Dean Health Plan, Inc.
| A Health Maintenance Organization |
| For changes in benefits see page 10 . |
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 8 for requirements.
| This Plan has Excellent Accreditation from NCQA.. See the 2005 Guide for more information on accreditation. |
(HMO)
Enrollment codes for this Plan:
WD1 Self Only
WD2 Self and Family
| RI 73-189 |
Dear Federal Employees Health Benefits Program Participant:
Welcome to the 2005 Open Season! By continuing to introduce pro-consumer health care ideas, the Office of Personnel Management (OPM) team has given you greater, cost effective choices. This year several national and local health plans are offering new options, strengthening the Federal Employees Health Benefits (FEHB) Program and highlighting once again its unique and distinctive market-oriented features. I remain firm in my belief that you, when fully informed as a Federal subscriber, are in the best position to make the decisions that meet your needs and those of your family. Plan brochures provide information to help subscribers make these fully informed decisions. Please take the time to review the plan's benefits, particularly Section 2, which explains plan changes.
Exciting new features this year give you additional opportunities to save and better manage your hard-earned dollars. For 2005, I am very pleased and enthusiastic about the new High Deductible Health Plans (HDHP) with a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) component. This combination of health plan and savings vehicle provides a new opportunity to save and better manage your money. If an HDHP/HSA is not for you and you are not retired, I encourage you to consider a Flexible Spending Account (FSA) for health care. FSAs allow you to reduce your out-of-pocket health care costs by 20 to more than 40 percent by paying for certain health care expenses with tax-free dollars, instead of after-tax dollars.
Since prevention remains a major factor in the cost of health care, last year OPM launched the HealthierFeds campaign. Through this effort we are encouraging Federal team members to take greater responsibility for living a healthier lifestyle. The positive effect of a healthier life style brings dividends for you and reduces the demands and costs within the health care system. This campaign embraces four key "actions" that can lead to a healthy America: be physically active every day, eat a nutritious diet, seek out preventative screenings, and make healthy lifestyle choices. Be sure to visit HealthierFeds at www.healthierfeds.opm.gov for more details on this important initiative. I also encourage you to visit the Department of Health and Human Services website on Wellness and Safety, www.hhs.gov/safety/index.html, which complements and broadens healthier lifestyle resources. The site provides extensive information from health care experts and organizations to support your personal interest in staying healthy.
The FEHB Program offers the Federal team the widest array of cost-effective health care options and the information needed to make the best choice for you and your family. You will find comprehensive health plan information in this brochure, in the 2005 Guide to FEHB Plans, and on the OPM Website at www.opm.gov/insure. I hope you find these resources useful, and thank you once again for your service to the nation.
Sincerely,
Kay Coles James
Director
Notice of the Office of Personnel Management's
Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you how OPM may use and give out ("disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
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:
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 the notice are effective April 14, 2003.
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 2005................................................................................................................... 10
Program-wide changes.......................................................................................................................... 10
Changes to this Plan............................................................................................................................... 10
Section 3. How you get care .............................................................................................................................. 11
Identification cards................................................................................................................................. 11
Where you get covered care.................................................................................................................. 11
� Plan providers................................................................................................................................. 11
� Plan facilities.................................................................................................................................... 11
What you must do to get covered care................................................................................................... 11
� Primary care.................................................................................................................................... 11
� Specialty care.................................................................................................................................. 11
� Hospital care................................................................................................................................... 13
Circumstances beyond our control......................................................................................................... 13
Services requiring our prior approval...................................................................................................... 13
Section 4. Your costs for covered services.......................................................................................................... 14
� Copayment...................................................................................................................................... 14
� Deductible....................................................................................................................................... 14
� Coinsurance.................................................................................................................................... 14
Section 5. Benefits - OVERVIEW (See page 10 for how our benefits changed this year and page 66 for a benefits summary.) 15..........................................................................................................................................................
