you are covered under that plan's 2003 benefits until the effective date of your coverage
with your new plan. 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
(TCC), or a conversion policy (a non-FEHB individual policy).
Spouse equity coverage If you are divorced from a Federal employee or annuitant, you may not 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 Temporary Continuation of Coverage and Former
60.
60
Page 61
62
2004 Health Net of Arizona, Inc. 58 Section 11
Spouse Enrollees, or other information about your coverage choices. You can also
download the guide from OPM's Web site, 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
http:// www. opm. gov/ insure.
It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your right to
convert. You must apply in writing to us within 31 days after you receive this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program; however, you
will not have to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.
Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal Group Health Plan Coverage law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you
have been enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans. For more information,
get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the
FEHB Program. See also the FEHB Web site (http:// www. opm. gov/ insure/ health);
refer to the
"TCC and HIPAA" frequently asked questions. These highlight HIPAA rules, such as
the requirement that Federal employees must exhaust any TCC eligibility as one
condition for guaranteed access to individual health coverage under HIPAA, and have
information about Federal and State agencies you can contact for more information.
61.
61
Page 62
63
2004 Health Net of Arizona, Inc. 59 Two new Federal Programs complement FEHB benefits
Two new Federal Programs complement FEHB benefits
Important information OPM wants to be sure you know about two new Federal programs that complement the FEHB Program. First, the Flexible Spending Account (FSA) Program, also known as
FSAFEDS, lets you set aside tax-free money to pay for health and dependent care
expenses. The result can be a discount of 20 to more than 40 percent on services you
routinely pay for out-of-pocket. Second, the Federal Long Term Care Insurance
Program (FLTCIP) covers long term care costs not covered under the FEHB.
The Federal Flexible Spending Account Program -FSAFEDS
What is an FSA? It is a tax-favored benefit that allows you to set aside pre-tax money from your paychecks to pay for a variety of eligible expenses. By using an FSA, you can reduce your taxes
while paying for services you would have to pay for anyway, producing a discount that
can be over 40%!!
There are two types of FSAs offered by the FSAFEDS Program:
Covers eligible health care expenses not reimbursed by this Plan, or any other medical, dental, or vision care plan you or your dependents may have
Eligible dependents for this account include anyone you claim on your Federal income tax return as a qualified dependent under the U. S. Internal Revenue Service
(IRS) definition and/ or with whom you jointly file your Federal income tax return,
even if you don't have self and family health benefits coverage. Note: The IRS has a
broader definition than that of a "family member" than is used under the FEHB
Program to provide benefits by your FEHB Plan.
The maximum amount that can be allotted for the HCFSA is $3,000 annually. The minimum amount is $250 annually.
Covers eligible dependent care expenses incurred so you can work, or if you are married, so you and your spouse can work, or your spouse can look for work or
attend school full-time.
Eligible dependents for this account include anyone you claim on your Federal income tax return as a qualified IRS dependent and/ or with whom you jointly file
your Federal income tax return.
The maximum that can be allotted for the DCFSA is $5,000 annually. The minimum amount is $250 annually. Note: The IRS limits contributions to a Dependent Care
FSA. For single taxpayers and taxpayers filing a joint return, the maximum is $5,000
per year. For taxpayers who file their taxes separately with a spouse, the maximum is
$2,500 per year. The limit includes any child care subsidy you may receive
Enroll during Open Season You must make an election to enroll in an FSA during the FEHB Open Season. Even if you enrolled during the initial Open Season for 2003, you must make a new election to
continue participating in 2004. Enrollment is easy!
Enroll online anytime during Open Season (November 10 through December 8, 2003) at http:// www. fsafeds. com.
Call the toll �free number 1-877-FSAFEDS (372-3337) Monday through Friday, from 9 a. m. until 9 p. m. eastern time and a FSAFEDS Benefit Counselor will help
you enroll.
What is SHPS? SHPS is a third-party administrator hired by OPM to manage the FSAFEDS Program. SHPS is the largest FSA administrator in the nation and will be responsible for
enrollment, claims processing, customer service, and day-to-day operations of
FSAFEDS.
Who is eligible to enroll? If you are a Federal employee eligible for FEHB � even if you're not enrolled in FEHB�
Health Care Flexible
Spending Account
(HCFSA)
Dependent Care Flexible
Spending Account
(DCFSA)
62.
