1999 Serving: St. Louis metropolitan area, Mid-Missouri, and Southern Missouri Enrollment in this Plan is limited; see pages 8-9 for requirements.
Enrollment code: H81 Self only H82 Self and family
RI 73-345
page 20.
Visit the OPM website at http://www.opm.gov/insure and this Plans website at http://www.unitedhealthcare.com Special Notice: United HealthCare Select, Enrollment code H8, and United HealthCare Choice,
Enrollment code VB, have merged. If you are currently enrolled in United HealthCare Choice, Enrollment code VB, your enrollment will be transferred automatically to United HealthCare Select, Enrollment code H8, unless you select another FEHB plan during the 1998 Open Season. Additionally, two counties previously in the service area of United HealthCare Choice have been eliminated. If you are enrolled in United HealthCare Choice and live or work in one of the follow- ing areas, you must select another plan during the Open Season to continue to receive full benefits: the Missouri counties of Jasper and Newton. If you live or work in one of these areas and do not select another FEHB plan, you must travel to a county in the Service Area to receive full Plan benefits.
2 United HealthCare Select
United HealthCare Select, 13655 Riverport Drive, Maryland Heights, MO 63043-8560, has entered into a contract (CS 2194) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a com- prehensive medical plan herein called United HealthCare Select, or the Plan.
This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stat- ed in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.
Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page 20 of this brochure.
Table of Contents Page Inspector General Advisory on Fraud ........................................................................................................................................ 3
General Information ..................................................................................................................................................................... 3-6
Confidentiality; If you are a new member; If you are hospitalized; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Conversion to individual coverage; and Certificate of Creditable Coverage)
Facts about this Plan..................................................................................................................................................................... 6-9
Information you have a right to know; Who provides care to Plan members? Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; Authorizations; For new members; Hospital care; Out-of-pocket maxi- mum; Deductible carryover; Submit claims promptly; Experimental/investigational determinations; Other considerations; The Plan's service area
General Limitations ...................................................................................................................................................................... 9-10
Important notice; Circumstances beyond Plan control; Arbitration of claims; Other sources of benefits
General Exclusions........................................................................................................................................................................ 10 Benefits ........................................................................................................................................................................................... 10-16
Medical and Surgical Benefits; Hospital/Extended Care Benefits; Emergency Benefits; Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits
Other Benefits................................................................................................................................................................................ 17
Dental care
Non-FEHB Benefits....................................................................................................................................................................... 18 How to Obtain Benefits ................................................................................................................................................................ 19-20 How United HealthCare Select Changes January 1999............................................................................................................ 20 Summary of Benefits..................................................................................................................................................................... 21 Rate Information........................................................................................................................................................................... 22
3 Inspector General Advisory: Stop Health Care Fraud!
Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to obtain FEHB benefits or increase the amount of FEHB benefits is subject to prosecution for FRAUD. This could result in CRIMI- NAL PENALTIES. Please review all medical bills, medical records and claims statements carefully. If you find that a provider, such as a doctor, hospital or pharmacy, charged your plan for services you did not receive, billed for the same service twice, or misrepre- sented any other information, take the following actions:
Call the provider and ask for an explanation - sometimes the problem is a simple error. If the provider does not resolve the matter, or if you remain concerned, call your plan at 314/592-7910 or 800/627-0607 and explain the situation.
If the matter is not resolved after speaking to your plan (and you still suspect fraud has been committed), call or write:
THE HEALTH CARE FRAUD HOTLINE 202/418-3300
The Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, N.W., Room 6400 Washington, D.C. 20415
The inappropriate use of membership identification cards, e.g., to obtain services for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse admin- istrative action by your agency.
General Information
Medical and other information provided to the Plan, including claim files, is kept confidential and will be used only: 1) by the Plan and its subcontractors for internal administration of the Plan, coordination of benefit provisions with other plans, and subrogation of claims; 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3) by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or educa- tion. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education.
Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you receive your identification card and member information from the Plan. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM to a provider or Plan facility as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Plan.
If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.
If you are a new member of this Plan, benefits and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on page 14. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See "If you are hospitalized" on page 4.
FEHB plans may not refuse to provide benefits for any condition you or a covered family member may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program.
Confidentiality If you are a new member
4 General Information continued
If you change plans or options, benefits under your prior plan or option cease on the effective date of your enrollment in your new plan or option, unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is discharged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this provision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage pro- vision does not apply; in such case, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.
It is your responsibility to be informed about your health benefits. Your employing office or retire- ment system can provide information about: when you may change your enrollment; who family members are; what happens when you transfer, go on leave without pay, enter military service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other mate- rials you need to make an informed decision.
The benefits in this brochure are effective on January 1 for those already enrolled in this Plan; if you changed plans or plan options, see "If you are a new member" above. In both cases, however, the Plan's new rates are effective the first day of the enrollee's first full pay period that begins on or after January 1 (January 1 for all annuitants).
Generally, you must be continuously enrolled in the FEHB Program for the last five years before you retire to continue your enrollment for you and any eligible family members after you retire.
The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self-support.
An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligi- ble family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period; both parent and child are covered only for care received from Plan providers, except for emergency benefits.
You will not be informed by your employing office (or your retirement system) or your Plan when a family member loses eligibility.
You must direct questions about enrollment and eligibility, including whether a dependent age 22 or older is eligible for coverage, to your employing office or retirement system. The Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.
An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive ben- efits under any other FEHB plan.
Report additions and deletions (including divorces) of covered family members to the Plan promptly. If you are an annuitant or former spouse with FEHB coverage and you are also covered by Medicare
Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is avail- able in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves.
Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay.