Section 5(a) Medical services and supplies provided by physicians and other health care professionals............. 16
Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals.......... 27
Section 5(c) Services provided by a hospital or other facility, and ambulance services...................................... 27
Section 5(d) Emergency services/accidents...................................................................................................... 35
Section 5(e) Mental health and substance abuse benefits.................................................................................. 37
Section 5(f) Prescription drug benefits............................................................................................................. 39
Section 5(g) Special features .......................................................................................................................... 43
�Flexible benefits option
Section 5(h) Dental benefit............................................................................................................................. 43
Section 6. General exclusions -- things we don't cover......................................................................................... 44
Section 7. Filing a claim for covered services....................................................................................................... 45
Section 8. The disputed claims process................................................................................................................ 46
Section 9. Coordinating benefits with other coverage ........................................................................................... 48
When you have other health coverage.................................................................................................... 48
What is Medicare?................................................................................................................................ 48
� Should I enroll in Medicare? ........................................................................................................... 48
� The Original Medicare Plan (Part A or Part B)................................................................................. 48
� Medicare Advantage....................................................................................................................... 51
TRICARE and CHAMPVA.................................................................................................................. 52
� Workers' Compensation.................................................................................................................. 52
� Medicaid ........................................................................................................................................ 52
� When other Government agencies are responsible for your care........................................................ 52
� When others are responsible for injuries........................................................................................... 52
Section 10. Definitions of terms we use in this brochure......................................................................................... 53
Section 11. FEHB facts ...................................................................................................................................... 54
Coverage information........................................................................................................................... 54
�No pre-existing condition limitation................................................................................................. 54
�Where you can get information about enrolling in the FEHB Program.............................................. 54
�Types of coverage available for you and your family....................................................................... 54
� Children's Equity Act.................................................................................................................... 55
�When benefits and premiums start.................................................................................................. 55
� When you retire......................................................................................................................... 56
When you lose benefits......................................................................................................................... 56
�When FEHB coverage ends........................................................................................................... 56
�Spouse equity coverage................................................................................................................. 56
�Temporary Continuation of Coverage (TCC)................................................................................. 56
�Converting to individual coverage................................................................................................... 57
�Getting a Certificate of Group Health Plan Coverage...................................................................... 57
Two Federal Programs complement FEHB benefits............................................................................................... 58
The Federal Flexible Spending Account Program - FSAFEDS............................................................... 58
The Federal Long Term Care Insurance Program................................................................................... 62
Index .......................................................................................................................................................... 63
2005 Summary of benefits for Dean Health Plan.................................................................................................... 64
Rate information for Dean Health Plan..................................................................................................... Back cover
Introduction |
This brochure describes the benefits of Dean Health Plan, Inc. under our contract (CS 1966) with the United States Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for Dean Health Plan, Inc. administrative offices is:
Dean Health Plan, Inc.
1277 Deming Way
Madison WI 53717
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, 2005, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2005, and changes are summarized on pages 7. Rates are shown at the end of this brochure.
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 Dean Health Plan, 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 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, Planning and 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 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.
� 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 800-279-1301 and explain the situation.
If we do not resolve the issue:
| CALL -- THE HEALTH CARE FRAUD HOTLINE 202-418-3300 OR WRITE TO: The United States Office of Personnel Management Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400 Washington, DC20415-1100 |
� 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.
� 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.
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 website (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
� Dean Health Plan Inc. is for-profit HMO, and has been is business since 1983. If you want more information about us, call 800-2719-1301, or write to Dean Health Plan, Attention Customer Service, 1277 Deming Way Madison WI 53717. You may also contact us by fax at 608-827-4152 or visit our website at www.deancare.com.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is: Adams, Columbia, Crawford, Dane, Dodge, Fond du Lac, Grant, Green, Green Lake, Iowa, Jefferson, Juneau, Lafayette, Marquette, Racine, Richland, Rock, Sauk, Vernon, Waukesha, and Walworth counties in Wisconsin.
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.
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
� In Section 9, we revised the Medicare Primary Payer Chart and updated the language regarding Medicare Advantage plans (formerly called Medicare + Choice plans).
� In Section 12, we revised the language regarding the Flexible Spending Account Program - FSAFEDS and the Federal Long Term Care Insurance Program.
Changes to this Plan
� Your share of the non-Postal premium will increase by 16.0% for Self Only or 28.9% for Self and Family.
� Growth Hormones are covered with $10 generic and 30% brand name copayment with required prior authorization.
� MRI (outpatient services only) are covered with a $50 copayment (3 copayment maximum $150 per member per year).
� Emergency Room copayment of $75 will be waived if admitted as inpatient through the Emergency room.
� Immunizations due to volunteer and education as it pertains to preventive treatment while traveling are now covered.
� Cochlear Implants are now covered in full with prior authorization.
� Tobacco cessation is now covered as a benefit and not a program. Coverage is for 3 (three) 4-week (28 day) courses of zyban and/or nicotine replacement therapy ("the patch") with doctor's prescription for, $10 copay per fill.
� Treatment of bunion and spurs are now covered subject to the $10 office copay.
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 800-279-1301 or write to us at 1277 Deming Way Madison WI 53717.
