This Plan has Excellent
accreditation from the NCQA.
See the 2001
Guide for more
information on the NCQA.
Serving: South Central Wisconsin
Enrollment in this Plan is
limited; see page 6 for requirements.
Enrollment codes for this Plan:
WJ1 Self Only
WJ2 Self and Family
RI 73-061
For changes in benefits
see page 7.
2001
EX CELL ENT 1
1 Page
2 3
Table of Contents
Introduction
..............................................................................................................................................................
4
Plain Language
..............................................................................................................................................................
4
Section 1. Facts about this HMO
plan....................................................................................................................
5
How we pay providers
..........................................................................................................................
5
Who provides my health care?
..............................................................................................................
5
Patients' Bill of Rights
..........................................................................................................................
5
Service Area
..........................................................................................................................................
6
Section 2. How we change for 2001
......................................................................................................................
7
Program-wide changes
..........................................................................................................................
7
Changes to this Plan
..............................................................................................................................
7
Section 3. How you get care
..................................................................................................................................
8
Identification
cards................................................................................................................................
8
Where you get covered care
..................................................................................................................
8
° Plan providers
....................................................................................................................................
8
° Plan facilities
......................................................................................................................................
8
What you must do to get covered care
..................................................................................................
8
° Primary
care........................................................................................................................................
8
° Specialty care
......................................................................................................................................
8
° Hospital care
......................................................................................................................................
9
Circumstances beyond our control
......................................................................................................
10
Services requiring our prior
approval..................................................................................................
10
Section 4. Your costs for covered services
..........................................................................................................
11
° Copayments
......................................................................................................................................
11
° Deductible
........................................................................................................................................
11
° Coinsurance
......................................................................................................................................
11
Your out-of-pocket maximum
............................................................................................................
11
Section 5.
Benefits................................................................................................................................................
12
Overview
............................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals ........ 13
(b) Surgical and anesthesia services provided
by physicians and other health care professionals .... 21
(c) Services
provided by a hospital or other facility, and ambulance services
.................................. 24
(d) Emergency services/ accidents
......................................................................................................
26
2001 Group Health Cooperative of South Central Wisconsin Table of Contents
2 2
2 Page 3 4
2001 Group Health Cooperative of South Central
Wisconsin Table of Contents 3
(e) Mental health and substance abuse
benefits
..............................................................................................
28
(f) Prescription drug benefits
..........................................................................................................................
30
(g) Special features
..........................................................................................................................................
32
(h) Dental
benefits............................................................................................................................................
33
Section 6. General exclusions Ñ things we don't cover
..................................................................................................
34
Section 7. Filing a claim for covered services
..................................................................................................................
35
Section 8. The disputed claims process
............................................................................................................................
36
Section 9. Coordinating benefits with other coverage
......................................................................................................
38
When you haveÉ
° Other health coverage
....................................................................................................................................
38
° Original Medicare
..........................................................................................................................................
38
° Medicare managed care plan
........................................................................................................................
40
TRICARE/ Workers' Compensation/ Medicaid
................................................................................................
40
Other Government agencies
............................................................................................................................
41
When others are responsible for
injuries..........................................................................................................
41
Section 10. Definitions of terms we use in this brochure
..................................................................................................
42
Section 11. FEHB facts
......................................................................................................................................................
43
Coverage
information......................................................................................................................................
43
° No pre-existing condition
limitation..............................................................................................................
43
° Where you get information about enrolling in the FEHB Program
.............................................................. 43
°
Types of coverage available for you and your family
....................................................................................
43
° When benefits and premiums start
................................................................................................................
44
° Your medical and claims records are confidential
........................................................................................
44
° When you
retire..............................................................................................................................................
44
When you lose benefits
....................................................................................................................................
44
° When FEHB coverage ends
..........................................................................................................................
44
° Spouse equity
coverage..................................................................................................................................
44
° Temporary Continuation of Coverage (TCC)
................................................................................................
44
° Enrolling in
TCC............................................................................................................................................
44
° Converting to individual coverage
................................................................................................................
45
° Getting a Certificate of Group Health Plan Coverage
..................................................................................
45
Inspector General advisory: Stop health care fraud!
......................................................................................
45
Index
................................................................................................................................................................
46
Summary of benefits
........................................................................................................................................
47
Rates
..................................................................................................................................................
Back cover 3
3 Page
4 5
2001 Group Health Cooperative of
South Central Wisconsin Introduction/ Plain Language 4
Introduction
Group Health Cooperative of South Central Wisconsin
8202 Excelsior
Drive
Madison, WI 53717
This brochure describes the benefits of Group Health Cooperative of South
Central Wisconsin under our contract
(CS 1828) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. This brochure is the official statement of benefits. No oral statement
can modify or otherwise affect the benefits,
limitations, and exclusions of
this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits
that were available before January 1, 2001, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2001, and are
summarized on page 7. Rates are shown
at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and
understandable
to the public by requiring agencies to use plain language. In response, a team
of health plan
representatives and OPM staff worked cooperatively to make
this brochure clearer. Except for necessary technical terms,
we use common
words. "You" means the enrollee or family member; "we" means
Group Health Cooperative of South
Central Wisconsin.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us" feedback
area at www. opm. gov/
insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and
Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.
4
4 Page 5 6
2001 Group Health Cooperative of South Central
Wisconsin Section 1 5
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other
providers that contract with
us. These Plan providers coordinate your health care services.
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.
Who provides your health care?
GHC is a Group-Practice Prepayment
(GPP) plan. We select qualified, experienced doctors for our medical staff. The
group medical practice at GHC allows for in-house consultations, peer
review, and regular staff audits of medical care so
that we can assure
quality care for you and your family members.
The first and most important decision you must make is to select your primary
care provider. Specialists who represent
every possible specialty area also
serve GHC members. Your Primary Care Provider (PCP) makes any necessary
referrals, with the following exceptions: A woman may see her Plan
gynecological provider for her annual routine
examination without a referral
(certified nurse midwives are not covered providers under this Plan); Vision
care; Dental
care; Mental Condition benefits; Substance Abuse benefits; and
Chiropractic care.
GHC uses the facilities and services of six hospitals in the South Central
Wisconsin area. Your primary care site (clinic)
determines the assigned
hospital for your routine care. Most specialty care is referred to the
University of Wisconsin
Hospital and Clinics in Madison. Babies are usually
delivered at St. Marys Hospital in Madison.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply
with the Patients' Bill of Rights, recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry.
You may get information about us, our
networks, providers, and facilities.
OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information
that we must make available to you. Some of the required
information is listed below.
° Years in existence: 25
° Profit status: Non-Profit
°
Accreditation: Excellent rating from NCQA
If you want more information about us, call 608/ 828-4827, or write to the
GHC Marketing Department, PO Box 44971,
Madison, WI 53744-4971. You may also
contact us by fax at 608/ 828-9333 or visit our website at www. ghc-hmo. com. 5
5 Page 6 7
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 includes the following counties and zip codes:
Entire counties of:
Dane
Green
Jefferson
Rock
Limited to zip codes in the following counties:
Columbia: 53555, 53911,
53925, 53955, 53960
Dodge: 53036, 54094, 53098, 53579
Iowa: 53503,
53506-7, 53516, 53544
Lafayette: 53504, 53516
Sauk: 53556, 53561, 53578,
53583, 53588
Walworth: 53114, 53115, 53190
Ordinarily, you must get your health care from providers who contract with
GHC. If you receive care outside of our
service area, we will pay only for
emergency care. We will not pay for any other health care services.
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
for-service plan or an HMO that has agreements with
affiliates in other areas. GHC has very limited reciprocity
agreements with
HMOs in other cities. Contact the GHC Member Services Department at 608/
251-3356 x4504 and ask
about the city where you or your dependent may need
health care services. 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.