You may also remain enrolled in this Plan when you join a Medicare prepaid plan.
If you are hospitalized
Your responsibility Things to keep in mind
5 General Information continued
Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1-800/638-6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.
Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).
When an employee's enrollment terminates because of separation from Federal service or when a fami- ly member is no longer eligible for coverage under an employee or annuitant enrollment, and the per- son is not otherwise eligible for FEHB coverage, he or she generally will be eligible for a free 31-day extension of coverage. The employee or family member may also be eligible for one of the following:
When a Federal employee or annuitant divorces, the former spouse may be eligible to elect coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the employ- ee's employing office (personnel office) or retiree's retirement system to get more facts about electing coverage.
If you are an employee whose enrollment is terminated because you separate from service, you may be eligible to temporarily continue your health benefits coverage under the FEHB Program in any plan for which you are eligible. Ask your employing office for RI 79-27, which describes TCC, and for RI 70- 5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you are eligible for TCC when you retire if you are unable to meet the five-year enroll- ment requirement for continuation of enrollment after retirement.
Your TCC begins after the initial free 31-day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charge. If you use your TCC until it expires, you are entitled to another free 31-day extension of coverage when you may con- vert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31-day extension of coverage and conversion option are not available.
Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualify- ing event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31-day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31-day extension of coverage when they may convert to nongroup coverage.
NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.
Separating employees Within 61 days after an employee's enrollment terminates because of separa- tion from service, his or her employing office must notify the employee of the opportunity to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.
Children You must notify your employing office or retirement system when a child becomes eligi- ble for TCC within 60 days after the qualifying event occurs, for example, the child reaches age 22 or marries.
Former spouses You or your former spouse must notify the employing office or retirement system of the former spouse's eligibility for TCC within 60 days after the termination of the marriage. A for- mer spouse may also qualify for TCC if, during the 36-month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The for- mer spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.
Things to keep in mind (cont'd)
Coverage after enrollment ends Former spouse coverage
Temporary continuation of coverage (TCC)
Notification and election requirements
6 General Information continued
The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of the qualifying court order.
Important: The employing office or retirement system must be notified of a child's or former spouse's eligibility for TCC within the 60-day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.
When none of the above choices are available or chosen when coverage as an employee or fami- ly member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evi- dence of good health and the plan is not permitted to impose a waiting period or limit coverage for pre- existing conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 31-day free extension of coverage that follows the event that terminates coverage, e.g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.
Under Federal law, if you lose coverage under the FEHB Program, you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This certificate, along with any certificates you receive from other FEHB plans you may have been enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new non-FEHB insurer. If you do not receive a certificate automatically, you must be given one on request.
Facts about this Plan
This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical emergency. Members are required to select a personal doctor from among participating Plan primary care doctors. Services of a specialty care doctor can only be received by referral from the selected primary care doctor. There are no claim forms when Plan doctors are used.
Your decision to join an HMO should be based on your preference for the plans benefits and delivery system, not because a particu- lar provider is in the plans network. You cannot change plans because a provider leaves the HMO.
Because the Plan provides or arranges your care and pays the cost, it seeks efficient and effective delivery of health services. By con- trolling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing compre- hensive health services and benefits for accidents, illness and injury, the Plan emphasizes preventive benefits such as office visits, physicals, immunizations and well-baby care. You are encouraged to get medical attention at the first sign of illness.
All carriers in the FEHB Program must provide certain information to you. If you did not receive information about this Plan, you can obtain it by calling the Carrier at 800/627-0607 or 314/592-7910 or you may write the Carrier at 13655 Riverport Drive, P.O. Box 2560, Maryland Heights, MO 63043- 8560. You may also contact the Carrier by fax at 314/592-7620, or at its website at http://www.united healthcare.com.
Information that must be made available to you includes: Disenrollment rates for 1997. Compliance with State and Federal licensing or certification requirements and the dates met. If non-
compliant, the reason for noncompliance. Accreditations by recognized accrediting agencies and the dates received. Carriers type of corporate form and years in existence. Whether the carrier meets State, Federal and accreditation requirements for fiscal solvency, confiden-
tiality and transfer of medical records.
Notification and election requirements
(cont'd)
Conversion to individual coverage
Certificate of Creditable Coverage Information you have a right to know
7 Facts about this Plan continued
United HealthCare Select is an Individual Practice Prepayment (IPP) plan offering coordinated services through more than 8,000 private practice doctors, 75 hospitals, and other health care providers. Each member may choose his or her own primary care doctor from the Plan's participating primary care doc- tors listed in the Provider Directory. Some primary care physicians belong to special networks in which all care will be directed to specialists and hospitals within that network. Always check the provider directory to see if your primary care physician belongs to a special network.
The first and most important decision each member must make is the selection of a primary care doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorization from the Plan before referring you to a specialist or making arrangements for hospitaliza- tion. Services of other providers are covered only when there has been a referral by the member's pri- mary care doctor, with the following exceptions: a woman may see her Plan obstetrician/gynecologist directly once a year with no need to be referred by her primary care doctor for a well-woman examina- tion; a member may see his/her Plan dentist directly for dental care; and a member may obtain an annu- al eye refraction (to provide a written lens prescription) from a participating optometrist. The member need only make an appointment with a participating optometrist who will then verify the members eli- gibility with the Plan. For the treatment of mental conditions/substance abuse, members need only con- tact United Behavioral Health (UBH) at 314/523-4700 to access mental health services.
The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists), with their locations and phone numbers, and notes whether or not the doctor is accept- ing new patients. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Services Department at 314/592-7910, or toll free 1-800/627- 0607; you can also find out if your doctor participates with this Plan by calling this number. If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this Plan, services (except for emergency benefits) are provided through the Plan's delivery system; the continued availability and/or participation of any one doctor, hospital, or other provider, cannot be guaranteed.