Where you get covered You get care from "Plan providers" and "Plan facilities." You will only
Care pay copayments, deductibles, 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 NCQA and Dean Health Plan standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website. Provider updates are also included in the quarterly mailing to all members in the Notables newsletter, or visit our website at www.deancare.com.
�Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at www.deancare.com.
| What you must do to get covered care |
� Primary care The following types of physician can be a primary care physician for you: Family Practice doctors treat people of all ages. They focus on family health problems. General Practice doctors treat people of all ages. Pediatric doctors treat children and adolescents, and generally manage their health. Internal Medicine doctors treat adult men and women. Obstetrics and Gynecology doctors manage a woman's care during pregnancy and childbirth. They also treat conditions unique to females. 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 arrange your referral to a specialist for needed care. You may also seek services from other Plan providers, including specialists, located at the same clinic as your primary care physician, without a referral. Written referrals are not required for the following types of services when provide by a Dean Health Plan Provider: MRI (Magnetic Resonance Imaging), Diagnostic tests & respiratory therapy, Home Health, Oral Surgery for covered procedures, Routine vision care, and Chiropractic care.
Here are other things you should know about specialty care:
� If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
� If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
� If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
� If you have a chronic or disabling condition and lose access to your specialist because we:
Terminate our contract with your specialist for other than cause; or
Drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or
Reduce our service area and you enroll in another FEHB Plan,
You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.
If you are in the 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 service department immediately at 800-279-1301. 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 92nd 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.
Circumstances beyond Under certain extraordinary circumstances, such as natural disaster, we may have
our control to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.
| Services requiring our prior approval
|
We call this review and approval process prior authorization. Your physician must obtain prior authorization before sending you to a hospital, referring you to a non-plan provider or facility, or recommending follow up care.
We will provide benefits for covered services only when the services are medically necessary to prevent, diagnose, or treat your illness or condition.
Section 4. Your costs for covered services |
You must share the cost of some services. You are responsible for:
� Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing 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 actual charges for diagnosis and treatment of infertility services, and 25% of charges for orthopedic services, prosthetic devices, lenses following cataract removal, and durable medical equipment.
Your catastrophic protection We do not have a catastrophic protection out-of-pocket maximum.
out-of-pocket
Section 5. Benefits -- OVERVIEW (See page 10 for how our benefits changed this year and page 66 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 800-279-1301 or at our website at www.deancare.com
Section 5(a) Medical services and supplies provided by physicians and other health care professionals 17-27
�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 |
Section 5(b) Surgical and anesthesia services provided by physicians and other health care professionals 28-23
�Surgical procedures �Reconstructive surgery |
�Oral and maxillofacial surgery �Organ/tissue transplants �Anesthesia |
Section 5(c) Services provided by a hospital or other facility, and ambulance services 33-35
�Inpatient hospital �Outpatient hospital or ambulatory surgical center
|
�Extended care benefits/skilled nursing care facility benefits �Hospice care �Ambulance |
Section 5(d) Emergency services/accidents.......................................................................... 36-37
�Medical emergency �Ambulance
Section 5(e) Mental health and substance abuse benefits...........................................................38-39
Mental health and substance abuse benefits.................................................................................. 38-39
Section 5(f) Prescription drug benefits..................................................... ............................ 40-43
Covered medications and supplies................................................................................................ 40-43
Section 5(g) Special features........................................................................................... 44
� Dean On Call
� Flexible benefits option
Section 5(h) Dental benefits..................................................................................... 45
Accidental injury benefit............................................................................ 65
Section 5(i)"No" Dental benefits.......................................................................................45
Summary of benefits for Dean Health Plan 2005.................................................................... 66
2005 Rate Information for Dean Health Plan......................................................................... 67
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; � National Transplant Program (NTP) � Limited Benefits - Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in an NCI- or NIH-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan's medical director in accordance with the Plan's protocols Note: We cover related medical and hospital expenses of the donor when we cover the recipient.
