Health Plan of Nevada http:// www.
sierrahealth. com
2001 A Health Maintenance Organization
with a
point of service product
Serving: Clark, Nye, Mineral and Lyon Counties and parts of Washoe
County
Enrollment in this Plan is limited; see page 5
for requirements.
Enrollment codes for this Plan:
NM1 Self Only NM2 Self and Family
For changes in benefits
see page 7.
2001 Heath Plan of Nevada, Inc. 2 Table of Contents
Table of Contents
Introduction
.....................................................................................................................................................................................
4
Plain
Language.................................................................................................................................................................................
4
Section 1. Facts about this HMO
plan.........................................................................................................................................
5
We also have point-of service (POS) benefits
........................................................................................................
5
How we pay
providers.................................................................................................................................................
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
.........................................................................................................................................................
9
· 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..................................................................................................................................
12
Section 5. Benefits
........................................................................................................................................................................
13
Overview......................................................................................................................................................................
13
(a) Medical services and supplies provided by
physicians and other health care professionals ............ 14
(b) Surgical and anesthesia services provided by physicians
and other health care professionals ........ 25
(c)
Services provided by a hospital or other facility, and ambulance services
.......................................... 29
(d)
Emergency services/ accidents
.....................................................................................................................
32
(e) Mental health and substance abuse
benefits..............................................................................................
34
(f) Prescription drug benefits
.............................................................................................................................
36
(g) Special
features...............................................................................................................................................
39
(h) Dental benefits
................................................................................................................................................
40
(i) Point of service product
................................................................................................................................
41 2
2 Page 3 4
2001 Heath Plan of Nevada, Inc. 3 Table of Contents
(j) Non-FEHB benefits available to Plan members
.......................................................................................
44
Section 6. General exclusions --things we don't
cover...........................................................................................................
45
Section 7. Filing a claim for covered services
.........................................................................................................................
46
Section 8. The disputed claims process
....................................................................................................................................
47
Section 9. Coordinating benefits with other
coverage............................................................................................................
49
When you have...
· Other health
coverage.......................................................................................................................................
49
· Original Medicare
.............................................................................................................................................
49
· Medicare Managed Care
Plan.........................................................................................................................
51
TRICARE/ Workers'Compensation/ Medicaid
.......................................................................................................
52
Other Government agencies
.....................................................................................................................................
52
When others are responsible for
injuries................................................................................................................
52
Section 10. Definitions of terms we use in this
brochure.......................................................................................................
53
Section 11. FEHB
facts................................................................................................................................................................
54
Coverage
information................................................................................................................................................
54
· No pre-existing condition
limitation..............................................................................................................
54
· Where you get information about enrolling in the FEHB
Program.......................................................... 54
· Types of coverage available for you and your family
................................................................................
54
· When benefits and premiums
start.................................................................................................................
55
· Your medical and claims records are
confidential.......................................................................................
55
· When you retire
.................................................................................................................................................
55
When you lose
benefits.............................................................................................................................................
55
· When FEHB coverage
ends............................................................................................................................
55
· Spouse equity coverage
..................................................................................................................................
55
· Temporary Continuation of Coverage
(TCC)..............................................................................................
55
· Converting to individual
coverage.................................................................................................................
56
· Getting a Certificate of Group Health Plan Coverage
................................................................................
56
Inspector General advisory: Stop health care
fraud!............................................................................................
56
Index.................................................................................................................................................................................................
57
Summary of
benefits......................................................................................................................................................................
59
Rates
.................................................................................................................................................................................
Back cover 3
3 Page
4 5
2001 Health Plan of Nevada, Inc. 4 Introduction/ Plain Language
Introduction
Health Plan of Nevada P. O. Box 15645
Las
Vegas, NV 89114-5645
This brochure describes the benefits of Health Plan of
Nevada under our contract (CS 1942) 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 Health
Plan of Nevada.
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 Health Plan of Nevada, Inc. 5 Section 1
Section 1.
Facts about this HMO plan
This Plan is a health maintenance organization
(HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health
care services.
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.
We also
have Point-of-Service (POS) benefits:
Our HMO offers Point-of-Service
(POS) benefits. This means you can receive covered services from a participating
provider without a required referral, or from a non-participating provider.
These out-of-network benefits have higher out-of-
pocket costs than our
in-network benefits.
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.
When we contract with a doctor or medical group to provide
health care services, the contract specifies the amount the doctor or medical
group will be paid for providing services— either on a fixed monthly basis
or as a payment per service
provided. In some cases, we and the doctor or
group agree upon financial goals based in part on the expected use of special
services by patients of the doctor who belong to our plan. These special
services may include referrals to
specialists, lab tests, and hospital
admissions. These types of arrangements are known as incentive plans. In most
incentive plans, the health plan retains a portion of this money. At the end
of the year, if the doctor or medical group meets the budgeted goals, the health
plan may give part or all of the withheld money to the doctor or medical group.
We have several types of payment arrangements with our doctors:
Arrangement A: Your doctor may be part of a contracted medical group and may
receive a salary. Some medical groups
may pay their doctors a bonus.
Arrangement B: Your doctor may receive a fixed amount of money each month,
called a "capitation" to provide services
to all Health Plan
patients they see. Capitation may be considered to be an incentive plan.