If you enroll, you will be asked to let the Plan know which primary care doctor(s) you've selected for you and each member of your family by sending a selection form to the Plan. If you need help choos- ing a doctor, call the Plan. Members may change their doctor selection by notifying the Plan prior to the first day of the month in which the change is to be effective.
If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with you for you to be seen by another participating doctor.
Except in a medical emergency, or when a primary care doctor has designated another doctor to see his or her patients, you must receive a referral from your primary care doctor before seeing any other doc- tor or obtaining special services. Referral to a participating specialist is given at the primary care doc- tor's discretion; if non-Plan specialists or consultants are required, the primary care doctor will arrange appropriate referrals.
When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits. All follow-up care must be pro- vided or authorized by the primary care doctor. Do not go to the specialist for a second visit unless your primary care doctor has arranged for, and the Plan has issued an authorization for, the referral in advance.
If you have a chronic, complex, or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals. This extended referral provision may be granted for a maximum of a twelve month period and exists for the following conditions: Allergy, Cystic Fibrosis, Depo-Provera for Contraception, HIV positive, Dialysis, Oncology patients, and Organ Transplant Follow-up.
The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. Your Plan doctor must obtain the Plans determina- tion of medical necessity prior to recommending inpatient confinements, outpatient surgery, and some specialty services.
Who provides care to Plan members? Role of a primary care doctor
Choosing your doctor
Referrals for specialty care Authorizations
8 Facts about this Plan continued
If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you to this specialist is now your Plan primary care doctor, you need only call to explain that you are now a Plan member and ask that you be referred for your next appointment.
If you are selecting a new primary care doctor and want to continue with this specialist, you must schedule an appointment so the primary care doctor can decide whether to treat the condition directly or refer you back to the specialist.
If you require hospitalization, your primary care doctor or authorized specialist will make the necessary arrangements and continue to supervise your care.
Copayments are required for a few benefits. However, copayments will not be required for the remainder of the calendar year after your out-of-pocket expenses for services provided or arranged by the Plan reach $650 per Self Only enrollment or $1,500 per Self and Family enrollment. This copay- ment maximum does not include costs of dental services, prescription drugs and inpatient care of men- tal conditions and substance abuse.
You should maintain accurate records of the copayments made, as it is your responsibility to determine when the copayment maximum is reached. You are assured a predictable maximum in out-of-pocket costs for covered health and medical needs. Copayments are due when service is rendered, except for emergency care.
If you changed to this Plan during open season from a plan with a deductible and the effective date of the change was after January 1, any expenses that would have applied to that plan's deductible will be covered by your old plan if they are for care you got in January before the effective date of your cover- age in this Plan. If you have already met the deductible in full, your old plan will reimburse these cov- ered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this year's benefits; benefit changes are effective January 1.
When you are required to submit a claim to this Plan for covered expenses, submit your claim prompt- ly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year fol- lowing the year in which the expense was incurred, unless timely filing was prevented by administra- tive operations of Government or legal incapacity, provided the claim was submitted as soon as reason- ably possible.
Decisions about technologies are driven by a thorough evaluation of clinical evidence by the Medical Technology Assessment Unit, a committee of physicians, researchers, and medical librarians trained in information resources. The Medical Technology Assessment Unit prepares an analysis or technology assessment of the drug, device, treatment or procedure after gathering data from the following sources: Milliman & Robertson ISP; Preference, the medical necessity guideline manual; review of medical and scientific material in the relevant fields; whether the drug or device has been granted approval by the Food and Drug Administration; whether the drug, device, treatment or procedure is the subject of ongoing Phase I or Phase II clinical trials; and whether further clinical trials are necessary to determine its efficacy. This assessment is then reviewed by the Plans Technology Assessment Committee, which is composed of Plan physicians, nurses, and pharmacists, and a determination is made as to whether a drug, device, treatment or procedure is experimental or investigational.
Plan providers will follow generally accepted medical practice in prescribing any course of treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures that may be recommended by Plan providers.
The service area for this Plan, where Plan providers and facilities are located, is described below. You must live or work in the service area to enroll in this Plan.
The service area for this Plan includes the following areas:
Missouri: St. Louis City, and Adair, Audrain, Bollinger, Boone, Butler, Callaway, Camden, Cape Girardeau, Carter, Chariton, Cole, Cooper, Crawford, Dent, Dunklin, Franklin, Gasconade, Howard, Iron, Jefferson, Knox, Laclede, Lewis, Linn, Lincoln, Macon, Madison, Maries, Miller, Mississippi, Moniteau, Monroe, Montgomery, Morgan, New Madrid, Oregon, Osage, Pemiscot, Perry, Pettis, Phelps, Pike, Pulaski, Randolph, Reynolds, Ripley, Saline, St. Charles, St. Francois, Ste. Genevieve, St. Louis, Schuyler, Scott, Scotland, Shannon, Shelby, Stoddard, Sullivan, Texas, Warren, Washington, Wayne, and Wright counties.
For New Members Hospital care Out-of-pocket maximum
Deductible carryover Submit claims promptly Experimental/ investigational determinations
Other Considerations The Plans service area
9 Facts about this Plan continued
Illinois: Bond, Calhoun, Clinton, Greene, Jersey, Macoupin, Madison, Monroe, Montgomery, Randolph, St. Clair, and Williamson counties.
Benefits for care outside the service area are limited to emergency services, as described on page 14 . If you or a covered family member move outside the service area, you may enroll in another approved plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.