|
Nothing
|
Not covered: � Donor screening tests and donor search expenses, except those performed for the actual donor � Implants of artificial organs � Transplants not listed as covered |
All charges. |
Anesthesia |
|
Professional services provided in - � Hospital (inpatient)
|
Nothing
|
Professional services provided in - � Hospital outpatient department � Skilled nursing facility � Ambulatory surgical center � Office
|
Nothing
|
Section 5 (e). Mental health and substance abuse benefits |
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I M P O R T A N T |
When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions. Here are some important things to keep in mind about these benefits: � Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. � Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. � YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below. |
I M P O R T A N T |
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Benefit Description |
You pay |
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|---|---|---|---|---|---|---|
Mental health and substance abuse benefits |
You Pay |
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All diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. Note: Plan benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve. |
Your cost sharing responsibilities are no greater than for other illness or conditions. |
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� Professional services, including individual or group therapy by providers such as psychiatrists, psychologists, or clinical social workers � Medication management � Diagnostic tests |
$10 per visit
Nothing |
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| 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. |
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Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all of the following authorization processes: If you are seeking care from a mental health or substance abuse provider at the same clinic as your primary care provider, no referral is needed. Your provider will need to file a treatment plan with us for prior approval for ongoing treatment. If you are seeking care outside your primary care provider or clinic, you must obtain a referral from your primary care provider before receiving services. On your behalf, your provider must submit referral request (and treatment plan if applicable) to us for prior approval. WE will provide written confirmation to the provider if approval is given for the services. For information on available plan providers or status of a referral, please contact Customer Service at 800-279-1301. |
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| Limitation We may limit
your benefits if you do not obtain a treatment plan.
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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. � Certain prescription drugs included in our formulary require prior authorization. The drug prior authorization process can be initiated by your Plan physician or your plan pharmacy by filling out a Drug Prior Authorization Request form. A copy of this request including the determination will then be mailed to you, your plan pharmacy, and plan physician. Updates to our drug formulary are provided in Notables, our quarterly news magazine sent to the member's home. Members may also obtain a listing by calling our Customer Service Department at 800-279-1301 or at our website at www.deancare.com. � 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 |
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There are important features you should be aware of. These include: � Who can write your prescription. A plan physician or referral doctor must write the prescription. � Where you can obtain them. You must fill the prescription at a plan pharmacy or national plan pharmacy. � We use a formulary. Prescription drugs are included in our formulary by our plan Pharmacy and Therapeutics Committee to ensure that our members receive safe, effective treatment at a reasonable cost. The committee is staffed by providers from may different specialties. Drugs recently approved by the Food and Drug Administration are not automatically included in the formulary but may be added after the committee determines therapeutic advantages of the drug and its medically appropriate application. In addition, certain drug products are excluded when therapeutic alternatives are available. If your physician prescribes a drug that is not on our formulary, the physician must obtain prior authorization from the plan in order for the prescription to be covered under plan benefits. In some cases, the physician will need to prescribe an alternative formulary drug if an alternative is available that is equally effective for the patient form treatment of the specific condition. To order a listing of the drugs that require prior authorization or are excluded, call our Customer Service Department at 800-279-1301 or our website at www.deancare.com. |
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These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral doctor and obtained at a plan pharmacy will be dispensed for up to a 30 day supply or 100 unit supply, whichever is less; 240 milligrams of liquid (8oz); 60 grams of ointment, creams or topical preparation; or one commercially prepared unit (i.e., one inhaler, one vial opthamolic medication or insulin). You pay $10 copay per prescription unit or refill for generic drugs and 30% coinsurance for name brand drugs when generic substitution is not permissible. When generic substitution is available, a generic equivalent will be dispensed, unless your physician specifically requires a name brand. If you received a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispensed as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic. If you are called to active duty and require medication during a national emergency call us at 800-279-1301 for assistance. |
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� Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in strength and dosage to the original brand name product. Generic drugs cost you and your plan less money than a name-brand drug. � When you have to file a claim. If you receive a prescription outside of the area or a situation arises where the pharmacy cannot process a prescription under the plan, you may submit an itemized receipt to us for reimbursement for all covered prescription drugs. Send the receipt to: Dean Health Plan, 1277 Deming Way, Madison, WI 53717.
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Benefit Description |
You pay |
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|---|---|---|---|---|---|---|
Covered medications and supplies |
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We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy: � Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase. � Insulin, with a copay charge applied to each vial. � Disposable needles and syringes for the administration of covered medications � Drugs for sexual dysfunction (see Prior authorization below) � Oral and injectable contraceptive drugs up to a 30 day supply; contraceptive diaphragms. � Infertility drugs: you pay 50% of the cost of the prescription unit or refill � Diabetic supplies, including disposable needles and syringes needed for injecting the covered prescribed medication, glucose test tablets and test tape, Benedict's solution or equivalent and acetone test tablets; a copay will apply for each item purchased. � Growth Hormones and Ceredase (prior authorization required) |
$10 per generic prescription 30% per name brand prescription
30% brand copay up to $1,500 brand drug out of pocket maximum per member per contract year: $10 copay applies thereafter.