2001 Group Health Cooperative of South Central Wisconsin Section 1 6 6
6 Page 7 8
2001 Group Health Cooperative of South Central
Wisconsin Section 2 7
Section 2. How we change for 2001
Program-wide changes
° The plain language team reorganized the
brochure and the way we describe our benefits. We hope this will make it
easier for you to compare plans.
° This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance abuse
parity. This means
that your coverage for mental health, substance abuse, medical, surgical, and
hospital services from
providers in our plan network will be the same with
regard to coinsurance, copays, and day and visit limitations when
you follow
a treatment plan that we approve. Previously, we placed shorter day or visit
limitations on mental health
and substance abuse services than we did on
services to treat physical illness, injury, or disease.
° Many healthcare organizations have turned their attention this past
year to improving healthcare quality and patient
safety. OPM asked all FEHB
plans to join them in this effort. You can find specific information on our
patient safety
activities by calling 608/ 251-3356, or checking our
website at www. ghc-hmo. com. You can find out more about patient
safety on
the OPM website, www. opm. gov/ insure. To improve your healthcare, take these
five steps:
°° Speak up if you have questions or concerns.
°° Keep a
list of all the medicines you take.
°° Make sure you get the results
of any test or procedure.
°° Talk with your doctor and health care
team about your options if you need hospital care.
°° Make sure you
understand what will happen if you need surgery.
° We clarified the language to show that anyone who needs a mastectomy
may choose to have the procedure performed
on an inpatient basis and remain
in the hospital up to 48 hours after the procedure. Previously the language
referenced
only women.
Changes to this Plan
° Your share of the non-Postal premium
will increase by 15.5% for Self Only or 21.4% for Self and Family.
°
Under "Rehabilitative therapies," coverage is now provided for one (1)
follow-up visit six (6) months after the date of a
member's last physical,
occupational, or speech therapy to assess the progress made following treatment.
There is a
$10 copayment for this visit. Previously, this was not shown in
the brochure (See page 17).
° Under "Preventive care, children," there is no copay for this
care for children through age 4, but for children age 5 and
older, there
will be a $10 copay per visit. Previously, the brochure did not show this (See
page 15).
° Under "Maternity care," there is a $10 copay only for the
first visit for prenatal care, and nothing for all follow-up
visits related
to the pregnancy. Previously, there was a $10 copay for each maternity visit
(See page 15).
° Under "Rehabilitative therapies," the Plan now provides
coverage for short-term rehabilitative therapy (physical,
speech, and
occupational) limited to 60 days and only subject to a $10 copay for the initial
office visit. Previously,
there was a $10 office visit copay per outpatient
session (See page 17).
° Under "Oral and maxillofacial surgery," dental care for
treatment of temporomandibular joint (TMJ) pain dysfunction
syndrome is
covered up to a maximum Plan payment of $1,250 per person per calendar year,
subject to a $10 copay
per office visit. Previously, this was not shown in
the brochure (See page 22). 7
7 Page 8 9
2001 Group Health
Cooperative of South Central Wisconsin Section 3 8
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
608/ 251-4156 x 4506.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments or
coinsurance, and you will not have to
file claims.
° Plan
providers Plan providers are physicians and other health care professionals
in
our service area that we contract with to provide covered services to
our members. We credential Plan providers according to
national
standards.
We list Plan providers in the GHC provider directory, which we
update
periodically. The list is also on our website.
° Plan facilities Plan facilities are hospitals and other
facilities in our service area
that we contract with to provide covered
services to our members.
We list these in the provider directory, which we
update periodically.
The list is also on our website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for
most of your health care. If you need assistance,
please call the GHC
Member Services Department at 608/ 251-3356 x4504.
° Primary care Your primary care physician can be a family
practitioner, an internist
or a pediatrician. (You may also select from
affiliated nurse
practitioners or physicians assistants.) Your primary care
physician
will provide most of your health care, or give you a referral to
see
a specialist.
If you want to change primary care physicians or if your primary
care
physician leaves the Plan, call us. We will help you select a
new one.
° Specialty care Your primary care physician will refer you to a
specialist for needed
care. However, you may see plan mental health and/ or
substance
abuse, vision care, dental care or chiropractic providers without
a
referral, and a woman may see her Plan gynecological provider for
her
annual routine examination without a referral. 8
8
Page 9 10
2001
Group Health Cooperative of South Central Wisconsin Section 3 9
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 Medical Utilization Management department immediately at
608/ 251-4156
x4514. If you are new to the FEHB Program, we will
arrange for you to
receive care. 9
9 Page
10 11
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.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to
provide them. In that case, we will make all reasonable
efforts to
provide you with the necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most
services. For certain services, however,
your physician must obtain
approval from us. Before giving approval, we
consider if the service
is covered, medically necessary, and follows
generally accepted
medical practice.
We call this review and approval process prior approval. Your
physician
must obtain prior approval for the following services:
Hospital care;
Referring you to a specialist;
Recommending follow-up
care;
All surgical procedures;
All physical, speech and occupational
therapy;
Infertility;
Breast reduction mammoplasty;
Plastic surgery;
Transplant of any organ;
All outpatient surgery; and
Growth hormone
therapy (GHT).
2001 Group Health Cooperative of South Central Wisconsin Section 3 10
10
10 Page 11
12
2001 Group Health Cooperative of South Central
Wisconsin Section 4 11
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 when
you
receive services.
Example: When you see your primary care physician, you pay a
copayment of
$10 per office visit.
° Deductible We do not have a deductible.
NOTE: If you change
plans during open season, you do not have to
start a new deductible under
your old plan between January 1 and the
effective date of your new plan. If
you change plans at another time
during the year, you must begin a new
deductible under your
new plan.
° Coinsurance Coinsurance is the percentage of our negotiated fee
that you must
pay for your care.
Example: In our Plan, you pay 50% of our allowance for sexual
dysfunction
drugs, and for preventive dental care services if a non-participating
dentist is used.
Your out-of-pocket maximum We do not have an out-of-pocket maximum.
for coinsurance and copayments 11
11 Page 12 13
Section 5. Your
costs for covered services (See page 7 for how our benefits changed this
year and page 47 for a benefits summary.)
NOTE: This benefits section
is divided into subsections. Please read the important things you should keep in
mind at
the beginning of each subsection. Also read the General Exclusions
in Section 6; they apply to the benefits in the
following subsections. To
obtain claims filing advice or more information about our benefits, contact us
at 608/ 251-
3356 x4504 or at our website at www. ghc-hmo. com.
(a) Medical services and supplies provided by physicians and other health
care professionals.................................... 13Ð 20
°
Diagnostic and treatment services ° Hearing services (testing, treatment,
and supplies)
° Lab, X-ray, and other diagnostic tests ° Vision
services (testing, treatment, and supplies)
° Preventive care, adult
° Foot care
° Preventive care, children ° Orthopedic and
prosthetic devices
° Maternity care ° Durable medical equipment
(DME)
° Family planning ° Home health services
° Infertility
services ° Alternative treatments
° Allergy care ° Educational
classes and programs
° Treatment therapies ° Rehabilitative
therapies
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................ 21Ð 23
°
Surgical procedures ° Organ/ tissue transplants
° Reconstructive
surgery ° Anesthesia
° Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services
.............................................................. 24Ð 25
° Inpatient hospital ° Hospice care
° Outpatient hospital or
ambulatory ° Ambulance
surgical center
° Extended care benefits/
skilled nursing care
facility benefits
(d) Emergency services/ accidents
..................................................................................................................................
26Ð 27
° Medical emergency ° Ambulance
(e) Mental health and substance abuse benefits
............................................................................................................
28Ð 29
(f) Prescription drug
benefits..........................................................................................................................................
30Ð 31
(g) Special features
..............................................................................................................................................................
32
° Services for deaf and hearing impaired; Reciprocity benefit; and
Centers of excellence for transplants
(h) Dental benefits
................................................................................................................................................................
33
Summary of benefits
............................................................................................................................................................