General Limitations
Although a specific service may be listed as a benefit, it will be covered for you only if, in the judg- ment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.
In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant number of Plan providers, complete or partial destruction of facilities, or other circumstances beyond the Plan's control, the Plan will make a good faith effort to provide or arrange for covered services. However, the Plan will not be responsible for any delay or failure in providing service due to lack of available facili- ties or personnel.
Any claim for damages for personal injury, mental disturbance or wrongful death arising out of the ren- dition or failure to render services under this contract must be submitted to binding arbitration.
This section applies when you or your family members are entitled to benefits from a source other than this Plan. You must disclose information about other sources of benefits to the Plan and complete all necessary documents and authorizations requested by the Plan.
If you or a covered family member is enrolled in this Plan and Medicare Part A and/or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except those for emergencies, unless you use Plan providers. You must tell your Plan that you or your family member is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.
This coordination of benefits (double coverage) provision applies when a person covered by this Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the payment of medical and hospital costs under no-fault or other automobile insurance that pays benefits without regard to fault. Information about the other coverage must be disclosed to this Plan.
When there is double coverage for covered benefits, other than emergency services from non-Plan providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no-fault or other automobile insurance or any other primary plan.
One plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced ben- efit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its bene- fits in full, or (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners. When benefits are payable under automobile insurance, including no-fault, the automo- bile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have. This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Plan to obtain information about benefits or services available from the other coverage, or to recov- er overpayments from other coverages.
If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first. As a member of a prepaid plan, special limita- tions on your CHAMPUS coverage apply; your primary care provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.
The Plans service area
(cont'd)
Important notice Circumstances beyond Plan control Arbitration of claims Other sources of benefits
Medicare Group health insurance and automobile insurance
CHAMPUS
10 General Limitations continued
If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. The Plan will not pay for services required as the result of occupational disease or injury for which any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workers' compensation (under section 8103 of title 5, U.S.C.) or by a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workers' compensation or similar laws. If medical benefits provided under such laws are exhausted, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were later found to be payable by OWCP (or the agency).
Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from the Plan for certain services and supplies provided to you or a family member to the extent that reimbursement is required under the Federal statutes govern- ing such facilities.
The Plan will not provide benefits for services and supplies paid for directly or indirectly by any other local, State, or Federal Government agency.
If a covered person is sick or injured as a result of the act or omission of another person or party, the Plan requires that it be reimbursed for the benefits provided in an amount not to exceed the amount of the recovery, or that it be subrogated to the person's rights to the extent of the benefits received under this Plan, including the right to bring suit in the person's name. If you need more information about subrogation, the Plan will provide you with its subrogation procedures.
General Exclusions
All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or treat your ill- ness or condition, and the Plan agrees, as discussed under Authorizations on page 7. The following are excluded:
Care by non-Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits)
Expenses incurred while not covered by this Plan Services furnished or billed by a provider or facility barred from the FEHB Program Services not required according to accepted standards of medical, dental, or psychiatric practice Procedures, treatments, drugs or devices that are experimental or investigational Procedures, services, drugs and supplies related to sex transformations; and Procedures, services, drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term.
Medical and Surgical Benefits
A comprehensive range of preventive, diagnostic and treatment services is provided by Plan doctors and other Plan providers. This includes all necessary office visits; you pay a $5 office visit copay, but no additional copay for laboratory tests and X-rays. Within the service area, house calls will be provid- ed if, in the judgment of the Plan doctor, such care is necessary and appropriate; you pay a $10 copay for a doctor's house call, and nothing for home visits by nurses and health aides.
The following services are included and are subject to the office visit copay unless stated otherwise: Preventive care, including well-baby care and periodic health assessments. The doctor may charge
an additional fee of up to $10 to complete the paperwork required for an annual school physical exam.
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Medicaid
Workers' compensation
DVA facilities, DoD facilities, and Indian Health Service
Other Government agencies
Liability insurance and third party actions
What is covered
11 Medical and Surgical Benefits continued
Mammograms are covered as follows: for women age 35 through age 39, one mammogram during these five years; for women age 40 through 49, one mammogram every one or two years; and for women age 50 and up, one mammogram every year. Coverage is also provided for one screening mammogram every year for women at increased risk, including those with a personal history of breast cancer, family history of breast cancer (mother or sister), women on estrogen replacement therapy and women with histologic abnormalities associated with an increased risk of cancer. In addition to routine screening, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness.
Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and X-rays Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and post-
natal care by a Plan doctor. After the initial office visit copay, all other copays are waived for mater- nity care. The mother, at her option, may remain in the hospital up to 48 hours after a regular deliv- ery and 96 hours after a caesarean delivery. Inpatient stays will be extended if medically necessary. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment.
Voluntary sterilization and family planning services; you pay a $50 copay for a tubal ligation or a vasectomy; a $25 copay for an IUD or for contraceptive diaphragms and their fitting; and 50% of charges for Norplant and its insertion.
Diagnosis and treatment of diseases of the eye Allergy testing and treatment, including testing and treatment materials (such as allergy serum); you
pay a $5 copay per office visit for testing or a $3 copay per allergy injection. The insertion of internal prosthetic devices, such as pacemakers and artificial joints Cornea, heart, heart/lung, kidney, liver and lung (single and double) transplants; 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. Services must be determined to be medically appropriate by the desig- nated Center of Excellence Physician Evaluator and must be performed in a Plan Center of Excellence. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan.
Women who undergo mastectomies may, at their option, have this procedure performed on an inpa- tient basis and remain in the hospital up to 48 hours after the procedure.
Dialysis Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity Home health services of nurses and health aides, including intravenous fluids and medications, when
prescribed by your Plan doctor, who will periodically review the program for continuing appropriate- ness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers.