Note: If there is no generic equivalent available, you will still have to pay the brand name copay.
50% of the cost |
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� Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits � Zyban is covered for one 2-month supply under the brand name prescription drug benefit through the Smoking Cessation program. |
30% coinsurance |
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� NOTE: (Limited Benefits): Drugs to treat sexual dysfunction are limited. Contact the plan for dose limits. |
You pay 50% copay up to the doses limit and all charges above that. |
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Here are some things to keep in mind about our prescription drug program. � A generic equilivant will be dispensed if it is available, unless your physician specifically required a name brand. If you receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispensed a Written for the brand drug, you have to pay the difference in cost between the name brand drug and the generic. � We administer a closed formulary. If your physician believes a name brand product is necessary or there is no generic available, your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of drug that we selected to meet patient needs at a lower cost. To order a listing of the drugs that require prior authorization or are excluded, call our Customer Service Department at 800-279-1301 or at our website www.deancare.com. Not covered: � Drugs and supplies for cosmetic purposes � Drugs to enhance athletic performance � Fertility drugs (not approved by the plan) � Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies � Vitamins, nutrients and food supplements even if a physician prescribes or administers them � Nonprescription medicines
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Feature |
Description |
|---|---|
Flexible benefits option
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Under the flexible benefits option, we determine the most effective way to provide services. � We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit. � Alternative benefits are subject to our ongoing review. � By approving an alternative benefit, we cannot guarantee you will get it in the future. � The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits. � Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. |
24 hour nurse line Dean On Call |
For any of your health concerns, 24 hours a day, 7 days a week, you may call 800-576-8773 or and talk with a registered nurse who will discuss treatment options and answer your health questions. |
Section 5 (h). Dental benefits |
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I M P O R T A N T |
Here are some important things to keep in mind about these benefits: � Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. � Plan dentists must provide or arrange your care. � We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for impatient 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 |
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Accidental injury benefit |
You pay |
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|---|---|---|---|---|---|
We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury. |
Nothing |
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Dental benefits |
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We have no other dental benefits. |
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The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition and we agree, as discussed under What Services Require Our Prior Approval on page 13.
We do not cover the following:
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 In most cases, providers and facilities file claims for you. Physicians must
benefits file on the form HCFA-1500, Health Insurance Claim Form. Your facilities will file on the UB-92 form. For claims questions and assistance, call us at 800-279-1301.
When you must file a claim -- such as for services you received 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: 1277 Deming Way, Madison WI 53717
Prescription drugs Send your prescription drug receipts to the address noted above.
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 Please reply promptly when we ask for additional information. We may
Information delay processing or deny your claim if you do not respond.
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: 1277 Deming Way, Madison WI 53171; 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.
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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.
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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.
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4 |
If you do not agree with our decision, you may ask OPM to review it. |
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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. |
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Write to OPM at: United States Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630. |
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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.
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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.
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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.
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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 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.
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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.
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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 800-279-1301 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/prior approval, then:
� If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or
� You may call OPM's Health Benefits Contracts Division 3 at 202/606-0737 between 8 a.m. and 5 p.m. eastern time.
Section 9. Coordinating benefits with other coverage |
When you have other You must tell us if you or a covered family member have coverage under
health coverage 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 reasonable charge. After the primary plan pays, we will pay either what is left of the reasonable charge or our regular benefit, whichever is less. We will not pay more than our reasonable charge. If we are the secondary payer, we may be entitled to received payment from your primary plan.
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.
Should I enroll in The decision to enroll in Medicare is yours. We encourage you to apply
Medicare? 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.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on weather you are in the Original Medicare Plan or a private Medicare Advantage plan.
?The Original Medicare The Original Medicare Plan (Original Medicare) is available everywhere
Plan (Part A or Part B) 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 (but coverage through private prescription drug plans will be available starting in 2006).
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. Tell us if you or a family member is enrolled in Medicare Part A and B. Medicare will determine who is responsible for paying for medical services and we will coordinate the payments. On occasion you may need to file a Medicare claim form.
Claims process when you have the Original Medicare Plan -- You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan.
� When we are the primary payer, we process the claim first.
� When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 800-279-1301.
We do not waive any costs if the Original Medicare Plan is your primary payer.
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.