Arrangement C: Your doctor may be paid a pre-determined amount for each
service he/ she provides. The plan may
designate a separate amount of money
to pay for special services (as described above). At the end of the year, that
money may be paid to the doctor or medical group, depending upon the management
and use of special services.
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 available to you . Some of the required information is listed
below. 5
5 Page 6 7
2001 Health Plan of Nevada, Inc. 6 Section 1
·
Health Plan of Nevada, Inc. has operated as a mixed model HMO in Nevada for 18
years. We are accredited by
NCQA, the organization that reviews HMO's. We
were re-reviewed by NCQA in March of 2000, and have received a commendable
accreditation.
· We understand the importance of getting your questions answered.
Whether you need an answer to a benefit question or have a concern about a
claim, or need help in selecting a provider, we are available Monday through
Friday, 8am to 5pm at (702) 242-7300 or (800) 777-1840.
· At times, services requested on your behalf by your provider may not
be approved by Health Plan of Nevada, Inc. The decision to deny coverage for
services requested, courses of treatment or inpatient care is made by a
physician.
These denials are based upon medical necessity, benefit coverage
and your individual needs. Written notification of the denial will be sent to
you, your primary care physician and the provider who requested the service. You
have the
right to appeal these decisions.
If you want more information
about us, call (702)-242-7300 or (800)-777-1840 or write to Health Plan of
Nevada, P. O. Box 15645, Las Vegas, NV 89114-5645. You may also contact us by
fax at (702) 242-9350 or visit our website at
www. sierrahealth. com.
Service Area
To enroll with us, you must live or work in our service area. This is
where our providers practice. Our service area is:
The Nevada counties of
Clark, Nye, Mineral and Lyon. Portions of Washoe County in Nevada are also
within the service area, as indicated by the zip codes: 89431, 89432, 89433,
89434, 89435, 89436, 89442, 89501, 89502, 89503, 89504,
89505, 89506, 89507,
89509, 89510, 89511, 89512, 89513, 89515, 89520, 89523, 89533, 89570.
Ordinarily, you must get your care from the providers who contract with us.
If you receive care outside our service area, we will pay only for emergency
care or point-of-service benefits. 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
fee-for-service
plan or an HMO that has agreements with affiliates in other
areas. If you or a family member move, you do not have to wait until Open Season
to change plans. Contact your employing or retirement office. 6
6 Page 7 8
2001 Health Plan of Nevada, Inc. 7 Section 2
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 deductibles, 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 Health Plan of Nevada, Inc. at (702) 242-7300 or
(800) 777-1840 or checking our website
www. sierrahealth. 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 tests 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 21.4% for self only, and 21.5% for self and family.
· Copayments for prescriptions have changed for this plan. You will
now pay a $5 copayment for generic drugs that
are on our formulary. You will
pay a $20 copayment for brand name drugs that are on our formulary. For drugs
not on our formulary, you will pay a $35 copayment.
· We reduced our service area by eliminating Mohave County. 7
7 Page 8 9
2001 Health Plan of Nevada, Inc. 8 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. 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 (702) 242-7300
or (800) 877-1840.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments,
and/ or coinsurance, and you will not have to file claims. If
you use our
point-of-service program, you can also get care from non-Plan
providers, or
from participating providers without a required referral, but it will cost you
more.
· Plan providers Plan providers are physicians and other health
care professionals in our service area that we contract with to provide covered
services to our
members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
· 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 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.
This plan has a provider director, which we urge you to
review before choosing your primary care physician
· Primary Care Your primary care physician can be a family
practitioner, pediatrician, Obstetrician/ Gynecologist or internist. 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. 8
8 Page
9 10
2001 Health Plan of Nevada, Inc.
9 Section 3
· Specialty care Your primary care
physician will refer you to a specialist for needed care. However, women may see
their Obstetrician/ Gynecologist without a referral.
Referrals to specialty
providers not listed in the plan's directory must be
arranged by your PCP
and will only be allowed if services are not available through plan providers.
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 work with the plan
and your specialist to develop a treatment plan that allows you to
see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating
your treatment plan (the physician may have to get an authorization or
approval beforehand).
· If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does not
participate with our Plan.
· If you are seeing a specialist and your specialist leaves the Plan,
call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we
can make arrangements for you to see someone else.
· If you have a chronic or disabling condition and lose access to your
specialist because we:
·· terminate our contract with your specialist for other than
cause; or
·· drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
·· reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of the
Program, contact your new plan.
If you are in the second or third
trimester of pregnancy and you lose access to your specialist based on the above
circumstances, you can continue to see
your specialist until the end of your
postpartum care, even if it is beyond the
90 days.
· Hospital Care Your Plan primary care physician or specialist
will make necessary hospital arrangements and supervise your care. This includes
admission to a skilled
nursing or other type of facility.
If you are in
the hospital when your enrollment in our Plan begins, call our customer service
department immediately at (702)-242-7300 or (800)-777-
1840. If you are new
to the FEHB Program, we will arrange foCould not acquire words on page 10 r you
to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until: 9
9 Page 10 11
10 Page 11 12
2001 Health Plan of Nevada 11 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
· Copayments A
copayment is a fixed amount of money you pay to the provider when you receive
services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit and when you go in the hospital, you pay $100 per
day, not
to exceed $200 per admission.
· Deductible A deductible is a fixed expense you must incur for
certain covered services and supplies before we start paying benefits for them.