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS What is covered
12 Limited benefits
What is not covered Medical and Surgical Benefits continued
Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures and excision of tumors and cysts. All other procedures involving the teeth or intra-oral areas surrounding the teeth are not covered except for dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome which is covered when referred by your Plan doctor and approved by the Plan.
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the con- dition can reasonably be expected to be corrected by such surgery.
Short-term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to 60 treatments per condition if significant improvement can be expected within two months; you pay a $5 copay per outpatient session. Speech therapy is limited to treatment of cer- tain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self-care and improved functioning in other activities of daily living.
Orthopedic devices, such as braces (arm, leg, back, or neck), are covered for the original placement only; you pay nothing.
Prosthetic devices, such as artificial limbs and external lenses following cataract removal, are covered for the initial placement or device only; you pay nothing.
Durable medical equipment, such as wheelchairs (customized wheelchairs are limited to the original purchase only) and hospital beds; you pay nothing.
Diagnosis and treatment of infertility is covered; you pay a $5 copay per visit. The following types of artificial insemination are covered: intravaginal insemination (IVI) and intracervical insemination (ICI); you pay 50% of covered charges; cost of donor sperm is not covered. Fertility drugs are covered under the Prescription Drug Benefit; you pay 50% of charges per prescription unit or refill. Other assisted reproductive technology (ART) procedures, such as in vitro fertilization and embryo transfer, are not covered.
Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is pro- vided for up to two months per condition; you pay a $5 copay per outpatient session.
Physical examinations that are not necessary for medical reasons, such as those required for obtain- ing or continuing employment or insurance, attending camp, or travel
Reversal of voluntary, surgically-induced sterility Surgery primarily for cosmetic purposes Homemaker services Hearing aids Transplants not listed as covered Long-term rehabilitative therapy Foot orthotics Chiropractic services Corrective eyeglasses, frames and contact lenses, including the fitting of contact lenses, except as
necessary for the first pair of corrective lenses following cataract surgery Refractions, including lens prescriptions Any eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsight-
edness (myopia), farsightedness (hyperopia), and astigmatism (blurring) Charges that a member may have to pay a Plan provider for copying requested medical records Blood and blood derivatives (no charge if replacement is arranged by the member and the need for
the blood is not elective)
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
13 Hospital/Extended Care Benefits
The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospital- ized under the care of a Plan doctor. You pay nothing. All necessary services are covered, including:
Semiprivate room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care
Specialized care units, such as intensive care or cardiac care units The Plan provides a comprehensive range of benefits for up to 90 days per condition per lifetime with no dollar limit when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay
nothing. All necessary services are covered, including: Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor. Supportive and palliative care for a terminally ill member is covered in the home or hospice facility. Services include inpatient and outpatient care, and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor. Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospital- ization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condi- tion.
Hospitalization for medical treatment of substance abuse is limited to emergency care, diagnosis, treat- ment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 15 for non-medical substance abuse benefits.
Personal comfort items, such as telephone and television Blood and blood derivatives (no charge if replacement is arranged by the member and the need for
the blood is not elective) Custodial care, rest cures, domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS What is covered
Hospital care Extended care
Hospice care Ambulance service
Limited benefits Inpatient dental procedures
Acute inpatient detoxification
What is not covered
14 Emergency Benefits
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires immediate medical or sur- gical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are poten- tially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action.
If you are in an emergency situation, please call your primary care doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 telephone sys- tem) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member should notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical emergency only if delay in reach- ing a Plan provider would result in death, disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.
$50 per hospital emergency room visit or $15 per urgent care center visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency room copay is waived.
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness
If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medi- ally feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or provided by Plan providers.
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.
$50 per hospital emergency room visit or $15 per urgent care center visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency room copay is waived.
Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctors' services Ambulance service approved by the Plan
Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
With your authorization, the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.
Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plan's decision, you may request reconsideration in accordance with the disputed claims procedure described on page 19.
What is a medical emergency? Emergencies within the service area
Plan pays... You pay...
Emergencies outside the service area Plan pays... You pay... What is covered
What is not covered Filing claims for non-Plan providers
15 Mental Conditions/Substance Abuse Benefits
Members need only contact United Behavioral Health (UBH) at 314/523-4700 to access mental health services.
To the extent shown below, the Plan provides the following services necessary for the diagnosis and treat- ment of acute psychiatric conditions, including the treatment of mental illness or disorders:
Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Hospitalization (including inpatient professional services)
Up to 20 outpatient visits to Plan doctors or other psychiatric personnel each calendar year; you pay a $25 copay for each covered visit -- all charges thereafter.
Up to 30 days of hospitalization or up to 60 visits as a day care patient each calendar year; you pay
50% of actual charges for the first 30 days or 60 day care visits -- all charges thereafter. Two day care visits shall equal one inpatient day.
Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short-term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short-term psychiatric condition
This Plan provides medical and hospital services such as acute detoxification services for the medical, non-psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition and, to the extent shown below, the services necessary for diagnosis and treatment.
All necessary outpatient visits to Plan providers for treatment; you pay 50% of charges for each cov- ered visit.
Up to 30 days of hospitalization or up to 60 visits as a day care patient each calendar year; you pay
nothing for the first 5 days and 50% of charges for the next 25 days or visits as a day care patient -- all charges thereafter. Two day care visits shall equal one inpatient day.
Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Mental conditions
What is covered Outpatient care Inpatient care
What is not covered
Substance abuse What is covered
Outpatient care Inpatient care
What is not covered
16 Prescription Drug Benefits
Prescription drugs prescribed by a Plan or referral doctor and obtained either at a Plan pharmacy or through the Home Delivery Pharmacy Service may be dispensed for up to a 90-day supply. For up to each 31-day supply, you pay a $5 copay per prescription unit or refill for generic drugs; a $10 copay per prescription unit or refill for name brand drugs; and a $20 copay per prescription unit or refill for drugs not on the Plan's preferred drug list (drug formulary).
You pay a $5 copay per prescription unit or refill for generic drugs, a $10 copay per prescription unit or refill for name brand drugs, or a $20 copay per prescription unit or refill for drugs not on the Plan's preferred drug list (drug formulary) when generic substitution is not permissible. When generic substi- tution is permissible (i.e., a generic drug is available and the prescribing doctor does not require the use of a name brand drug or a drug not on the Plan's preferred drug list), but you request the name brand drug or a drug not on the Plans preferred drug list, you pay the price difference between the generic and name brand drug as well as the $5 copay per prescription unit or refill for the name brand drug; or
you pay the price difference between the generic and the drug not on the Plans preferred drug list as well as the $5 copay per prescription unit or refill for the drug not on the Plans preferred drug list.
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's preferred drug list (drug formulary). Non-preferred drugs (nonformulary drugs) will be covered when prescribed by a Plan doctor.
Covered medications and accessories include: Drugs for which a prescription is required by law Oral contraceptive drugs; contraceptive diaphragms and injectable contraceptive drugs, such as Depo
Provera (when dispensed at your participating doctor's office) Implanted time-release medications, such as Norplant. For Norplant you pay 50% of charges for all
services including the implant kit, insertion, replacement and removal. There will be no refund of any portion of these charges if the implanted time-released medication is removed before the end of its expected life.
Insulin Disposable needles and syringes needed to inject covered prescribed medications Diabetic supplies, including insulin syringes, needles, and test strips Aerosol inhalers and inhalant solutions are covered only when supplied by your participating physi-
cian Intravenous fluids and medication for home use, implantable drugs, and some injectable drugs are cov- ered under Medical and Surgical Benefits.
Fertility drugs; you pay 50% of charges per prescription unit or refill Sexual dysfunction drugs are subject to dosage limits set by the Plan. Contact the Plan for details.
Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Drugs to enhance athletic performance Smoking cessation drugs and medication, including nicotine patches Drugs for weight loss and appetite suppressants
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS What is covered
Limited Benefits
What is not covered
17 Other Benefits
Restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must directly result from an accidental injury, not biting or chewing.
You pay a $5 copay. Other dental services not shown as covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS Dental care
What is covered Accidental injury benefit
What is not covered
18
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made available to all enrollees and family members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out-of- pocket maximums. These benefits are not subject to the FEHB disputed claims procedure.
Benefits on this page are not part of the FEHB contract.
Service Code
DIAGNOSTIC Initial oral examination 0110 Periodic oral examination 0120 Emergency oral examination 0130 Topical application of fluorde 1201 (including prophylaxis-child to age 16) Topical application of fluoride 1203 (excluding prophylaxis-child to age 16) Topical application of fluoride 1204 (excluding prophylaxis-adult) Topical application of fluoride 1205 (including prophylaxis-adult)
PREVENTIVE Prophylaxis-adult; once per six months 1110 CARE Prophylaxis-child; once per six months 1120
RADIOGRAPHS X-rays-complete series including bitewings; 0210 once every five years Intraoral-single 0220 Intraoral-each additional 0230 Intraoral-first film occlusal 0240 Bitewing-single film; once per year 0270 Bitewings-two films; once per year 0272 Bitewings-four films 0274 Panoramic film; once every five years 0330
Service Code
SEALANTS AND Sealant-per tooth 1351 SPACE Space maintainer-unilateral 1510 MAINTAINERS Space maintainer-bilateral 1515
Space maintainer-removal unilateral 1520 Space maintainer-removable-bilateral 1525
ENDODONTICS (includes all visits, X-rays and follow up care) Pulpotomy 3220 Endodontics-one canal-traditional 3310 Endodontics-two canals-traditional 3320 Endodontics-three canals-traditional 3330 Endodontics-four canals-traditional 3340
RESTORATIVE (includes polishing) Amalgam-one surface, primary 2110 Amalgam-two surfaces, primary 2120
Non-FEHB Dental Care United HealthCare Dental Advantage Benefit Summary SCHEDULE A
Maximum annual benefit (Schedule A and B combined).....................................$1,000 Member copayment per visit for Schedule A services ...........................................$10
Service Code
RESTORATIVE (contd) Amalgam-three surfaces, primary 2130 Amalgam-four surfaces, primary 2131 Amalgam-one surface, permanent 2140 Amalgam-two surfaces, permanent 2150 Amalgam-three surfaces, permanent 2160 Amalgam-four or more surfaces, permanent 2161 Resin-one surface, anterior 2330 Resin-two surfaces, anterior 2331 Resin-three surfaces, anterior 2332 Resin-four or more surfaces involving 2335
incisal angle PERIODONTICS (includes postoperative services)
Comprehensive periodontal examination 4110 (includes probing and consultation by specialist) Periodontal scaling and root planing-per 4341
quadrant Periodontal maintanance procedures 4910
following active therapy Stainless steel crown - primary tooth 2930 Sedative Filling 2940 Pin retention-per tooth, in addition to 2951
restoration ORAL SURGERY Extraction single tooth permanent 7110
Extraction single tooth primary 7111 Extraction additional tooth permanent 7120 Extraction additional tooth primary 7121 Root removal exposed roots 7130 Surgical removal of of erupted tooth 7210 requiring elevation of mucoperiosteal lap and removal of bone and/or section of the tooth
SCHEDULE C Service Code Cost
ORAL SURGERY Member cost Remove impacted tooth-soft tissue.........................7220..............................$105 Remove impacted tooth-partial bony......................7230..............................$150 Remove impacted tooth-complete bony..................7240.............................$175
ORTHODONTIC SERVICES Comprehensive orthodontic treatment for children under 18...................$2,775 (Total fee includes all phases of treatment including orthodontic records, and the placement of retainers following active treatment)
Non-FEHB Benefits Available to Plan Members SCHEDULE B
Maximum annual benefit (Schedule A and B combined)........................................$1,000 Member copayment per visit for Schedule B services .................................................$10 Member coinsurance for Schedule B services.......30% of established maximum fee schedule (copies of the schedule available on request)
LIMITATIONS AND EXCLUSIONS 1. Services are available only from the list of participating dentists. 2. Only those services listed under Schedule A & B are covered as a paid benefit. Services listed under Schedule C and provided by a participating
dentist or dental specialist are charged to the member at the rate noted in the schedule. 3. Hospital fees or prescription drug charges. 4. Dental expenses incurred in connection with any dental procedure started after termination of eligibility for coverage are not covered. 5. Dental expenses incurred in connection with any dental procedure started prior to participants eligibility with this dental plan are not covered.