Primary Payer Chart |
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|---|---|---|
A. When you - or your covered spouse - are age 65 or over and have Medicare and you... |
The primary payer for the individual with Medicare is... |
|
Medicare |
This Plan |
|
1) Have FEHB coverage on your own as an active employee or through your spouse who is an active employee |
� |
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2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant |
� |
|
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) and you are not covered under FEHB through your spouse under #1 above |
� |
|
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) and you are not covered under FEHB through your spouse under #1 above |
� |
|
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) ave 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 a covered family member are eligible for Medicare solely due to disability and you... |
||
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee |
� |
|
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant |
� |
|
D. When you are covered under the FEHB Spouse Equity provision as a former spouse |
� |
|
*Workers' Compensation is primary for claims related to your condition under Workers' Compensation
�Medicare Advantage If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs) in some areas of the country. In most Medicare Advantage plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare Advantage plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare Advantage plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www.medicare.gov.
If you enroll in a Medicare Advantage plan, the following options are available to you:
This Plan and another plan's Medicare Advantage plan: You may enroll in another plan's Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan's network and/or service area (if you use our Plan providers), but we will not waive any of our co-payments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage 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 Advantage plan's service area.
TRICARE and TRICARE is the health care program for eligible dependents of military persons,
CHAMPVA 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
� 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.
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 a 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 We do not cover services and supplies when a local, State,
agencies are responsible or Federal Government agency directly or indirectly pays for them.
for your care
When others are When you receive money to compensate you for medical or hospital
responsible for injuries care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.
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 thepercentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. 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 The type of care given when the basic goal is to help a person in the activities of daily life. This includes help in walking; getting in and out of bed, bathing, dressing ,eating , using the toilet, preparing special diets, taking medications properly and 24 hour supervision for potentially unsafe behavior. Such care is custodial when it does not require continued attention by trained medical personnel. Such care is custodial even if provided by registered nurses, licensed practical nurses, or other trained medical personnel. Custodial care that lasts 90 days or more is sometimes known as Long term care.
| Experimental or investigational services |
We regularly evaluate new medical devices, new techniques, and new uses for older existing procedures. This process is both proactive and reactive. Health care experts in the Dean organization, including physician, and specialty providers, review and evaluate all pertinent information. If new technology is approved, procedures and policies are revised or established to implement this decision.
Medical necessity The services or supplies provided by a hospital, or plan provider (or a non-plan provider if there is an authorized referral requested or in an emergency or urgent care situation) that are required to identify or treat a member's illness or injury as which, as determined by the Health Services Department, are: (a) consistent with the illness or injury; (b) in accordance with generally accepted standards of acceptable medical practice; (c) not solely for the convenience of a member, hospital, plan provider, or other provider; and (d) the most appropriate supply or level of services that can be safely provided to the member.
Plan allowance Plan allowance is the amount we use to determine our payment and your coinsurance for covered services.
Us/We Us and we refer to Dean Health Plan
You You refers to the enrollee and each covered family member.
Coverage Information
?No pre-existing We will not refuse to cover the treatment of a condition that you had
condition limitation before you enrolled in this Plan solely because you had the condition before you enrolled.
?Where you can get See www.opm.gov/insure. Also, your employing or retirement
information about office can answer your questions, and give you a Guide to Federal
enrolling in the FEHB Employees Health Benefits Plans, brochures for other plans, and other
Program 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 Self Only coverage is for you alone. Self and Family coverage is for
available for you and you, your spouse, and your unmarried dependent children under age 22,
your family 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 children. If you do not do so, your employing office will enroll you involuntarily as follows:
� If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option,
� if you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self and Family in the same option of the same plan; or
� if you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you have other coverage for the children. If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot make any changes after retirement. Contact you 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 2004 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 (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 Spouse Enrollees, or other information about your coverage choices. You can also download the guide from OPM's website, www.opm.gov/insure.
? Temporary If you leave Federal service, or if you lose coverage because you no longer
Continuation of qualify as a family member, you may be eligible for Temporary
Coverage (TCC) Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your job, if you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees, from your employing or retirement office or from www.opm.gov/insure. It explains what you have to do to enroll.
� Converting to You may convert to a non-FEHB individual policy if:
individual coverage
� Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
� You decided not to receive coverage under TCC or the spouse equity law; or
� 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) Group Health Plan is a Federal law that offers limited Federal protections for health coverage Coverage availability and continuity to people who lose employer group coverage.
If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage. Your new plan must reduce or eliminate waiting periods, limitations, or exclusions for health related conditions based on the information in the certificate, as long as you enroll within 63 days of losing coverage under this Plan. If you have been enrolled with us for less than 12 months, but were previously enrolled in other FEHB plans, you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the FEHB web site (www.opm.gov/insure/archive/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.