47
2001 Group Health Cooperative of South Central Wisconsin Section 5 12
12
12 Page 13
14
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A
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2001 Group Health Cooperative of South Central Wisconsin Section 5 (a) 13
Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals
Here are some important things to keep in
mind about these benefits:
° Please remember that all benefits are
subject to the definitions, limitations,
and exclusions in this brochure and
are payable only when we determine they
are medically necessary.
°
Plan physicians must provide or arrange your care.
° We have no calendar
year deductible.
° Be sure to read Section 4, Your costs for covered
services, for valuable
information about how cost sharing works. Also
read Section 9 about
coordinating benefits with other coverage, including
with Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians $10 per visit
° In physician's
office
° In an urgent care center
° Office medical consultations
° Second surgical opinion
Professional services of physicians Nothing
° During a hospital stay
° In a skilled nursing facility
° Initial examination of a
newborn child covered under a
family enrollment
° At home 13
13 Page
14 15
2001 Group Health Cooperative of
South Central Wisconsin Section 5 (a) 14
Lab, X-ray and other
diagnostic tests You pay
Tests, such as: Nothing if you receive these
° Blood tests services during your office
° Urinalysis visit;
otherwise, $10 per visit
° Non-routine pap tests
° Pathology
° X-rays
° Non-routine Mammograms
° Cat Scans/ MRI
° Ultrasound
° Electrocardiogram and EEG
Preventive care, adult You pay
Routine screenings, such as: $10
per visit
° Blood lead levelÑ one annually
° Total Blood
CholesterolÑ once every five years, ages 18 and above
°
Colorectal Cancer Screening, including
°° Fecal occult blood test
°° Sigmoidoscopy, screeningÑ every five years starting at age
50
Prostate Specific Antigen (PSA test)Ñ one annually for men age 50 and
older
Routine pap test
Routine mammogramÑ covered for women age
35 and older, as follows:
° From age 35 through 39, one during this five
year period (if a family
history of breast cancer in first degree family
members)
° From age 40 through 49, at the discretion of the provider and
patient
° At age 50 and older, one every calendar year
Routine Immunizations, limited to:
° Tetanus-diphtheria (Td)
boosterÑ once every 10 years, ages 19 and
over (except as provided
for under Childhood immunizations)
° Influenza/ Pneumococcal vaccines,
annually, age 65 and over
Not covered: Physical exams required for obtaining or continuing
employment All charges.
or insurance, attending schools or camp, or travel.
14
14 Page 15
16
2001 Group Health Cooperative of South Central
Wisconsin Section 5 (a) 15
Preventive care, children You pay
° Childhood immunizations recommended by the American Academy
Nothing to age 5; $10
of Pediatrics per visit age 5 and older
°
Examinations, such as:
°° Eye exams through age 17 to determine the
need for vision correction.
°° Ear exams through age 17 to determine
the need for hearing correction
°° Examinations done on the day of
immunizations ( through age 22)
° Well-child care charges for routine
examinations, immunizations and care
(through age 22)
Maternity care You pay
Complete maternity (obstetrical) care, such
as: $10 for the initial maternity
° Prenatal care visit; nothing for all
other
° Delivery maternity related visits.
° Postnatal care
Note: Here are some things to keep in mind:
° You may remain in the
hospital up to 48 hours after a regular delivery and
96 hours after a
cesarean delivery. We will extend your inpatient stay if
medically
necessary.
° We cover routine nursery care of the newborn child during
the covered
portion of the mother's maternity stay. We will cover other care
of an
infant who requires non-routine treatment only if we cover the infant
under
a Self and Family enrollment.
° We pay hospitalization and
surgeon services (delivery) the same as for
illness and injury. See Hospital
benefits (Section 5c) and Surgery
benefits (Section 5b).
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning You pay
° Voluntary sterilization
$10 per visit
° Surgically implanted contraceptives
° Injectable
contraceptive drugs
° Intrauterine devices (IUDs)
° Diaphragms
Not covered: Reversal of voluntary surgical sterilization, genetic
counseling All charges. 15
15 Page 16 17
2001 Group
Health Cooperative of South Central Wisconsin Section 5 (a) 16
Infertility services You pay
Diagnosis and treatment of
infertility, such as: $10 per visit
° Artificial insemination:
°° intracervical insemination (ICI)
° Fertility drugs
Note: We only cover the oral fertility drug (clomiphene citrate) under the
prescription drug benefit.
Not covered: All charges.
° Artificial insemination:
°° Intravaginal insemination (IVI)
°° Intrauterine
insemination (IUI)
° Assisted reproductive technology (ART) procedures,
such as:
°° in vitro fertilization
°° embryo transfer
and GIFT
° Services and supplies related to excluded ART procedures
° Cost of donor sperm
° Injectable and oral fertility drugs,
except for clomiphene citrtate
Allergy care You pay
Testing and treatment $10 per visit
Allergy injection
Allergy serum Nothing
Not covered: Provocative food testing and
sublingual All charges.
allergy desensitization
Treatment therapies You pay
° Chemotherapy and radiation
therapy $10 per visit
Note: High dose chemotherapy in association with
autologous bone marrow
transplants are limited to those transplants listed
under Organ/ Tissue
Transplants on page 23.
° Respiratory and inhalation therapy
° DialysisÑ
hemodialysis and peritoneal dialysis
° Intravenous (IV)/ infusion
therapyÑ home IV and antibiotic therapy
° Growth hormone therapy
(GHT)
Note: We will only cover GHT when we preauthorize the treatment.
Call your primary care physician for preauthorization. If we determine that
GHT is not medically necessary, we will not cover the GHT or related
services and supplies. See Services requiring our prior approval in Section
3. 16
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2001 Group Health Cooperative of South Central
Wisconsin Section 5 (a) 17
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy $10 per
initial visit
° 60 consecutive days per condition for the services of
each of the following: per condition
°° qualified physical
therapists;
°° speech therapists; and
°° occupational
therapists.
Note: We only cover therapy to restore bodily function or speech
when there
has been a total or partial loss of bodily function or functional
speech due
to illness or injury.
We will allow you to make one follow-up visit six months after the date of
$10 per visit
your last physical, occupational or speech therapy treatment.
Cardiac rehabilitation following a heart transplant, bypass surgery, a $10
for the initial visit
myocardial infarction, unstable angina pectoris, or
angioplasty is provided
for up to 36 sessions over a 12-week time period.
Not covered: All charges.
° Long-term rehabilitative therapy
° Exercise programs
Hearing services (testing, treatment, and supplies) You pay
°
Hearing testing Nothing to age 5; $10 per
visit for age 5 and older
Not covered: Hearing aids, testing and examinations for them All charges.
Vision services (testing, treatment, and supplies) You pay
° Annual vision examinations Nothing to age 5; $10 per
visit for
age 5 and older
° Annual eye refractions Nothing
° Lenses following intraocular
surgery (such as for cataract removal) or $10 per visit
for Keratoconus when
there is a change in visual acuity requiring a
new prescription
Not covered: All charges.
° Eyeglasses or contact lenses, except
as above
° Eye exercises and orthoptics
° Radial keratotomy and
other refractive surgery 17
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2001 Group
Health Cooperative of South Central Wisconsin Section 5 (a) 18
Foot
care You pay
Routine foot care when you are under active treatment for a
metabolic or $10 per visit
peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe
inserts.
Not covered: All charges.
° Cutting, trimming or removal of corns,
calluses, or the free edge of toenails,
and similar routine treatment of
conditions of the foot, except as stated above
° Treatment of weak,
strained or flat feet or bunions or spurs; and of any
instability, imbalance
or subluxation of the foot (unless the treatment is by
open cutting surgery)
Orthopedic and prosthetic devices You pay
° Artificial limbs
and eyes $10 per visit
° Externally worn breast prostheses and surgical
bras, including necessary
replacements, following a mastectomy
°
Internal prosthetic devices, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy.
Note: See
Section 5( b) for coverage of the surgery to insert the device.