Example: root canal in progress. 6. Services covered by Workers Compensation or by existing medical insurance.
Non-FEHB Vision Care What is covered Annual eye refractions (to provide a written lens prescription for eyeglasses) may be obtained from
participating optometrists. You need only make an appoiment with a participating optometrist who, in turn, will verify your eligibility with the Plan. You pay nothing.
What is not Corrective lenses or frames
covered Eye exercises
19 Notes
20 How to Obtain Benefits
If you have a question concerning Plan benefits or how to arrange for care, contact the Plan's Membership Services Office at 314/592-7910 (TDD 1-800/627-0607); toll-free at 800/627-0607 or you may write to the Plan at 13655 Riverport Drive, P.O. Box 2560, Maryland Heights, MO 63043-8560. You may also contact the Plan by fax at 314/592-7620, or at its website at http://www.unitedhealth care.com.
If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing and within six months of the date of the denial, to reconsider its denial before you request a review by OPM. (This time limit may be extended if you show you were prevented by circumstances beyond your con- trol from making your request within the time limit.) OPM will not review your request unless you demonstrate that you gave the Plan an opportunity to reconsider your claim. Your written request to the Plan must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.
Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writ- ing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.
If the Plan affirms its denial, you have the right to request a review by OPM to determine whether the Plan's actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Plan's letter affirming its initial denial.
You may also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan needed additional information, either from you or from your doctor or hospital.
This right is available only to you or the executor of a deceased claimant's estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written con- sent to pursue payment of the disputed claim. OPM must receive a copy of your written consent with their request for review.
Your written request for an OPM review must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided. If the Plan has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.
Your request must include the following information or it will be returned by OPM: A copy of your letter to the Plan requesting reconsideration; A copy of the Plan's reconsideration decision (if the Plan failed to respond, provide instead (a) the
date of your request to the Plan or (b) the dates the Plan requested and you provided additional infor- mation to the Plan);
Copies of documents that support your claim, such as doctors' letters, operative reports, bills, med- ical records, and explanation of benefit (EOB) forms; and
Your daytime phone number. Medical documentation received from you or the Plan during the review process becomes a permanent part of the disputed claim file, subject to the provisions of the Freedom of Information Act and the Privacy Act.
Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division 3, P.O. Box 436, Washington, DC 20044.
You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treat- ment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review proce- dure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Plan's decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.
Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plan's benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Plan's denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.
Questions Disputed claims review
Plan reconsideration
OPM review
21 How to Obtain Benefits continued
Privacy Act statement -- If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U.S.C., to use the information collected from you and the Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/or the Plan in support of OPM's decision on the disputed claim.
How United HealthCare Select Changes January 1999
Do not rely on this page; it is not an official statement of benefits. Several changes have been made to comply with the Presidents mandate to implement the recom- mendations of the Patient Bill of Rights.
If you have a chronic, complex, or serious medical condition that causes you to frequently see a Plan specialist your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist, without the need to obtain further referrals. This extended referral provision may be granted for a maximum of a twelve month period and exists for the following conditions: Allergy, Cystic Fibrosis, Depo-Provera for contracep- tion, HIV Positive, Dialysis, Oncology Patients and Organ Transplant Follow-Up (See page 7 for details).
A medical emergency is defined as the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires imme- diate medical or surgical care (See page 14).
The medical management of mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits. Office visits for the medical aspects of treatment do not count toward the 20 outpatient Mental Conditions visit limit.
Coverage of drugs for sexual dysfunction are shown under the Prescription Drug Benefit (See page 16). Prescriptions written by a Plan doctor may be filled for up to a 90-day supply at either a participating pharmacy or through the Home Delivery Pharmacy Service. For up to each 31-day supply the member pays a $5 copay per prescription unit or refill for generic drugs; a $10 copay per prescription unit or refill for name brand drugs; and a $20 copay per prescription unit or refill for drugs not on the Plans preferred drug list (drug formulary). Previously, the copays were $2, $7, and $12 respectively, and prescriptions were only dispensed for up to a 30-day supply from a Plan pharmacy, and the copays were $4, $14, and $20 respectively, and prescriptions were dispensed for up to a 90-day supply through the Home Delivery Pharmacy Service (See page 16).
Fertility drugs are now subject to a member copay of 50% of charges per prescription unit or refill. Previously, these drugs were subject to the applicable prescription drug copay per prescription unit or refill (See page 16).