Section 12.Two Federal Programs complement FEHB benefits |
Important information OPM wants to make sure you are aware of two Federal programs that complement the FEHB Program. First, the Federal 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% 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 FSAFEDS:
| Health Care Flexible Spending Account (HCFSA)
|
� 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 annual amount that can be allotted for the HCFSA is $4,000 annually. Note: The Federal workforce includes a number of employees married to each other. If each spouse/employee is eligible for FEHB coverage, both may enroll for a HCFSA up to the maximum of $4,000 each ($8,000 total). Both are covered under each other's HCFSA. The minimum amount is $250 annually.
| Dependent Care Flexible Spending Account (DCFSA)
|
� Covers eligible dependent care expenses incurred so you, or your spouse, if married, can work, look for work, or attend school full-time.
� Qualifying dependents for this account include your dependent children under age13, or any person of any age whom you claim as a dependent on your Federal Income Tax return (and who is mentally or physically incapable of self care).
� The maximum that can be allotted for the DCFSA is $5,000 annually. The minimum amount is $250. Note: The IRS limits contributions to a DCFSA. 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 You must make an election to enroll in an FSA during the 2005 FEHB
Season Open Season. Even if you enrolled during the initial Open Season for
2004, you must make a new election to continue participation in 2005.
Enrollment is easy!
� Online: visit www.fsafeds.com and click and Enroll.
� Telephone: call an FSAFEDS Benefits Counselor toll -free 1-877-FSAFEDS (372-3337) Monday through Friday, from 9 a.m. until 9 p.m. Eastern Time.
TTY: 1-800-952-0450.
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- you can choose to participate in either, or both, of the FSAs. However, if you enroll in a high deductible plan (HDHP) with a Health Savings Account (HAS),you are not eligible to participate in an HCFSA.
Almost all Federal employees are eligible to enroll for the DCFSA. 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 to participate. 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 regardless of the agency for which you work.
� How much should I Plan carefully when deciding how much to contribute to an FSA. Because
contribute to my FSA? of the tax benefits an FSA provides, the IRS places strict guidelines on how the money can be used. Under current IRS tax rules, you are required to forfeit any money for which you did not incur an eligible expense under your FSA account(s) during the Plan Year. This is known as the "use-it-or-lose-it" rule. You will have until April 30, following the end of the Plan Year to submit claims for your eligible expenses incurred from January 1 through December 31. For example if you enroll in FSAFEDS for 2005 Plan Year, you will have until April 30, 2006 to submit claims for eligible expenses.
The FSAFEDS Calculator at 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 plan includes cost sharing features, such as deductibles you
pay for? must 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 14 and detailed throughout this brochure. Your HCFSA will reimburse you when costs are for qualified medical care for you and your dependents that is NOT covered by this FEHB Plan or any other coverage that you have.
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. The FSAFEDS Web site also has a comprehensive list of eligible expenses at www.FSAFEDS.com/fsafeds/eligileespenses.asp If you do not see your service or expense listed, 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 be less. 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:
Annual Tax Savings Example |
With FSA |
Without FSA |
|---|---|---|
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),your state of residence, and 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 Federal Income Tax-free from the first dollar. In addition, you may be reimbursed from your 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 shown above, 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 www.fsafeds.com and download the Dependent Care Tax Credit Worksheet from the Forms and Literature page to help you determine what is best for your situation. You may also wish to consult a tax professional for more details.
No. Section 1127 of The National Defense Authorization Act (Public Law 108-136) requires agencies that offer FSAFEDS to employees to cover the administrative fee(s) on behalf of their employees. However, 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, resulting in the forfeiture of funds remaining in your account (the IRS "use-it-or-lose-it" rule). |
� Contact us To learn enroll, please visit the FSAFEDS Web site at
www.fsafeds.com, or contact SHPS directly via email or by phone. FSAFEDS Benefits Counselors are available Monday through Friday, from 9:00 a.m. until 9:00 p.m. eastern time.
� 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 Why should you consider applying for coverage under the in the Federal Long Term Care Insurance Program (FLTCP)?
� FEHB plans do not cover the cost of long term care. Also called "custodial care," long term care is help you receive to preform activities of daily living - such as bathing or dressing yourself - or supervision you receive because of a severe cognitive impairment. The 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. With FLTCIP coverage, you won't have to worry about relying on your loved ones to provide or pay for your care.
� It's to your advantage to apply sooner rather than later. In order to qualify for coverage under the FLTCIP, you must apply for, and pass a medical screening (called underwriting) in order to be enrolled. Certain medical conditions, or combination of 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. Newly married spouses of employees also have a limited opportunity, to apply using abbreviated 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 www.ltcfeds.com.