Copayments do not
count toward any deductible. We do not have a deductible
for HMO coverage, but your point of service benefit does include a deductible.
· The calendar year deductible is $220 per person for Point of Service
benefits. Under a family enrollment, the deductible is considered satisfied
and benefits are payable for all family members when the combined
covered expenses applied to the calendar year deductible for family members
reach $750.
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.
And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your old
option to any deductible of your new option.
· Coinsurance Coinsurance is the percentage of our negotiated
fee that you must pay for your care. Coinsurance doesn't begin until you meet
your deductible.
Example: In our Plan, you pay 50% of our allowance for
infertility services and durable medical equipment. You also pay 20% of our
allowance for
most services obtained under the point of service benefit. 11
11 Page 12 13
2001 Health Plan of Nevada 12 Section 4
Your out-of-pocket maximum for deductibles, copayments and
co-insurance
After your copayments total $3,320 per person or $7,804 per family enrollment
in any calendar year, you do not have to pay any more for
covered services
After you have met the calendar year deductible for point of service
benefits, if your coinsurance payments total $1,500 per person or $ 4,500
per family enrollment in any calendar year, you do not have to pay any
more for covered services.
Be sure to keep accurate records of your
co-payments and coinsurance payments since you are responsible for informing us
when you reach the
maximum. 12
12 Page 13 14
2001 Health Plan of Nevada 13 Section 5
Section 5.
Benefits --OVERVIEW
(See page 7 for how our
benefits changed this year and page 59 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
subsection. To obtain claims
forms, claims filing advice, or more information about our benefits, contact us
at (702) 242-7300 or (800) 777-1840 or at our website at www. sierrahealth. com
(a) Medical services and supplies provided by
physicians and other health care professionals ..............................
14-24
· Diagnostic and treatment services
· Lab, X-ray,
and other diagnostic tests
· Preventive care, adult
·
Preventive care, children
· Maternity care
· Family
planning
· Infertility services
· Allergy care
· Treatment therapies
· Rehabilitative therapies
· Hearing services (testing, treatment, and supplies)
·
Vision services (testing, treatment, and supplies)
· Foot care
· Orthopedic and prosthetic devices
· Durable medical
equipment (DME)
· Home health services
· Alternative
treatments
· Educational classes and programs
(b) Surgical and anesthesia services provided by
physicians and other health care professionals ........................... 25-28
· Surgical procedures
· Reconstructive surgery
· Oral and maxillofacial surgery
· Organ/ tissue
transplants
· Anesthesia
(c) Services provided by a hospital or other facility,
and ambulance services
............................................................. 29-31
·
Inpatient hospital
· Outpatient hospital or ambulatory surgical
center
· Extended care benefits/ skilled nursing care facility benefits
· Hospice care
· Ambulance
(d) Emergency services/ accidents
.........................................................................................................................................
32-33
· Medical emergency · Ambulance
(e)
Mental health and substance abuse
benefits................................................................................................................
34-35
(f) Prescription drug benefits
...............................................................................................................................................
36-38
(g) Special
features.......................................................................................................................................................................
39
· Flexible Benefits Option · 24 Hour Nurse Hotline
· Services for the deaf and hearing impaired · Preventive
Healthcare/ Disease Management
· Centers of Excellence
(h) Dental benefits
........................................................................................................................................................................
40
(i) Point of service benefits
..................................................................................................................................................
41-43
(j) Non-FEHB benefits available to Plan members
...............................................................................................................
44
Summary of
benefits......................................................................................................................................................................
59 13
13 Page
14 15
2001 Health Plan of Nevada, Inc. 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically
necessary.
· Plan physicians
must provide or arrange your care.
· Be sure to read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
· In physician's office
$10 per office visit
Professional services of physicians
· In an urgent care center
· During a hospital stay
· In a skilled nursing facility
· Initial examination of a newborn child covered under a family
enrollment
· Office medical consultations
· Second surgical opinion
$10 per office visit
At home $20 per visit
Diagnostic and treatment services --Continued on
next page 14
14 Page
15 16
2001 Health Plan of Nevada, Inc.
15 Section 5( a)
Diagnostic and treatment services
(Continued) You pay
Lab, X-ray and other diagnostic tests
Tests, such as:
· Blood tests
· Urinalysis
·
Non-routine Pap tests
· Pathology
· X-rays
·
Non-routine Mammograms
· CAT Scans/ MRI
· Ultrasound
· Electrocardiogram EEG
Nothing if you receive these services during your office visit;
For
services not received during
your office visit, you pay $5 per procedure for
complex diagnostic
services (e. g. EEG, Nuclear Scans,
MRI), You pay nothing for simple
diagnostic services (e. g. EKG,
ultrasound).
Preventive care, adult
Routine screenings, such as:
·
Blood lead level – One annually
· Total Blood Cholesterol
– once every three years, ages 19 through 64
· Colorectal
Cancer Screening, including
·· Fecal occult blood test
$10 per office visit
·· Sigmoidoscopy, screening – every five years starting
at age 50 $10 per office visit
Prostate Specific Antigen (PSA test) –
one annually for men age 40 and older $10 per office visit
Routine Pap test
Note: The office visit is covered if Pap test is received on the same day;
see Diagnostic and Treatment Services, above.