° Braces
° Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome
Not covered: All charges.
° Orthopedic and corrective shoes
° Arch supports
° Cost of a cochlear implanted device
°
Foot orthotics
° Heel pads and heel cups
° Lumbosacral supports
° Corsets, trusses, elastic stockings, support hose, and other
supportive devices
° Prosthetic replacements, unless the item is no
longer useful and has
exceeded its reasonable lifetime under normal use; or
the member's
condition has changed so as to make the original equipment
inappropriate. 18
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2001 Group Health Cooperative of
South Central Wisconsin Section 5 (a) 19
Durable medical equipment
(DME) You pay
Rental or purchase, at our option, including repair and
adjustment, of durable $10 per visit
medical equipment prescribed by your
Plan physician, such as oxygen and
dialysis equipment. Under this benefit,
we also cover:
° hospital beds;
° standard wheelchairs;
° crutches;
° walkers;
° blood glucose monitors; and
° insulin pumps.
Note: Call us at 608/ 251-4156 x4514 as soon as
your Plan physician
prescribes this equipment. We will arrange with a health
care provider to
rent or sell you durable medical equipment at discounted
rates and will tell
you more about this service when you call.
Not covered: All charges.
° Motorized wheel chairs
° DME
replacements, unless the item is no longer useful and has exceeded its
reasonable lifetime under normal use; or the member's condition has
changed so as to make the original equipment inappropriate.
Home health services You pay
° Home health care ordered by a
Plan physician and provided by a registered Nothing
nurse (R. N.), licensed
practical nurse (L. P. N.), licensed vocational nurse
(L. V. N.), or home
health aide.
° Services include oxygen therapy, intravenous therapy and
medications.
Not covered: All charges.
° Nursing care requested by, or for the
convenience of, the patient or the
patient's family;
° Nursing care
primarily for hygiene, feeding, exercising, moving the patient,
homemaking,
companionship or giving oral medication.
Alternative treatments You pay
° Chiropractic services, but
only when related to a specific injury $10 per visit
Not covered: All charges.
° Chiropractic services for chronic
problems or for maintenance
° Acupuncture
° Naturopathic
services
° Hypnotherapy
° Biofeedback 19
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2001 Group Health Cooperative of South Central
Wisconsin Section 5 (a) 20
Educational classes and programs You pay
Coverage may include: Some fees requiredÑ contact
°
Smoking cessation GHC Health Education
° Diabetes self-management
Department at 608/ 257-9705
° Nutrition for fees and schedules
°
Weight management
° Stress management
° Prenatal
° First
aid
° Fitness programs 20
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Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals
Here are some important things to keep in mind about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations,
and exclusions in this brochure and are payable only when we
determine
they are medically necessary.
° Plan physicians must
provide or arrange your care.
° We have no calendar year deductible.
° Be sure to read Section 4, Your costs for covered services, for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
° The amounts listed below are for the charges billed by a physician or
other
health care professional for your surgical care. Look in Section 5( c)
for
charges associated with the facility (i. e., hospital, surgical center,
etc.).
° YOUR PLAN DOCTOR MUST GET PRIOR APPROVAL OF SOME
SURGICAL
PROCEDURES. Please refer to the prior approval information
shown in Section
3 to be sure which services require prior approval and
identify which
surgeries require prior approval.
Benefit Description You pay
Surgical procedures
° Treatment of fractures, including casting $10 per office visit;
° Normal pre-and post-operative care by the surgeon Nothing for hospital
visit
° Correction of amblyopia and strabismus
° Endoscopy
procedure
° Biopsy procedure
° Removal of tumors and cysts
° Correction of congenital anomalies (see reconstructive surgery)
° Surgical treatment of morbid obesityÑ a condition in which an
individual
weighs 100 pounds or 100% over his or her normal weight according
to
current underwriting standards; eligible members must be age 18 or over
° Insertion of internal prosthetic devices. See Section 5( a)Ñ
Orthopedic and
prosthetic devices for device coverage information.
°
Voluntary sterilization
° Norplant (a surgically implanted
contraceptive) and intrauterine devices
(IUDs) Note: Devices are covered
under Section 5( a).
° Treatment of burns
Note: Generally, we pay
for internal prostheses (devices) according to where
the procedure is done.
For example, we pay Hospital benefits for a pacemaker
and Surgery benefits
for insertion of the pacemaker.
Not covered: All charges.
° Reversal of voluntary sterilization
° Routine treatment of conditions of the foot; see Foot care
°
Cost of a cochlear implanted device 21
21
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2001
Group Health Cooperative of South Central Wisconsin Section 5 (b) 22
Reconstructive surgery You pay
Surgery to correct a
functional defect $10 per office visit;
° Surgery to correct a condition
caused by injury or illness if: Nothing for hospital visit
°° the
condition produced a major effect on the member's appearance and
°°
the condition can reasonably be expected to be corrected by such surgery
° Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate;
birth marks; webbed fingers; and webbed toes.
° All stages
of breast reconstruction surgery following a mastectomy, such as:
°°
surgery to produce a symmetrical appearance on the other breast;
°°
treatment of any physical complications, such as lymphedemas;
°°
breast prostheses and surgical bras and replacements
(see Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the
procedure
performed on an inpatient basis and remain in the hospital up to
48 hours
after the procedure.
Not covered: All charges
° Cosmetic surgeryÑ any surgical
procedure (or any portion of a procedure)
performed primarily to improve
physical appearance through change in
bodily form, except repair of
accidental injury
° Surgeries related to sex transformation
Oral and maxillofacial surgery You pay
Oral surgical procedures,
limited to: $10 per office visit;
° Reduction of fractures of the jaws
or facial bones; Nothing for hospital visit
° Surgical correction of
cleft lip, cleft palate or severe functional malocclusion;
° Removal of
stones from salivary ducts;
° Excision of leukoplakia or malignancies;
° Excision of cysts and incision of abscesses when done as independent
procedures; and
° Other surgical procedures that do not involve the
teeth or their
supporting structures.
° Dental treatment of Temporomandibular joint (TMJ) syndrome is limited
$10 per office visit
to a maximum Plan payment of $1250 per person per
calendar year.
Not covered: All charges.
° Oral implants and transplants
° Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone) 22
22 Page 23 24
2001 Group Health Cooperative of South Central
Wisconsin Section 5 (b) 23
Organ/ tissue transplants You pay
Limited to: $10 per office visit
° Cornea for evaluation;
° Heart Nothing in hospital
° 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
° National Transplant
Program (NTP) ÑUW Hospital & Clinics
Limited benefitsÑ 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.
Not covered: All charges
° Donor screening tests and donor search
expenses, except those performed
for the actual donor
° Implants of
artificial organs
° Transplants not listed as covered
Anesthesia You pay
Professional services provided in Nothing
° Hospital (inpatient)
Professional services provided in $10 per visit
° Hospital outpatient
department
° Skilled nursing facility
° Ambulatory surgical
center
° Office 23
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Section 5 (c). Services provided by a hospital or other facility,
and
ambulance services
Here are some important things to remember about these benefits:
° Please remember that all benefits are subject to the definitions,
limitations,
and exclusions in this brochure and are payable only when we
determine they
are medically necessary.
° Plan physicians must
provide or arrange your care and you must be
hospitalized in a Plan
facility.
° Be sure to read Section 4, Your costs for covered
services, for valuable
information about how cost sharing works. Also
read Section 9 about
coordinating benefits with other coverage, including
with Medicare.
° The amounts listed below are for the charges billed by
the facility (i. e.,
hospital or surgical center) or ambulance service for
your surgery or care.
Any costs associated with the professional charge (i.
e., physicians, etc.) are
covered in Section 5( a) or (b).
Benefit Description You pay
Inpatient hospital
Room and board, such as Nothing
° ward, semiprivate, or intensive
care accommodations;
° general nursing care; and
° meals and
special diets.