62
Page 63
64
2004 Health Net of Arizona, Inc. 60 Two new Federal Programs complement FEHB benefits
you can choose to participate in either, or both, of the flexible spending accounts. If you
are not eligible for FEHB, you are not eligible to enroll for a Health Care FSA. However,
almost all Federal employees are eligible to enroll for the Dependent Care FSA. The
only exception is intermittent (also called when actually employed [WAE]) employees
expected to work less than 180 days during the year.
Note: FSAFEDS is the FSA Program established for all Executive Branch employees
and Legislative Branch employees whose employers signed on. Under IRS law, FSAs
are not available to annuitants. In addition, the U. S. Postal Service and the Judicial
Branch, among others, are Federal agencies that have their own plans with slightly
different rules, but the advantages of having an FSA are the same no matter what agency
you work for.
How much should I Plan carefully when deciding how much to contribute to an FSA. Because of the tax contribute to my FSA? benefits of an FSA, the IRS places strict guidelines on them. You need to estimate how
much you want to allocate to an FSA because current IRS regulations require you forfeit
any funds remaining in your account( s) at the end of the FSA plan year. This is referred
to as the "use-it-or-lose-it" rule. You will have until April 29, 2004 to submit claims for
your eligible expenses incurred during 2003 if you enrolled in FSAFEDS when it was
initially offered. You will have until April 30, 2005 to submit claims for your eligible
expenses incurred from January 1 through December 31, 2004 if you elect FSAFEDS
during this Open Season.
The FSAFEDS Calculator at http:// www. fsafeds. com
will help you plan your FSA allocations
and provide an estimate of your tax savings based on your individual situation.
What can my HCFSA Every FEHB health plan includes cost sharing features, such as deductibles you must
pay for? meet before the Plan provides benefits, coinsurance or copayments that you pay when you and the Plan share costs, and medical services and supplies that are not covered by
the Plan and for which you must pay. These out-of-pocket costs are summarized on page
13 and detailed throughout this brochure. Your HCFSA will reimburse you for such costs
when they are for tax deductible medical care for you and your dependents that is NOT
covered by this FEHB Plan or any other coverage that you have.
Under the Standard Option of this Plan, typical out-of-pocket expenses include: office
visit copayments, inpatient hospital copayment, outpatient prescription drug copayments,
eyewear, lasik surgery or routine chiropractic care.
The IRS governs expenses reimbursable by a HCFSA. See Publication 502 for a
comprehensive list of tax-deductible medical expenses. Note: While you will see
insurance premiums listed in Publication 502, they are NOT a reimbursable expense
for FSA purposes. Publication 502 can be found on the IRS Web site at
http:// www. irs. gov/ pub/ irs-pdf/ p502. pdf.
If you do not see your service or expense listed
in Publication 502, please call a FSAFEDS Benefit Counselor at 1-877-FSAFEDS (372-
3337), who will be able to answer your specific questions.
Tax savings with an FSA An FSA lets you allot money for eligible expenses before your agency deducts taxes from your paycheck. This means the amount of income that your taxes are based on will
be lower, so your tax liability will also be lower. Without an FSA, you would still pay for
these expenses, but you would do so using money remaining in your paycheck after
Federal (and often state and local) taxes are deducted. The following chart illustrates a
typical tax savings example:
63.
63
Page 64
65
2004 Health Net of Arizona, Inc. 61 Two new Federal Programs complement FEHB benefits
If your taxable income is: $50,000 $50,000
And you deposit this amount into a FSA: $ 2,000 -$ 0-
Your taxable income is now: $48,000 $50,000
Subtract Federal & Social Security taxes: $13,807 $14,383
If you spend after-tax dollars for expenses: -$ 0-$ 2,000
Your real spendable income is: $34,193 $33,617
Your tax savings: $576 -$ 0-
Note: This example is intended to demonstrate a typical tax savings based on 27%
Federal and 7.65% FICA taxes. Actual savings will vary based upon in which retirement
system you are enrolled (CSRS or FERS), as well as your individual tax situation. In this
example, the individual received $2,000 in services for $1,424, a discount of almost 36%!
You may also wish to consult a tax professional for more information on the tax
implications of an FSA.
Tax credits and You cannot claim expenses on your Federal income tax return if you receive deductions reimbursement for them from your HCFSA or DCFSA. Below are some guidelines that
may help you decide whether to participate in FSAFEDS.
Health care expenses The HCFSA is tax-free from the first dollar. In addition, you may be reimbursed from the HCFSA at any time during the year for expenses up to the annual amount you've
elected to contribute.