$10 per office visit 15
15 Page 16 17
2001 Health
Plan of Nevada, Inc. 16 Section 5( a)
Preventive care, adult
(Continued) You pay
Routine mammogram –covered for
women age 35 and older, as follows:
· From age 35 through 39, one during this five year period
· From age 40 through 64, one every calendar year
· At age
65 and older, one every two consecutive calendar years
$10 per office visit
Not covered: Physical exams or immunizations required for obtaining or
continuing employment or insurance, attending schools or camp, or
travel.
All charges.
Routine Immunizations, limited to:
· Tetanus-diphtheria (Td)
booster – once every 10 years, ages19 and over (except as provided for
under Childhood immunizations)
· Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit No charge at immunization clinics.
Preventive care, children
· Childhood immunizations
recommended by the American Academy
of Pediatrics
$10 per office visit
No charge at immunization clinics.
· 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)
$10 per office visit 16
16 Page 17 18
2001 Health
Plan of Nevada, Inc. 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
· Prenatal
care
· Delivery
· Postnatal care
Note: Here are some
things to keep in mind:
· You do not need to precertify your normal
delivery; see page 9 for other circumstances, such as extended stays for you or
your baby.
· You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary.
· We cover routine nursery care of
the newborn child during the covered portion of the mother's maternity stay. We
will cover other
care of an infant who requires non-routine treatment only if we cover
the
infant under a Self and Family enrollment.
· We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
$10 per office visit
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
· Voluntary sterilization
· Surgically implanted contraceptives
· Injectable
contraceptive drugs
· Intrauterine devices (IUDs)
Note: See Section 5( f) for prescription drug coverage.
Note: Other
co-pays may apply for surgical services. See section 5( b).
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges. 17
17 Page 18 19
2001 Health
Plan of Nevada, Inc. 18 Section 5( a)
Infertility services You
pay
Diagnosis and treatment of infertility, such as:
·
Artificial insemination:
·· intravaginal insemination (IVI)
·· intracervical insemination (ICI)
··
intrauterine insemination (IUI)
$10 per office visit
Not covered:
· Assisted reproductive technology (ART)
procedures, such as:
·· in vitro fertilization
·· embryo transfer and GIFT
·
Services and supplies related to excluded ART procedures
· Injectible and oral fertility drugs
· Cost of
donor sperm
All charges.
Allergy care
Testing and treatment
Allergy injection
$5
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges. 18
18 Page 19 20
2001 Health Plan of Nevada, Inc. 19 Section 5( a)
Treatment therapies You pay
· Chemotherapy and
radiation therapy
Note: High dose chemotherapy in association with
autologous bone marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 28.
·
Respiratory and inhalation therapy
· Dialysis – Hemodialysis
and peritoneal dialysis
· Intravenous (IV)/ Infusion Therapy –
Home IV and antibiotic therapy
· Growth hormone therapy (GHT)
Note: – We will only cover GHT when we prior authorize the treatment.
Call (702) 242-7300 or (800) 777-1840 for prior authorization. We will ask
you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin
treatment;
otherwise, we will only cover GHT services from the date you submit the
information. If you do not ask or if we determine GHT
is not medically necessary, we will not cover the GHT or related
services
and supplies. See Services requiring our prior approval in
Section 3.
GHT is covered under the pharmacy benefit. See page 37 for
additional
information on pharmacy coverage
$10 per office visit
$10 per office visit
$10 per office visit
$10 per office visit
See page 37 for information on
pharmacy coverage.
Not covered:
Sports medicine treatment plan intended to primarily
improve athletic ability
All charges. 19
19
Page 20 21
2001
Health Plan of Nevada, Inc. 20 Section 5( a)
Rehabilitative
therapies You pay
Physical therapy, occupational therapy and speech
therapy --
· 2 consecutive months per condition for the services of
each of the
following:
·· 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.
· Cardiac
rehabilitation is provided for up to 30 days following a heart transplant,
bypass surgery or a myocardial infarction.
Cardiac rehabilitation is not covered unless provided in a
physician-monitored program.
$10 per office visit
$10 per office visit
Not covered:
· Long-term rehabilitative therapy
·
exercise programs
· Milieu therapy, behavior modification,
sensitivity training, electrohypnosis, electrosleep therapy, electronarcosis,
narcosynthesis, rolfing, residential treatment, vocational
rehabilitation or wilderness programs
All charges.
Hearing services (testing, treatment, and supplies)
· First
hearing aid and testing only when necessitated by accidental
injury
· Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered:
· all other hearing testing
· hearing aids, testing and examinations for them
All charges. 20
20 Page 21 22
2001 Health
Plan of Nevada, Inc. 21 Section 5( a)
Vision services
(testing, treatment, and supplies) You pay
· One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit
· Eye exam to determine the need for vision correction for children
through age 17 (see preventive care)
· Annual eye refractions
$10
per office visit
Not covered:
· Eyeglasses, frames or contact lenses,
including fitting of lenses
· Eye exercises and orthoptics
· Radial keratotomy and other refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
· Cutting, trimming or removal of corns,
calluses, or the free edge of
toenails, and similar routine treatment of
conditions of the foot, except as stated above
· Treatment of weak, strained or flat feet or bunions or spurs; and
of
any instability, imbalance or sublaxation of the foot (unless the
treatment is by open cutting surgery)
2001 Health Plan of Nevada, Inc. 22 Section 5( a)
Orthopedic and prosthetic devices You pay
· Artificial
limbs and eyes; stump hose
· Externally worn breast prostheses and
surgical bras, including necessary replacements, following a mastectomy
· Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast
implant following mastectomy. Note: See 5( b) for coverage of the surgery to
insert the
device.