NOTE: If you want a private room when it is not medically
necessary, you
pay the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as:
° Operating, recovery,
maternity, and other treatment rooms
° Prescribed drugs and medicines
° Diagnostic laboratory tests and X-rays
° Administration of
blood and blood products
° Blood or blood plasma, if not donated or
replaced
° Dressings, splints, casts, and sterile tray services
° Medical supplies and equipment, including oxygen
°
Anesthetics, including nurse anesthetist services
° Take-home items
° Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home
Not covered: All charges.
° Custodial care
° Non-covered
facilities, such as nursing homes, extended care
facilities, schools
° Personal comfort items, such as telephone, television, barber
services,
guest meals and beds
° Private nursing care 24
24 Page 25 26
2001 Group Health Cooperative of South Central
Wisconsin Section 5 (c) 25
Outpatient hospital or ambulatory surgical
center You pay
° Operating, recovery, and other treatment rooms
Nothing
° Prescribed drugs and medicines
° Diagnostic laboratory
tests, X-rays, and pathology services
° Administration of blood, blood
plasma, and other biologicals
° Blood and blood plasma, if not donated
or replaced
° Pre-surgical testing
° Dressings, casts, and
sterile tray services
° Medical supplies, including oxygen
°
Anesthetics and anesthesia service
NOTE: We cover hospital services and
supplies related to dental procedures
when necessitated by a non-dental
physical impairment. We do not cover the
dental procedures.
Not covered: Blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care You pay
facility benefits
We provide a comprehensive range of benefits for up to a 100 days per Nothing
calendar year when fulltime 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.
Not covered: Custodial care All charges
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered in
Nothing
the home. Services include 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 stage of an illness, with a
life expectancy of six
months or less.
Not covered: Independent nursing, homemaker services All charges
Ambulance You pay
° Local professional ambulance service
when medically appropriate Nothing 25
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Section 5 (d). Emergency services/ accidents
Here are some important
things to keep in mind about these benefits:
° Please remember that
all benefits are subject to the definitions, limitations,
and exclusions in
this brochure.
° We have no calendar year deductible.
° 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.
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers
your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some
problems are emergencies because, if not
treated promptly, they might become more serious; examples include
deep cuts
and broken bones. Others are emergencies because they are potentially life
threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we
may determine are medical emergenciesÑ what they all have in common is
the need for
quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
doctor. In extreme emergencies, if you are unable to contact your doctor,
contact the nearest emergency system
(e. g., the 911 telephone system) or go
to the nearest hospital emergency room. Be sure to tell emergency room
personnel that you are a GHC Plan member so they can notify us. You or a
family member must also notify us
within 48 hours. It is your responsibility
to make certain that the Plan has been notified.
If you need to be hospitalized in a non-Plan facility, you or a family member
must notify the Plan within 48
hours or on the first working day following
your admission, unless it is not reasonably possible to do so. If a
GHC plan
doctor believes that you will receive better care in a Plan hospital, we will
transfer you when it is
medically feasible and we will pay all ambulance
charges for the transfer.
Benefits are available for care by non-Plan providers in a medical emergency
only if delay in reaching a Plan
provider would result in death, disability
or significant jeopardy to your condition.
Any follow up care recommended by non-plan providers in such a medical
emergency must be approved by
GHC or provided by GHC plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that
is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, you or a family member must notify the Plan
within 48 hours or on the first
working day following your admission, unless
it is not reasonably possible to do so. If a GHC Plan doctor
believes you
will receive better care in a Plan hospital, we will transfer you when it is
medically feasible and we
will pay all ambulance charges for that transfer.
Any follow-up care recommended by non-plan providers in such a medical
emergency must be approved by
GHC or provided by GHC plan providers. 26
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2001 Group Health Cooperative of South Central
Wisconsin Section 5 (d) 27
Benefit Description You pay
Emergency
within our service area
° Emergency care at a doctor's office $10 per visit
° Emergency care at an urgent care center Nothing
° Emergency
care as an outpatient or inpatient at a hospital, including
doctors'
services
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
° Emergency care at a
doctor's office $10 per visit
° Emergency care at an urgent care center Nothing
° Emergency
care as an outpatient or inpatient at a hospital, including
doctors'
services
Not covered: All charges.
° Elective care or non-emergency care
° Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
° Medical
and hospital costs resulting from a normal full-term delivery of a
baby
outside the service area
Ambulance
Professional ambulance service, as well as air
ambulance, when Nothing
medically appropriate.
See Section 5( c) for non-emergency service. 27
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Section 5 (e). Mental health and substance abuse benefits
Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse
benefits
will achieve "parity" with other benefits. This means
that we will provide
mental health and substance abuse benefits differently
than in the past.
When you get our approval for services and follow a treatment plan we
approve,
cost sharing and limitations for Plan mental health and substance
abuse benefits
will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
° All benefits are subject to the definitions, limitations, and
exclusions in
this brochure.
° Be sure to read Section 4, Your
costs for covered services, for valuable
information about how cost
sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and Your
cost sharing
contained in a treatment plan that we approve. The treatment
plan may include responsibilities are no
services, drugs and supplies
described elsewhere in this brochure. greater than for other
illnesses or
conditions.
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.
° Professional services, including individual or group therapy by
providers $10 per visit
such as psychiatrists, psychologists, or
clinical-social workers.
° Medication management
° Diagnostic tests Nothing if you receive
these services during your
office visit; otherwise,
$10 per visit
° Services provided by a hospital or other facility Nothing
°
Services in approved alternative care settings such as partial hospitalization,
full-day hospitalization, facility based intensive outpatient treatment.
Mental health and substance abuse benefits continued on next page 28
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2001 Group Health Cooperative of South Central
Wisconsin Section 5 (e) 29
Mental health and substance abuse benefits
(continued)
Not covered: Services we have not approved. All charges.
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.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all of our network authorization processes. These
include:
° Patients may make their own appointments for mental health
and/ or substance
abuse services as follows:
Outpatient Mental HealthÑ GHC Mental Health Department
Telephone:
608/ 257-9700 or 800/ 605-4327
Inpatient Mental HealthÑ US Hospital & Clinics
Substance
AbuseÑ Outpatient and Inpatient Services
Gateway Recovery Services,
Inc.
608/ 278-8200 (Madison, WI)
608/ 877-1855 (Stoughton, WI)
________________________________________________________________________________________________
Special transitional If a mental health or substance abuse
professional provider is treating you under benefit our plan as of
January 1, 2001, you will be eligible for continued coverage with
your
provider for up to 90 days under the following condition:
° If your
mental health or substance abuse professional provider with whom you
are
currently in treatment leaves the plan at our request for other than cause.
If this condition applies to you, we will allow you reasonable time to
transfer
your care to a Plan mental health or substance abuse professional
provider.
During the transitional period, you may continue to see your
treating provider
and will not pay any more out-of-pocket than you did in
the year 2000 for
services. This transitional period will begin with our
notice to you of the
change in coverage and will end 90 days after you
receive our notice. If we
write to you before October 1, 2000, the 90-day
period ends before January 1
and this transitional benefit does not apply.
Limitation We may limit your benefits if you do not follow your
treatment plan. 29
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Section 5 (f). Prescription drug benefits
Here are some important
things to keep in mind about these benefits:
° We cover prescribed
drugs and medications, as described in the chart
beginning on the next page.
° All benefits are subject to the definitions, limitations and exclusions
in
this brochure and are payable only when we determine they are
medically necessary.
° Be sure to read Section 4, Your costs for covered services, for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
There are important features you should be aware of. These include:
° Who can write your prescription. A plan physician or licensed
dentist must
write the prescription.
° Where you can obtain them. You must fill the prescription at a
plan pharmacy.
° We use a formulary. A drug formulary is a list of prescription
medications,
representing the current judgment of medical practitioners, for
the treatment of
disease. A drug not included in a Formulary is generally
just an alternative
choice to other drugs that are included in that
Formulary. Formularies may
affect what is covered under a prescription
benefit plan. The benefit may only
cover the drugs included in the
Formulary, which is called a closed Formulary.