Only health care expenses exceeding 7.5% of your adjusted gross income are eligible to
be deducted on your Federal income tax return. Using the example listed in the above
chart, only health care expenses exceeding $3,750 (7.5% of $50,000) would be eligible to
be deducted on your Federal income tax return. In addition, money set aside through a
HCFSA is also exempt from FICA taxes. This exemption is not available on your
Federal income tax return.
Dependent care expenses The DCFSA generally allows many families to save more than they would with the Federal tax credit for dependent care expenses. Note that you may only be reimbursed
from the DCFSA up to your current account balance. If you file a claim for more than
your current balance, it will be held until additional payroll allotments have been added
to your account.
Visit http:// www. fsafeds. com
and download the Dependent Care Tax Credit Worksheet from
the Quick Links box to help you determine what is best for your situation. You may also
wish to consult a tax professional for more details.
Does it cost me anything Probably not. While there is an administrative fee of $4.00 per month for an HCFSA to participate in FSAFEDS? and 1.5% of the annual election for a DCFSA, most agencies have elected to pay these
fees out of their share of employment tax savings. To be sure, check the FSAFEDS. com
web site or call 1-877-FSAFEDS (372-3337). Also, remember that participating in
FSAFEDS can cost you money if you don't spend your entire account balance by the end
of the plan year and wind up forfeiting your end of year account balance, per the IRS
"use-it-or-lose-it" rule.
Annual Tax Savings Example With FSA Without FSA
64.
64
Page 65
66
2004 Health Net of Arizona, Inc. 62 Two new Federal Programs complement FEHB benefits
Contact us To find out more or to enroll, please visit the FSAFEDS Web site at http:// www. fsafeds. com,
or contact SHPS by email or by phone. SHPS Benefit Counselors are
available from 9: 00 a. m. until 9: 00 p. m. eastern time, Monday through Friday.
� E-mail: fsafeds@ shps. net
� Telephone: 1-877-FSAFEDS (372-3337)
� TTY: 1-800-952-0450 (for hearing impaired individuals that would like to utilize a text messaging service)
The Federal Long Term Care Insurance Program
It's important protection Here's why you should consider enrolling in the Federal Long Term Care Insurance Program:
FEHB plans do not cover the cost of long term care. Also called "custodial care," long term care is help you receive when you need assistance performing activities of
daily living � such as bathing or dressing yourself. This need can strike anyone at
any age and the cost of care can be substantial.
The Federal Long Term Care Insurance Program can help protect you from the potentially high cost of long term care. This coverage gives you control over the
type of care you receive and where you receive it. It can also help you remain
independent, so you won't have to worry about being a burden to your loved ones.
It's to your advantage to apply sooner rather than later. Long term care insurance is something you must apply for, and pass a medical screening (called
underwriting) in order to be enrolled. Certain medical conditions will prevent some
people from being approved for coverage. By applying while you're in good health,
you could avoid the risk of having a change in health disqualify you from obtaining
coverage. Also, the younger you are when you apply, the lower your premiums.
You don't have to wait for an open season to apply. The Federal Long Term Care Insurance Program accepts applications from eligible persons at any time. You will
have to complete a full underwriting application, which asks a number of questions
about your health. However, if you are a new or newly eligible employee, you (and
your spouse, if applicable) have a limited opportunity to apply using the abbreviated
underwriting application, which asks fewer questions. If you marry, your new
spouse will also have a limited opportunity to apply using abbreviated underwriting.
Qualified relatives are also eligible to apply with full underwriting.
To find out more and Call 1-800-LTC-FEDS (1-800-582-3337) (TTY 1-800-843-3557)
to request an application or visit http:// www. ltcfeds. com.
65.