· Corrective orthopedic appliances for non-dental
treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
Note: orthopedic and prosthetic devices are limited to a combined HMO/ POS
lifetime maximum of $10,000 including repairs, except
externally worn breast
prostheses and surgical bras, including necessary replacements, following a
mastectomy.
Nothing, however, limited to a
$10,000 combined HMO/ POS lifetime maximum
50% of our plan allowance.
Coverage of services and devices for treatment
of TMJ is limited to
$2,500 per member per year.
Not covered:
· orthopedic and corrective shoes
· arch supports
· foot orthotics
· heel pads and heel cups
· lumbosacral
supports
· corsets, trusses, elastic stockings, support hose,
and other supportive
devices
· prosthetic replacements provided less than 3 years after the last
one we covered
All charges. 22
22 Page 23 24
2001 Health
Plan of Nevada, Inc. 23 Section 5( a)
Durable medical
equipment (DME) You pay
Rental or purchase, at our option, including
repair and adjustment, of
durable medical equipment prescribed by your Plan
physician, and prior authorized by the Plan such as oxygen and dialysis
equipment. Under
this benefit, we also cover:
· hospital beds;
·
wheelchairs;
· crutches;
· walkers;
· blood
glucose monitors; and
· insulin pumps.
Note: Call us at (702)
242-7300 or (800) 777-1840 as soon as your Plan physician prescribes this
equipment. All DME must be
medically necessary and prior authorized by the Plan to be covered.
50% of our plan allowance
Combined HMO/ POS maximum benefit of $4000 per
member per
calendar year.
Not covered:
· Motorized wheel chairs
·
Outpatient oxygen and its administration unless prior authorized
All charges.
Home health services
· Home health care ordered by a Plan
physician and provided by a
registered nurse (R. N.), licensed practical
nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.
· Services include oxygen therapy, intravenous therapy and
medications.
Nothing
Not covered:
· nursing care requested by, or for the
convenience of, the patient or
the patient's family;
·
nursing care primarily for hygiene, feeding, exercising, moving the patient,
homemaking, companionship or giving oral medication
.
All charges.
Alternative treatments
Chiropractic services for manual
manipulation of the spine (except for reductions of fractures or dislocations)
$10 per office visit
Not covered:
· acupuncture
·
naturopathic services
· hypnotherapy
·
biofeedback
All charges. 23
23 Page 24 25
2001 Health
Plan of Nevada, Inc. 24 Section 5( a)
Educational classes and
programs
Coverage is limited to:
· Smoking Cessation –
Up to $100 for one smoking cessation program
per member per lifetime,
including all related expenses such as drugs.
· Diabetes self-management –includes coverage for medication,
equipment, supplies and appliances for treatment of diabetes. Diabetes
includes type I, type II and gestational diabetes. Covered
services include training and education for:
· The care and management of diabetes after an initial diagnosis,
including counseling in nutrition and the proper use of equipment and
supplies;
· Necessary because of a significant change in your symptoms or
condition which requires a modification of self management program;
· Necessary because of the development of new techniques or
equipment for the treatment of diabetes.
$10 per office visit
$10 per office visit $5 per educational site visit
24
24 Page 25 26
2001 Health Plan of Nevada, Inc. 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
· Plan physicians must provide or arrange your care.
· Be
sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with
Medicare.
· The amounts listed below are for the charges billed by
a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e.
hospital,
surgical center, etc.).
· YOU MUST GET PRIOR AUTHORIZATION OF SURGICAL PROCEDURES. Please refer to the
prior authorization information shown in Section 3 to be sure which services
require prior
authorization and identify which surgeries require prior authorization
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
Surgical procedures
· Treatment of fractures, including
casting
· Normal pre-and post-operative care by the surgeon
· 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 obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according
to current underwriting standards; eligible members must
be age 18 or over. Surgical treatment of morbid obesity is covered
only
when authorized and only as a treatment of last resort.
· Insertion of internal prosthetic devices. See 5(
a) – Orthopedic braces and prosthetic devices for device coverage
information.
$10 per office visit, plus $5 per procedure
$50 per outpatient facility
visit, plus $50 per procedure
$100 per inpatient visit, plus
$100 per
procedure
Surgical procedures continued on next page. 25
25 Page 26 27
2001 Health Plan of Nevada, Inc. 26 Section
5( b)
Surgical procedures (Continued) You pay
· Voluntary sterilization
· Norplant (a surgically
implanted contraceptive) and intrauterine devices (IUDs) Note: Devices are
covered under 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.
$10 per office visit, plus
$50 per procedure
$50 per outpatient facility visit, plus $50 per procedure
$100 per inpatient visit, plus $100 per procedure
Not covered:
· Reversal of voluntary sterilization
· Routine treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
· Surgery to correct a functional
defect
· Surgery to correct a condition caused by injury or illness
if:
·· the condition produced a major effect on the member's
appearance and
·· the condition can reasonably be expected to be corrected by
such surgery
· Surgery to correct a condition that existed at or from
birth and is a
significant deviation from the common form or norm. Examples
of congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$10 per office visit, plus
$5 per procedure
$50 per outpatient facility visit, plus $50 per procedure
$100 per inpatient visit, plus $100 per procedure 26
26 Page 27 28
2001 Health Plan of Nevada, Inc. 27 Section
5( b)
Reconstructive surgery (Continued) You pay
· 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.