Or the benefit may recommend
the drugs included in the Formulary, but cover
all drugs, which is called an
open Formulary.
There is a process for the practitioners to request an exception be made to
cover a non-formulary drug. The process is practitioner-driven since the
justification of such requests must be based on evidence of medical
necessity.
This process is sometimes labeled with different names, such as
pre-certification,
prior authorization, or formulary exception.
These are the dispensing limitations. We furnish a 34-day supply of a
prescribed drug.
° When you have to file a claim. Generally you will not need to
file a claim.
An exception would be a drug prescribed in an emergency or
urgent situation
when you are out of the area. Forward such claims to GHC
Claims Department,
PO Box 44971, Madison, WI 53744-4971. Be sure to include
your member
number and an explanation of why you are submitting the claim.
30
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2001 Group Health Cooperative of South Central
Wisconsin Section 5 (f) 31
Benefit Description You pay
Covered
medications and supplies
We cover the following medications and supplies prescribed by a Plan Nothing
physician or referral doctor and obtained from a Plan pharmacy.
°
Drugs and medicines that by federal law of the United States require a
physician's prescription for their purchase, except as excluded below.
° Insulin
° Diabetic supplies, including insulin syringes,
needles, insulin infusion
pumps, injection pens, glucose test tablets and
test tape, Benedict's solution
or equivalent and acetone test tablets
° Pre-natal vitamins
° Disposable needles and syringes for the
administration of
covered medications
° Contraceptive drugs and
devices
° Nicotine patches when participating in the Plan's behavior
modification program
° Oral fertility drug, clomiphene citrate,
limited to a lifetime maximum of
one year
Drugs for sexual dysfunction are subject to dosage limits. 50%
Contact
the Plan for details.
Here are some things to keep in mind about our prescription drug program:
° A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand
° We have an open
formulary. If your physician believes a name brand
product is necessary or
there is no generic available, your physician may
prescribe a name brand
drug from a formulary list. This list of name brand
drugs is a preferred
list of drugs that we selected to meet patient needs at a
lower cost. To
order a prescription drug brochure, call Member Services at
608/ 251-3356
x4504.
° Not covered: All Charges
° Drugs and supplies for cosmetic
purposes
° Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies
° Vitamins, nutrients and food supplements that can be
purchased without a
prescription, except for pre-natal vitamins
°
Medical supplies, such as dressings and antiseptics
° Nonprescription
medicines
° Drugs to enhance athletic performance
° Smoking
cessation drugs and medications, except nicotine patches when
participating
in the Plan's behavior modification program
° Fertility drugs, except
the oral fertility drug, clomiphene citrate, which is
limited to a lifetime
maximum of one year
° Weight loss drugs, appetite suppressants, weight
loss programs or classes,
except when medically necessary for the treatment
of morbid obesity 31
31 Page 32 33
2001 Group
Health Cooperative of South Central Wisconsin Section 5 (g) 32
Section 5 (g). Special Features
Feature Description
Services for deaf and Hearing impaired interpreter for non-emergency
services can be reached at this hearing impaired TDD line: 608/ 257-7391.
Centers of excellence Our local center of excellence is associated
with the University of Wisconsin for transplants/ Hospital and Clinics in
Madison, WI
heart surgery/ etc.
Reciprocity benefit GHC has very limited reciprocity agreements with
HMOs in other cities. Contact the GHC Member Services Department at 608/
251-3356 x4504 and
ask about the city where you or your dependent may need
health care services. 32
32 Page 33 34
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2001 Group Health Cooperative of South Central Wisconsin Section 5 (h) 33
Section 5 (h). Dental benefits
Here are some important things to keep
in mind about these benefits:
° Please remember that all benefits
are subject to the definitions, limitations,
and exclusions in this brochure
and are payable only when we determine they
are medically necessary.
° Plan dentists must provide or arrange your care.
° We have no
calendar year deductible.
° We cover hospitalization for dental
procedures only when a nondental physical
impairment exists which makes
hospitalization necessary to safeguard the
health of the patient; 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.
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair and Nothing up to $1500 per
replace sound natural teeth. The need for these services must result from an
accident, all charges above
accidental injury. You must be seen within 48
hours of the accident; however, $1500 per accident
treatment may be delayed
due to your medical condition. Damage to teeth
caused by chewing or biting
does not constitute an accidental injury.
Dental benefits
Service You pay
° Prophylaxis or cleaning (one every six months) Nothing if you use a GHC
° Topical applications of fluoride through age fifteen (one every six
months) Plan dentist; 50% of charges
if you use a non-participating
dentist. 33
33 Page
34 35
2001 Group Health Cooperative of
South Central Wisconsin Section 6 34
Section 6. General
exclusionsÑ things we don't cover
The exclusions in this section
apply to all benefits. Although we may list a specific service as a benefit,
we will
not cover it unless your Plan doctor determines it is medically
necessary to prevent, diagnose, or treat your
illness, disease, injury, or
condition, and we agree, as discussed under What services require our
prior approval
on page 10.
We do not cover the following:
° Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
°
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
° Services, drugs, or supplies that are not medically necessary;
° Services, drugs, or supplies not required according to accepted
standards of medical, dental, or
psychiatric practice;
° Experimental or investigational procedures, treatments, drugs or
devices;
° Services, drugs, or supplies related to abortions, except
when the life of the mother would be endangered
if the fetus were carried to
term or when the pregnancy is the result of an act of rape or incest;
° Services, drugs, or supplies related to sex transformations; or
° Services, drugs, or supplies you receive from a provider or facility
barred from the FEHB Program. 34
34 Page 35 36
2001 Group
Health Cooperative of South Central Wisconsin Section 7 35
Section 7.
Filing a claim for covered services
When you see Plan physicians,
receive services at Plan hospitals and facilities, or fill your prescription
drugs at Plan
pharmacies, you will not have to file claims. Just present
your identification card and pay your copayment or
coinsurance, if
applicable.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, Hospital and Drug benefits In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance
Claim Form. Facilities will file on the UB-92 form. For
claims
questions and assistance, call us at 608/ 251-3356 x4504.
When you must file a claimÑ such as for out-of-area careÑ
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, ID number, and Social Security 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 payerÑ such as the Medicare
Summary Notice (MSN); and
° Receipts, if you paid for your services.
Submit your claims to: Group Health Cooperative, Claims
Department, PO
Box 44971, Madison, WI 53744-4971.
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by
administrative operations of government or legal incapacity,
provided
the claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 35
35 Page
36 37
2001 Group Health Cooperative of
South Central Wisconsin Section 8 36
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 suppliesÑ 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: Group Health Cooperative Member Services, PO Box 44971,
Madison, WI
53744-4971; and
(c) Include a statement about why you
believe our initial decision was wrong, based on specific benefit
provisions
in this brochure; and
(d) Include copies of documents that support your
claim, such as physicians' letters, operative reports, bills,
medical
records, and explanation of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial Ñ 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
requestÑ go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information
was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
° 90 days after the date of our letter
upholding our initial decision; or
° 120 days after you first wrote to
us Ñ if we did not answer that request in some way within 30 days; or
° 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
P. O. Box 436, Washington, D. C. 20044-0436.
36
36 Page 37 38
2001 Group Health Cooperative of South Central
Wisconsin Section 8 37
Send OPM the following information:
° A
statement about why you believe our decision was wrong, based on specific
benefit provisions in
this brochure;
° Copies of documents that
support your claim, such as physicians' letters, operative reports, bills,
medical
records, and explanation of benefits (EOB) forms;
° Copies
of all letters you sent to us about the claim;
° Copies of all letters
we sent to you about the claim; and
° Your daytime phone number and the
best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or
death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
608/ 251-3356 x4504 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 can call OPM's Health
Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m.
eastern time. 37
37 Page
38 39
2001 Group Health Cooperative of
South Central Wisconsin Section 9 38
Section 9. Coordinating benefits
with other coverage
When you have other health coverage You must tell us
if you are covered or a family member is covered under another group health plan
or have automobile insurance that
pays health care expenses without regard
to fault. This is called
"double coverage."