65
Page 66
67
2004 Health Net of Arizona, Inc. 63 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 19 Alternative treatment 26
Allogeneic (donor) bone marrow transplant 30 Ambulance 34, 36
Anesthesia 31 Autologous bone marrow transplant 30
Blood and blood plasma 33 Breast cancer screening 16
Casts 32, 33 Catastrophic protection out-of-pocket
maximum 13 Changes for 2004 9
Chemotherapy 20 Childbirth 17
Chiropractic 25 Cholesterol tests 16
Circumcision 18 Claims 46
Coinsurance 13 Colorectal cancer screening 16
Congenital anomalies 27 Contraceptive devices and drugs 18, 40
Coordination of benefits 49, 50, 51, 52, 53 Covered charges 54
Covered providers 10
Crutches 24 Deductible 13
Definitions 54, 55 Dental care 43
Diagnostic services 15, 16 Disputed claims review 47, 48
Donor expenses (transplants) 30 Dressings 32, 33
Durable medical equipment (DME) 24 Educational classes and programs 26
Effective date of enrollment 57 Emergency 35, 36
Experimental or investigational 54 Eyeglasses 22
Family planning 18 Fecal occult blood test 16
Fraud 5
General Exclusions 45 Hearing services 21
Home health services 25 Hospice care 34
Home nursing care 25 Hospital 32
Immunizations 17 Infertility 18, 19
Inhospital physician care 15 Inpatient Hospital Benefits 32
Insulin 40 Laboratory and pathological
services 16 Machine diagnostic tests 16
Magnetic Resonance Imagings (MRIs) 16
Mail Order Prescription Drugs 40 Mammograms 16
Maternity Benefits 17, 18 Medicaid 53
Medically necessary 54 Medicare 49, 50, 51, 52
Members 5, 65 Mental Conditions/ Substance
Abuse Benefits 37 Neurological testing 42
Newborn care 17 Non-FEHB Benefits 44
Nurse Licensed Practical Nurse 25
Registered Nurse 25 Nursery charges 17
Obstetrical care 17 Occupational therapy 21
Office visits 9, 15 Oral and maxillofacial surgery 29
Orthopedic devices 23 Out-of-pocket expenses 13
Outpatient facility care 33
Oxygen 33 Pap test 16
Physical examination 16, 17 Physical therapy 21
Physician 10, 15 Preventive care, adult 16
Preventive care, children 17 Prescription drugs 39, 40, 41
Preventive services 16, 17 Prior approval 12
Prostate cancer screening 16 Prosthetic devices 23
Psychologist 37, 38 Psychotherapy 37, 38
Radiation therapy 20 Renal dialysis 20
Room and board 32 Second surgical opinion 15
Skilled nursing facility care 33 Smoking cessation 26
Speech therapy 21 Sterilization procedures 18
Subrogation 53 Substance abuse 37, 38
Surgery
Anesthesia 31 Oral 29
Outpatient 27 Reconstructive 28
Syringes 40 Temporary continuation of coverage
57, 58 Transplants 30
Treatment therapies 20 Vision services 22
Well child care 17 Wheelchairs 24
Workers' compensation 52, 53 X-rays 9, 16, 32
66.
66
Page 67
68
2004 Health Net of Arizona, Inc. 64 Summary
Summary of benefits for Health Net of Arizona 2004
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................... Office visit copay: $15 primary care; $15 specialist 15
Services provided by a hospital:
Inpatient.................................................................................................
Outpatient ..............................................................................................
$100 per day up to 5 days per admission
$50 per visit
32
27
Emergency benefits:
In-area..................................................................................................
Out-of-area ..........................................................................................
$100 per visit or $50 per urgent care visit
$100 per visit or $50 per urgent care visit
36
36
Mental health and substance abuse treatment........................................ Regular cost sharing. 37
Prescription drugs ..................................................................................... $10 per generic drugs; $30 per preferred brand
name drugs; $45 per non-preferred brand name
drugs and $40 for approved self-injectable. Mail
Order program 2.5 retail copays
39
Dental Care ............................................................................................ No benefit. 43
Vision Care ............................................................................................ Eye exam every 24 month 22
Special features: Flexible benefit option, Services for deaf and hearing impairment, Centers of excellence, High risk
pregnancies and Case management services.
42
Protection against catastrophic costs
(your catastrophic protection out-of-pocket maximum) ......................
Nothing after $2,000/ Self Only or
$4, 000/ Family enrollment per year
Some costs do not count toward this protection
13
67.
67
Page 68
2004 Health Net of Arizona, Inc. 65
2004 Rate Information for
Health Net of Arizona, Inc.
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer
to the FEHB Guide for that category or contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for
United States Postal Service Employees, RI 70-2. Different postal rates apply and 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 who are not career postal employees. Refer to the applicable FEHB Guide.
Type of
Enrollment Code
Non-Postal Premium
Biweekly Monthly
Gov't Your Gov't Your
Share Share Share Share
Postal Premium
Biweekly
USPS Your
Share Share
Self Only
Self & Family
A71
A72
$106.22 $35.41 $230.15 $76.72
$269.14 $89.71 $583.13 $194.38
$125.70 $15.93
$318.48 $40.37
68.