Index |
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 45
Allergy tests 20
Alternative treatment 27
Allogenetic (donor) bone marrow transplant 31
Ambulance 35
Anesthesia 31
Autologous bone marrow transplant 31
Biopsies 19
Birthing centers 19
Blood and blood plasma 34
Breast cancer screening 18
Casts 33
Changes for 2005 10
Chemotherapy 21
Childbirth 19
Chiropractic 27
Cholesterol tests 18
Circumcision 19
Claims 47
Coinsurance 14
Colorectal cancer screening 18
Congenital anomalies 28
Contraceptive devices and drugs 40
Coordination of benefits 50
Covered charges 11
Covered providers 11
Crutches 25
Definitions 55
Dental care 45
Diagnostic services 17
Disputed claims review 48
Donor expenses (transplants) 31
Dressings 34
Durable medical equipment (DME) 25
Educational classes and programs 27
Effective date of enrollment 57
Emergency 36
Experimental or investigational 46
Eyeglasses 23
Family planning 20
Fecal occult blood test 18
Fraud 5
Genal Exclusions 46
Hearing services 23
Home health services 34
Hospice care 34
Home nursing care 33
Hospital 33
Immunizations 18
Infertility 20
Inhospital physician care 33
Inpatient Hospital Benefits 33
Insulin 42
Laboratory and pathological services 17
Machine diagnostic tests 17
Magnetic Resonance Imagings (MRIs) 17
Mammograms 18
Maternity Benefits 19
Medicaid 54
Medically necessary 55
Medicare 50
Mental Conditions/Substance Abuse Benefits 38
Newborn care 19
Obstetrical care 19
Occupational therapy 22
Office visits 17
Oral and maxillofacial surgery 30
Ostomy and catheter supplies 25
Out-of-pocket expenses 14
Outpatient facility care 34
Oxygen 25
Pap test 18
Physical examination 17
Physical therapy 22
Physician 17
Precertification 13
Preventive care, adult 18
Preventive care, children 19
Prescription drugs 40
Preventive services 18
Prior approval 13
Prostate cancer screening 18
Prosthetic devices 24
Psychologist 38
Psychotherapy 38
Radiation therapy 21
Renal dialysis 21
Room and board 33
Skilled nursing facility care 34
Smoking cessation 27
Speech therapy 22
Splints 25
Sterilization procedures 20
Subrogation 54
Substance abuse 38
Surgery 28
� Anesthesia 31
� Oral 30
� Outpatient 34
� Reconstructive 29
Syringes 42
Temporary continuation of coverage 58
Transplants 31
Treatment therapies 21
Vision services 23
Well child care 18
Wheelchairs 25
Workers' compensation 53
X-rays 17
� Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look inside.
� If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
� We only cover services provided or arranged by Plan physicians, except in emergencies.
Benefits |
You Pay |
Page |
|---|---|---|
Medical services provided by physicians: � Diagnostic and treatment services provided in the office...... |
Office visit copay: $10 copayment per office visit |
14 |
Services provided by a hospital: � Inpatient............................................................................
|
Nothing
|
27
|
| � Outpatient......................................................................... | $10 for office visit or a house call by a doctor (except for well child care through age 17 and maternity visits) | 28 |
Emergency benefits: � In-area............................................................................. |
$75 per hospital emergency room visit | 30 |
� Out-of-area..................................................................... |
$75 per hospital emergency room visit |
30 |
Mental health and substance abuse treatment........................ |
$10 copayment for each visit |
31 |
Prescription drugs................................................................. |
$10 copayment per generic prescription or refill 30% Coinsurance per brand prescription or refill up to $1,500; $10 thereafter |
33 |
Dental Care....................................................................... |
No benefit |
36 |
Vision Care....................................................................... |
One refraction annually $10 per office visit |
19 |
2005 Rate Information for
Dean Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and 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.
| |
|
Non-Postal Premium |
Postal Premium |
||||
|---|---|---|---|---|---|---|---|
| |
|
Biweekly |
Monthly |
Biweekly |
|||
| Type of Enrollment |
Code |
Gov�t Share |
Your Share |
Gov�t Share |
Your Share |
USPS Share |
Your Share |
| Location Information: South Central Wisconsin | |||||||
|
High Option Self Only |
WD1 |
$117.74 |
$39.25 |
$255.11 |
$85.04 |
$139.33 |
$17.66 |
|
High Option Self and Family |
WD2 |
$298.23 |
$117.76 |
$646.17 |
$255.14 |
$352.08 |
$63.91 |