When you have double coverage, one plan normally pays its benefits
in
full as the primary payer and the other plan pays a reduced benefit
as the
secondary payer. We, like other insurers, determine which
coverage is
primary according to the National Association of
Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in
this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our
allowance, up to our
regular benefit. We will not pay more than
our allowance.
What is Medicare? Medicare is a Health Insurance Program for: °
People 65 years of age and older.
° Some people with disabilities, under
65 years of age.
° People with End-Stage Renal Disease (permanent kidney
failure
requiring dialysis or a transplant)
Medicare has two parts:
° Part A (Hospital Insurance). Most people do
not have to pay
for Part A.
° Part B (Medical Insurance). Most
people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you
get
your health care. Medicare managed care plan is the term used to
describe
the various health plan choices available to Medicare
beneficiaries. The
information in the next few pages shows how we
coordinate benefits with
Medicare, depending on the type of
Medicare managed care plan you have.
°The Original Medicare Plan The Original Medicare Plan is
available everywhere in the
United States. It is the way most people get
their Medicare Part A
and Part B benefits. You may go to any doctor,
specialist or hospital
that accepts Medicare. Medicare pays its share and
you pay your
share. Some things are not covered under Original Medicare,
like
prescription drugs.
When you are enrolled in this Plan and Original Medicare, you still
need
to follow the rules in this brochure for us to cover your care.
Your care
must continue to be authorized by your Plan primary
care physician.
We will not waive any of our copayments or coinsurance.
(Primary payer
chart begins on next page.) 38
38 Page 39 40
2001 Group
Health Cooperative of South Central Wisconsin Section 9 39
The following
chart illustrates whether Original 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
A. When either youÑ or your covered
spouseÑ are age 65 or over andÉ Then the primary payer isÉ
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a family member are eligible for
Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government whenÉ
a) The position is excluded from FEHB, or
b) The
position is not excluded from FEHB
Ask your employing office which of these applies to you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge
who retired under Section 7447 of title 26, U. S. C.
(or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B (for other
services) services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are (except
for claims
unable to return to duty, related to Workers'
Compensation.)
B. When youÑ or a covered family memberÑ have Medicare based
on end
stage renal disease (ESRD) andÉ
1) Are within the first 30 months of eligibility to receive Part A benefits
solely
because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary
for you under another provision,
C. When you or a covered family member have FEHB andÉ
1)
Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare. 39
39
Page 40 41
2001
Group Health Cooperative of South Central Wisconsin Section 9 40
Claims processÑ You probably will never have to file a
claim form
when you have both our Plan and Medicare.
° When we are the primary payer, we process the claim first.
°
When Original Medicare is the primary payer, Medicare processes
your claim
first. In most cases, your claims will be coordinated
automatically and we
will pay the balance of covered charges. You
will not need to do anything.
To find out if you need to do
something about filing your claims, call us at
608/ 251-4156 x4269.
° Medicare managed care plan If you are eligible for Medicare, you
may choose to enroll in and get
your benefits from a Medicare managed care
plan. These are health
care choices (like HMOs) in some areas of the
country. In most
Medicare managed care plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare managed
care plans cover all Medicare Part A and B benefits. Some cover
extras,
like prescription drugs. To learn more about enrolling in a
Medicare managed
care plan, contact Medicare at 1-800-
MEDICARE (1-800-633-4227) or at www.
medicare. gov. If you
enroll in a Medicare managed care plan, the following
options are
available to you:
This Plan and another Plan's Medicare managed care plan:
You may
enroll in another plan's Medicare managed care plan and
also remain enrolled
in our FEHB plan. We will still provide benefits
when your Medicare managed
care plan is primary, even out of the
managed care plan's network and/ or
service area (if you use our
Plan providers), but we will not waive any of
our copayments
or coinsurance.
Suspended FEHB coverage and a Medicare managed care plan:
If you
are an annuitant or former spouse, you can suspend your
FEHB coverage to
enroll in a Medicare managed care plan,
eliminating your FEHB premium. (OPM
does not contribute to your
Medicare managed care plan premium.) For
information on
suspending your FEHB enrollment, contact your retirement
office.
If you later want to re-enroll in the FEHB Program, generally you
may do so only at the next open season unless you involuntarily lose
coverage or move out of the Medicare managed care plan's
service area.
° Enrollment in Note: If you choose not to enroll in Medicare Part
B, you can still be
Medicare Part B covered under the FEHB Program.
We cannot require you to enroll
in Medicare.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the
CHAMPUS
program. If both TRICARE and this Plan cover you, we
pay first. See your
TRICARE Health Benefits Advisor if you have
questions about TRICARE
coverage. 40
40 Page
41 42
2001 Group Health Cooperative of
South Central Wisconsin Section 9 41
Workers' Compensation We do
not cover services that:
° you need because of a workplace-related
disease 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 benefits. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other government agencies We do not cover services and supplies
when a local, state, are responsible for your care or federal government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for for injuries medical or hospital 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. 41
41 Page
42 43
2001 Group Health Cooperative of
South Central Wisconsin Section 10 42
Section 10. Definitions of
terms we use in this brochure
Calendar year January 1 through December
31 of the same year. For new enrollees, the calendar year begins on the
effective date of their enrollment and
ends on December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 11.
Covered services Care we provide
benefits for, as described in this brochure.
Deductible We do not
have a deductible.
Experimental or We use the following criteria to
determine if a service or procedure investigational services is
considered experimental or investigational:
1. The technology involved must have final approval from the
appropriate
government regulatory bodies;
2. The scientific evidence must allow
conclusions to be drawn based
on health outcomes;
3. The technology
involved must improve the health outcome of
the member;
4. The
technology involved must be as good for a patient as any of
the already
established alternatives; and
5. Possible harm from the procedure (including
long term effects)
must be well understood and not outweigh the benefits.
Contact us if you would like more information about the criteria
used in
deciding whether a service or procedure is experimental
or investigational.
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 Group Health Cooperative of South Central
Wisconsin.
Yo u You refers to the enrollee and each covered family
member. 42
42 Page
43 44
2001 Group Health Cooperative of
South Central Wisconsin Section 11 43
Section 11. FEHB facts
No
preexisting condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition
before you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office about enrolling in the can answer your questions, and give you a
Guide to Federal
FEHB Program Employees Health Benefits
Plans, brochures for other plans, and other materials you need to make an
informed decision about:
° When you may change your enrollment;
° How you can cover your
family members;
° What happens when you transfer to another Federal
agency, go on
leave without pay, enter military service, or retire;
° When your enrollment ends; and
° When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age
22, including any foster
children or stepchildren your employing or
retirement office authorizes
coverage for. Under certain
circumstances, you may also continue coverage
for a disabled child
22 years of age or older who is incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and
Family
enrollment if you marry, give birth, or add a child to your
family. You may
change your enrollment 31 days before to 60 days
after that event. The Self
and Family enrollment begins on the first
day of the pay period in which the
child is born or becomes an
eligible family member. When you change to Self
and Family
because you marry, the change is effective on the first day of
the pay
period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until
you
marry.
Your employing or retirement office will not notify you when a
family member is no longer eligible to receive health benefits, nor
will
we. Please tell us immediately when you add or remove family
members from
your coverage for any reason, including divorce, or
when your child under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that
person may not be enrolled in or covered as a family member by
another FEHB
plan. 43
43 Page
44 45
2001 Group Health Cooperative of
South Central Wisconsin Section 11 44
When benefits and The
benefits in this brochure are effective on January 1. If you are premiums
start new to this Plan, your coverage and premiums begin on the first day
of your first pay period that starts on or after January 1.
Annuitants'
premiums begin on January 1.