See above.
Not covered:
· Cosmetic surgery – any surgical
procedure (or any portion of a procedure) performed primarily to improve
physical appearance
through change in bodily form, except repair of accidental injury
· Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
· Reduction of fractures of the jaws or facial bones;
· Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
· Removal of stones from salivary ducts;
· Excision of leukoplakia or malignancies;
· Excision of
cysts and incision of abscesses when done as independent
procedures; and
· Other surgical procedures that do not involve the teeth or their
supporting structures.
$10 per office visit, plus $5 per procedure
$50 per outpatient facility
visit, plus
$50 per procedure
$100 per inpatient visit, plus $100 per procedure
Not covered:
· Oral implants and transplants
· Procedures that involve the teeth or their supporting
structures (such
as the periodontal membrane, gingiva, or alveolar bone)
· Surgical procedures that are dental in nature
·
Shortening of he mandible or maxillae for cosmetic purposes
All charges. 27
27 Page 28 29
2001 Health
Plan of Nevada, Inc. 28 Section 5( b)
Organ/ tissue
transplants You pay
Limited to:
· Cornea
· Heart
· Kidney
· Liver
· 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
Limited Benefits -Treatment for breast cancer, multiple
myeloma, and epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
$10 per office visit, plus $5 per procedure
$50 per outpatient facility
visit, plus
$50 per procedure
$100 per inpatient visit, plus $100 per procedure
Not covered:
· Donor screening tests and donor search
expenses, except those
performed for the actual donor
·
Implants of artificial organs
· Transplants not listed as covered
All charges
Anesthesia
Professional services provided in –
·
Hospital (inpatient)
· Hospital outpatient department
·
Skilled nursing facility
· Ambulatory surgical center
·
Physician Office
$10 per office visit 28
28 Page 29 30
2001 Health Plan of Nevada 29 Section 5( c)
Section 5
(c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and
exclusions in this brochure and are payable
only when we determine they are medically necessary.
· Plan physicians must provide or arrange your care and you must be
hospitalized
in a Plan facility.
· Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about
coordinating benefits with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by the
facility (i. e., hospital or surgical center) or ambulance service for your
surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Section 5( a) or (b).
· YOU MUST GET PRIOR AUTHORIZATION OF ELECTIVE
HOSPITAL STAYS.
Please refer to Section 3 to be sure which services require prior
authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
· ward, semiprivate, or intensive care accommodations;
· general nursing care; and
· meals and special diets.
NOTE: If you want a private room or special duty nursing when it is not
medically necessary, you pay the additional charge above the semiprivate
room rate.
$100 per day, to a maximum of $200 per admission
Inpatient hospital continued on next page. 29
29 Page 30 31
2001 Health Plan of Nevada 30 Section 5( c)
Inpatient hospital (Continued) You pay
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
$100 per surgical procedure to a maximum of $200 per admission
Not covered:
· Custodial care
·
Non-covered facilities
· Personal comfort items, such as
telephone, television, barber services, guest meals and beds
· Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
·
Operating, recovery, and other treatment rooms
· 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.
$50 per visit
Not covered: blood and blood derivatives not replaced by the member All
charges 30
30 Page
31 32
2001 Health Plan of Nevada
31 Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You pay
Skilled nursing facility (SNF), including :
· Bed, board and general nursing care
· Drugs,
biologicals, supplies and equipment ordinarily provided by the skilled nursing
facility when prescribed by a plan doctor
$100 per day, up to a maximum of $200 per admission
Not covered: custodial care All charges
Hospice care
Supportive and palliative care for terminally ill members is covered in
the home or in a hospice facility. Covered Services include:
Inpatient and outpatient care and counseling
Outpatient bereavement counseling for each family member upon the death of a
terminally ill member up to a maximum of 5 group therapy
visits or $500 in
benefits per calendar year, whichever is less.
Outpatient Respite care for
family members of a terminally ill member, up to a maximum benefit of $1,000 per
calendar year.
Inpatient Respite care for a terminally ill member, up to a maximum benefit
of $1,500 per calendar year.
$100 per day, up to a maximum of $200 per admission.
$20 per visit
Nothing
$100 per day, up to a maximum
of $200 per admission
Not covered: Independent nursing, homemaker services All charges
Ambulance
· Local professional ambulance service when
medically appropriate and ordered or authorized by a plan physician $25 per trip
31
31 Page 32 33
2001 Health Plan of Nevada 32 Section 5( d)
Section 5
(d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
· Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including
with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more
serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially life
threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for
quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
physician. In extreme emergencies, if you are unable to contact your physician,
contact your
local emergency system (e. g. 911) or go to the nearest
hospital emergency room. Be sure to tell the
emergency personnel that you
are a plan member so they can notify the plan. You or a family member must
notify the Plan within 48 hours, unless it was not reasonably possible to do so.
It is your
responsibility to ensure that the Plan receives timely notification.