The Plan now provides coverage for diabetic supplies, including insulin syringes, needles, and test- strips under the Prescription Drug Benefit. Previously, only needles and syringes were covered under the Prescription Drug Benefit, and other diabetic supplies were covered under Medical and Surgical Benefits (See page 16).
Drugs prescribed for weight loss and appetite suppressants are excluded from coverage. Previously, this exclusion was not shown in the brochure (See page 16).
The Plan now waives all copays for maternity care, except for the initial office visit copay. Previously, copays were not waived for maternity care (See page 11).
Program-wide Changes:
Changes to this Plan:
22 How United HealthCare Select Changes January 1999 continued
The Plan now provides one screening mammogram every year for women at increased risk, including those with a personal history of breast cancer, family history of breast cancer (mother or sister), women on estrogen replacement therapy and women with histologic abnormalities associated with an increased risk of cancer. Previously, this benefit was not shown in the brochure (See page 11).
The Plan provides coverage for durable medical equipment, such as wheelchairs (customized wheel- chairs are limited to the original purchase only) and hospital beds subject to no member copay. Previously, the brochure did not show that there was no copay applied to this coverage (See page 12).
The Plan limits coverage for orthopedic devices, such as braces (arm, leg, back, or neck) to the origi- nal placement only subject to no member copay. Previously, the brochure did not show that there was no copay applied to this coverage, or that it was limited to the original placement only (See page 12).
The Plan excludes charges for corrective eyeglasses, frames and contact lenses, including the fitting of contact lenses, except as necessary for the first pair of corrective lenses following cataract surgery. Previously, this exclusion was not shown in the brochure (See page 12).
The Plan excludes charges for refractions, including lens prescriptions. Previously, this exclusion was not shown in the brochure (See page 12).
The Plan excludes coverage for any eye surgery solely for the purpose of correcting refractive defects of the eye, such as nearsightedness (myopia), farsightedness (hyperopia), and astigmatism (blurring). Previously, this exclusion was not shown in the brochure (See page 12).
The Plan excludes charges that a member may have to pay a Plan provider for copying requested medical records. Previously, this exclusion was not shown in the brochure (See page 12).
United HealthCare Select, Enrollment code H8, and United HealthCare Choice, Enrollment code VB, have merged. If you are currently enrolled in United HealthCare Choice, Enrollment code VB, your enrollment will be transferred automatically to United HealthCare Select, Enrollment code H8, unless you select another FEHB plan during the 1998 Open Season. Additionally, two counties previously in the service area of United HealthCare Choice have been eliminated. If you are enrolled in United HealthCare Choice and live or work in one of the following areas, you must select another plan during the Open Season to continue to recieve full benefits: the Missouri counties of Jasper and Newton. If you live or work in one of these areas and do not select another FEHB plan, you must travel to a coun- ty in the Service area to recieve full plan benefits (See front cover and pages 8-9).
Program-wide Changes:
23 Summary of Benefits for United HealthCare Select - 1999
Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.
Benefits Plan pays/provides Page Hospital Comprehensive range of medical and surgical services without dollar or day limit. Includes in-
hospital doctor care, room and board, general nursing care, private room and private nursing care if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room, inten- sive care and complete maternity care. You pay nothing................................................................13
Extended care All necessary services, up to 90 days per condition per lifetime. You pay nothing .......................13
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care or up to
Conditions 60 day-care visits per year. You pay 50% of charges......................................................................15
Substance Up to 30 days of hospitalization or up to 60 visits as a day-care patient per year. You pay nothing for the first 5 days and 50% of charges for the next 25 days or visits as a day-care patient ..........15
Comprehensive range of services such as diagnosis and treatment of illness or injury, including specialists care; preventive care, including well-baby care, periodic check-ups and routine immu- nizations; laboratory tests and X-rays; complete maternity care. You pay a $5 copay per office visit; the $5 copay is waived after the first visit for maternity care; $10 per house call by a doctor .....................................................................................................................................................10-12
Home health All necessary visits by nurses and health aides. You pay nothing .............................................10,11
care Mental Up to 20 outpatient visits per year. You pay a $25 copay per visit................................................15
conditions Substance All necessary outpatient visits. You pay 50% of charges per visit ................................................15
abuse Emergency care Reasonable charges for services and supplies required because of a medical emergency. You pay a
$50 copay to the hospital for each emergency room visit and any charges for services that are not covered by this Plan..........................................................................................................................14
Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy or through the Home Delivery Pharmacy Service. You pay a $5 copay for generic drugs, a $10 copay for name brand drugs, and a $20 copay for drugs not on the preferred drug list (drug formulary) per prescription unit or refill.. ..........................................................................................................................................................16
Dental care Accidental injury benefit; you pay a $5 copay................................................................................17
Vision care No current benefit.
Out-of-pocket maximum Copayments are required for a few benefits; however, after your out-of-pocket expenses reach a maximum of $650 per Self Only or $1,500 per Self and Family enrollment per calendar year, cov- ered benefits will be provided at 100%. This copay maximum does not include costs of prescrip- tion drugs, inpatient care of mental conditions/substance abuse, or dental coverage .......................8
Inpatient care
Outpatient care
1999 Rate Information for United HealthCare Select
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 most career U.S. Postal Service employees, but do not apply to non-career Postal employees, Postal retirees, certain special Postal employment categories or associate members of any Postal employee organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category.
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
Self Only H81 $71.06 $23.69 $153.97 $51.32 $84.09 $10.66 Self and Family H82 $160.39 $57.61 $347.51 $124.82 $183.29 $34.71
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