Your medical and claims We will keep your medical and claims
information confidential. records are confidential Only the following
will have access to it:
° OPM, this Plan, and subcontractors when they
administer
this contract;
° This Plan, and appropriate third
parties, such as other insurance
plans and the Office of Workers'
Compensation Programs (OWCP),
when coordinating benefit payments and
subrogating claims;
° Law enforcement officials when investigating and/
or prosecuting
alleged civil or criminal actions;
° OPM and the
General Accounting Office when conducting audits;
° Individuals involved
in bona fide medical research or education
that does not disclose your
identity; or
° OPM, when reviewing a disputed claim or defending
litigation
about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the
last five years of your Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such
as
temporary continuation of coverage (TCC).
When you lose benefits ° When FEHB coverage ends You will receive
an additional 31 days of coverage, for no additional
premium, when:
° Your enrollment ends, unless you cancel your enrollment, or
°
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation
of Coverage.
° Spouse equity If you are divorced from a Federal employee or
annuitant, you may
coverage not continue to get benefits under your
former spouse's enrollment.
But, you may be eligible for your own FEHB
coverage under the
spouse equity law. If you are recently divorced or are
anticipating a
divorce, contact your ex-spouse's employing or retirement
office to
get RI 70-5, the Guide to Federal Employees Health Benefits
Plans
for Temporary Continuation of Coverage and Former Spouse
Enrollees, or other information about your coverage choices.
° TCC If you leave Federal service, or if you lose coverage
because you no
longer qualify as a family member, you may be eligible for
Temporary Continuation of Coverage (TCC). For example, you can
receive
TCC if you are not able to continue your FEHB enrollment
after you retire.
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. 44
44 Page 45 46
2001 Group Health Cooperative of South Central
Wisconsin Section 11 45
° 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 If you leave the FEHB Program, we will give
you a Certificate of Group Health Plan Coverage 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.
Inspector General Advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has
charged you for services you did not receive, billed you twice
for
the same service, or misrepresented any information, do
the
following:
° Call the provider and ask for an explanation. There may be an error.
° If the provider does not resolve the matter, call us at 608/ 251-3356
x4504 and explain the situation.
° If we do not resolve the issue,
call THE HEALTH CARE
FRAUD HOTLINEÑ 202/ 418-3300 or write to:
The United States Office of Personnel Management,
Office of the
Inspector General Fraud Hotline,
1900 E Street, NW, Room 6400, Washington,
DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can
be prosecuted for fraud. Also, the Inspector General
may investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your agency may
also
take administrative action against you. 45
45
Page 46 47
Index
Do not rely on this page; it is for your convenience and
does not explain your benefit coverage.
2001 Group Health Cooperative of South Central Wisconsin Index 46
Accidental injury 33
Allergy tests 16
Allogeneic (donor)
bone marrow
transplant 23
Alternative treatment 19
Ambulance 25, 27
Anesthesia 23
Autologous bone marrow
transplant 23
Biopsies
21
Blood and blood plasma 25
Breast cancer screening 14
Casts
21
Changes for 2001 7
Chemotherapy 16
Childbirth 15
Chiropractic 19
Cholesterol tests 14
Claims 35
Coinsurance 11,
42
Colorectal cancer screening 14
Congenital anomalies 21, 22
Contraceptive devices
and drugs 15
Coordination of benefits 38
Covered charges 42
Covered providers 5, 8
Crutches 19
Deductible 11, 42
Definitions 42
Dental care 33
Diagnostic services 13
Disputed claims review 36
Donor expenses
(transplants) 23
Dressings 24
Durable medical equipment
(DME) 19
Educational classes
and programs 20
Effective date of
enrollment 44
Emergency 26
Experimental or
investigational 42
Eyeglasses 17
Family planning 15
Fecal occult blood test 14
Foot care 18
General Exclusions 34
Hearing services 17, 32
Home health services 19
Hospice care
25
Home nursing care 19
Hospital 9
Immunizations 14, 15
Infertility 16
In hospital physician care 13
Inpatient Hospital
Benefits 24
Insulin 19
Laboratory and pathological
services
14
Machine diagnostic tests 14
Magnetic Resonance Imagings
(MRIs) 14
Mammograms 14
Maternity Benefits 15
Medicaid 41
Medicare 38
Members 43
Mental Conditions/
Substance Abuse
Benefits 28
Newborn care 13
Nurse
Licensed Practical Nurse 19
Nurse Anesthetist 24
Nurse Practitioner 8
Registered Nurse 19
Nursery charges 15
Obstetrical care 15
Occupational therapy
17
Office visits 13
Oral and maxillofacial surgery 22
Orthopedic
devices 18
Orthotics 18
Ostomy and catheter supplies 19
Out-of-pocket expenses 4
Outpatient facility care 25
Oxygen 19
Pap test 14
Physical examination 14
Physical therapy 17
Physician 5, 8
Physicians' Assistant 8
Preadmission testing 25
Preventive care, adult 14
Preventive care, children 15
Prescription
drugs 30
Preventive services 14, 15
Prior approval 10
Prostate cancer
screening 14
Prosthetic devices 18
Radiation therapy 16
Rehabilitation therapies 17
Room and board 24
Second surgical
opinion 13
Skilled nursing facility care 25
Smoking cessation 20
Speech therapy 17
Splints 24
Sterilization procedures 15, 21
Subrogation 41
Substance abuse 28
Surgery 21
° Anesthesia 23
° Oral 22
° Outpatient 25
° Reconstructive 22
Syringes 51
Temporary continuation
of coverage 44
Transplants 23
Treatment therapies 16
Vision services 17
Well child care 15
Wheelchairs 19
Workers' compensation 41
X-rays 14 46
46 Page
47 48
2001 Group Health Cooperative of
South Central Wisconsin Benefit Summary 47
Summary of benefits for
Group Health Cooperative -2001
° Do not rely on this chart alone.
All benefits are provided in full unless indicated and are subject to the
definitions,
limitations, and exclusions in this brochure. On this page we
summarize specific expenses we cover; for more
detail, look inside.
° If you want to enroll or change your enrollment in this Plan, be sure
to put the correct enrollment code from the cover
on your enrollment form.
° We only cover services provided or arranged by Plan physicians, except
in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
° Diagnostic and treatment services provided in the office Office visit
copay: $10 primary care; 13
$10 specialist
Services provided by a hospital:
° Inpatient Nothing 24
° Outpatient Nothing 25
Emergency benefits:
° In-area Nothing 27
° Out-of-area Nothing 27
Mental health and substance abuse treatment Regular cost sharing 28
Prescription drugs Nothing 30
Dental CareÑ Preventive dental care
Nothing if by a Participating dentist; 33
50% if by a non-Participating
dentist
ÑAccidental injury benefit Nothing
Vision Care Ñ One refraction annually Nothing 17
Special features:
Services for deaf and hearing impaired; Reciprocity benefit; and Centers of
excellence 32
for transplants/ heart surgery, etc.
Protection against catastrophic costs We do not have an out-of-pocket 11
(your out-of-pocket maximum) maximum 47
47
Page 48
2001 Group Health Cooperative
of South Central Wisconsin Premium Page 48
2001 Rate Information for
Group Health Cooperative of South Central Wisconsin
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 Postal Service employees. Most
employees should refer to the FEHB Guide for United
States Postal Service
Employees, RI 70-2. Different postal rates apply and special FEHB guides are
published for Postal
Service Nurses and Tool and Die employees (see RI
70-2B); and for Postal Service Inspectors and Office of Inspector
General
(OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal
employee organization. Refer to the
applicable FEHB Guide.
Non-Postal premium Postal Premium
Biweekly Monthly Biweekly
Type
of Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share
Share Share
Self Only WJ1 $74.63 $24.87 $161.89 $53.89 $88.31 $11.19
Self and Family
WJ2 $195.82 $69.76 $424.28 $151.14 $231.17 $34.41 48