You may also receive care at the Plan's 24 hour Urgent Care Center at 888
South Rancho Drive, Las Vegas, NV. Benefits are available from non-Plan
providers in a medical emergency only if delay in
reaching a Plan provider
would result in death, disability or significant jeopardy to your condition.
To be covered by this plan, any follow-up care recommended by non-Plan
providers must be approved by
the plan or provided by Plan providers, except
as covered by your Point of Service benefit.
We pay reasonable and customary charges for emergency services to the extent
the services would have
been covered if received from plan providers.
Emergencies outside our service area: You are covered for any
medically necessary health service that is immediately required because of
injury or unforeseen illness. If you need to be hospitalized,
the Plan must
be notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If a Plan doctor believes care can be
provided in a Plan hospital, you
will be transferred when medically appropriate with any charges covered in full.
To be covered by this plan, any follow-up care recommended by non-Plan
providers must be approved by
the plan or provided by Plan providers except
as covered by your Point of Service benefit.
We pay reasonable and customary charges for emergency services to the extent
the services would have
been covered if received from plan providers. 32
32 Page 33 34
2001 Health Plan of Nevada 33 Section 5( d)
Benefit
Description You pay
Emergency within our service area
· Emergency care at a doctor's office
· Emergency care at
an urgent care center
· Emergency care as an outpatient or inpatient
at a hospital, including doctors' services
$25 per office visit
$15 per visit
$25 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
· Emergency care at
a doctor's office
· Emergency care at an urgent care center
· Emergency care
as an outpatient or inpatient at a hospital, including doctors' services
$25 per office visit
$15 per visit
$25 per visit
Not covered:
· Elective care or non-emergency care
· Emergency care provided outside the service area if the need
for care
could have been foreseen before leaving the service area
· Medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
$25 per ambulance trip
Not covered: air ambulance unless medically appropriate All charges.
33
33 Page 34
35
2001 Health Plan of Nevada 34 Section 5( e)
Section 5
(e). Mental health and substance abuse benefits
I
M
P
O
R
T
A
N
T
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.
· YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
I
M
P
O
R
T
A
N
T
Benefit Description You pay
After the calendar year deductible…
Note: The calendar year deductible applies to almost all benefits in this
Section. We say "No deductible" when it does not apply.
Mental
health and substance abuse benefits
Diagnostic and treatment services
recommended by a Plan provider and contained in a treatment plan that we
approve. The treatment plan
may include services, drugs, and supplies
described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive the
care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater
than for other illness
or conditions.
· Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
· Medication management
$10 per office visit
Network mental health and substance abuse benefits --Continued on next
page. 34
34 Page
35 36
2001 Health Plan of Nevada 35 Section 5( e)
Mental
health and substance abuse benefits (Continued) You pay
· Diagnostic tests $10 per office visit
· Services provided by a hospital or other facility
·
Services in approved alternative care settings such as partial hospitalization,
half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment.
$100 per day to a maximum of
$200 per admission
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order
us to pay or provide one
clinically appropriate treatment plan in favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
· Contacting Behavioral Healthcare Options (BHO) to make arrangements
to authorize medically necessary care. BHO may be
contacted at
(800)-873-2246. You may obtain more information on BHO by visiting their website
at
www.
behavioralhealthcareoptions. com
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under out plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following conditions:
· 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. 35
35 Page
36 37
2001 Health Plan of Nevada 36 Section 5( f)
Section 5
(f). Prescription drug benefits
I M
P
O R
T
A N
T
Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the
chart beginning on the next page.
· All benefits are subject to the definitions, limitations and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
· Be sure to read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating
benefits with other
coverage, including with Medicare.
I M
P
O R
T
A N
T
There are important features you should be aware of. These
include:
· Who can write your prescription? Except for
emergencies or services obtained from a non-plan provider accessed under the
point of service benefit, a plan physician or licensed dentist must write
the prescription.
· Where you can obtain them. You must
fill the prescription at a plan pharmacy, or by mail for
certain maintenance
medications. Medications available through mail order are limited to those
determined by the Plan to be maintenance medications. The list of maintenance
medications is
maintained by the Plan at its sole discretion.
· We use a
formulary. Our Formulary is a list of FDA approved Generic and Brand Name
medications developed and maintained by /the Plan. The Formulary is reviewed by
physicians and
pharmacists on a regular basis and may change throughout the year at the
Plan's sole discretion.
Patient needs, scientific data, drug effectiveness,
availability of drug alternatives currently on the Formulary, and cost are
considerations in selecting medications for inclusion on the Formulary.
Inclusion of drugs on the Formulary does not guarantee that your provider
will prescribe that
medication.
· These are the dispensing
limitations. A dispensing limitation is the quantity of a medication for
which benefits are available for a single applicable co-payment, or in the case
of maintenance drugs, two co-payments.
The dispensing limitation may be 1) a predetermined period of time
established by the Plan; or 2) a period of time that a specific medication is
recommended by the FDA to be an appropriate course
of treatment when
prescribed in connection with a particular condition. Dispensing limitations may
be
less than but shall not exceed a 30-day supply for drugs obtained at a
Plan Pharmacy. Maintenance drugs dispensing limitations may be for up to a
90-day supply provided the medication is on the plan
maintenance drug list. Prescriptions that exceed the dispensing limitations
established by the plan will
not be covered.
· When you have to file a claim. You normally won't have to
submit claims to us. If you do need to file a claim, please send us all of the
documents for your claim (including itemized billings) as soon as
possible.
You must submit claims by December 31 of the year after the year you received
the service. Either OPM or we can extend this deadline if you show that
circumstances beyond your control
prevented you from filing on time. Send
completed claims to Health Plan of Nevada Attn: Claims
Department, P. O. Box
15645, Las Vegas, NV 89114.
.
Prescription drug benefits begin on the next page. 36
36 Page 37 38
2001 Health Plan of Nevada 37 Section 5( f)
Benefit Description You pay After the calendar year
deductible…
Covered medications and supplies
We cover the
following medications and supplies prescribed by a Plan physician and obtained
from a Plan pharmacy or through our mail order
program:
· Drugs and medicines that by Federal law of the United
States require a physician's prescription for their purchase, except as
excluded below.
· Insulin (whole vials up to 40 ml)
·
Diabetic supplies, including insulin syringes, needles, blood
glucose
measuring strips, and urine checking reagents.
· Nitroglycerine, phenobarbital or Thyroid U. S. P. when prescribed in
quantities of 100, a single co-payment will apply.
· Vitamins which require a prescription
· Disposable
needles and syringes for the administration of covered medications
· Drugs for sexual dysfunction. Sexual dysfunction drugs have
specific dispensing limitations and require prior authorization by the Plan.
Contact the Plan for details.
· Contraceptive drugs and devices
· Smoking cessation drugs
and medication, including nicotine patches
$5 per generic prescription
$20 per brand name prescription
$35 for
non-formulary drugs
You pay two applicable co-payments for medications
obtained
through our mail order program
Note: If there is no generic equivalent
available, you will still
have to pay the brand name copay.
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 brand name. If you receive a name
brand drug when a Federally approved generic drug is
available, and your physician has not specified Dispense as
Written for
the brand name drug, you have to pay the difference in cost between the brand
name drug and the generic.
· We administer an open formulary. If your physician believes a
name brand product is necessary or there is no generic available, your
physician may prescribe a brand name drug from a formulary
list. This list of brand name 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 (702) 242-7300 or (800) 777-
1840. For drugs you obtain which are not included our formulary,
you will
pay the lesser of the cost of the drug or a $35 copayment. 37
37 Page 38 39
2001 Health Plan of Nevada 38 Section 5( f)
Not covered:
· Drugs and supplies for cosmetic purposes
· Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
· Nonprescription medicines
· Anorexic agents
· Injectible and oral prescription drugs to treat infertility
· Drugs to enhance athletic performance
·
Drugs obtained at a non-Plan pharmacy, except for out of area emergencies
All Charges 38
38 Page 39 40
2001 Health
Plan of Nevada 39 Section 5( g)
Section 5 (g). Special
Features
Feature Description
24 hour nurse line For any of your
health concerns, 24 hours a day, 7 days a week, you may call 1-( 800)-622-6252
and talk with a registered nurse who will
discuss treatment options and
answer your health questions.
Services for deaf and hearing impaired We have a TTY/ TDD number for
use by hearing impaired members. The TTY/ TDD number is (702)-242-8214 or
(800)-349-3538.
Preventive Health/ Disease Management · Health Plan of Nevada
offers numerous preventive health management programs to assist members with
early detecting and prevention of
serious illnesses. These programs promote
services such as childhood
immunizations, breast and cervical cancer
screenings, or prenatal care.
· HPN also offers disease management programs to assist members with
chronic conditions such as pediatric asthma, diabetes, and congestive heart
failure. These are comprehensive programs that usually include
patient education classes, specialty clinics, or case management
monitoring. 39
39 Page
40 41
2001 Health Plan of Nevada 40 Section 5( h)
Section 5
(h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this
brochure and are payable
only when we determine they are medically necessary.
· Plan dentists must provide, coordinate, or arrange your care.
· We cover hospitalization for dental procedures only when a
non-dental 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.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury. Outpatient and inpatient surgery and
inpatient admission co-payments for medical benefits also apply to
these
services.
$25 per emergency room visit
$10 per office visit
Dental benefits
We have no other dental benefits 40
40 Page 41 42
2001 Health Plan of Nevada 41 Section 5( i)
Section 5 (i). Point of service benefits
Point of Service (POS)
Benefits Facts about this Plan's POS option
At your option, you may
choose to obtain benefits covered by this Plan from non-Plan doctors and
hospitals whenever you need care, except for
the benefits listed below under "What is not covered." Benefits not
covered under Point of Service must either be received from or arranged by Plan
doctors to be covered. When you obtain covered non-emergency medical
treatment from a non-Plan doctor without a referral from a Plan doctor, you
are subject to the deductibles, coinsurance and maximum benefit stated
below.
What is covered · Physician services including primary care and
specialist office visits · Care and consultations received while
inpatient
· Preventive Healthcare (well child care, routine physical
exams and pap smear, routine diagnosis) subject to a maximum benefit of $100 per
member per calendar year
· Manual manipulation performed by a
chiropractor, D. O. or physical
therapist, subject to a maximum benefit of
$500 per member per calendar year and a $5,000 maximum lifetime benefit per
member
· Inpatient hospital services
· Outpatient hospital and
ambulatory surgical facility services
· Skilled nursing facility
services subject to a maximum benefit of 12 days per calendar year
· Surgical assistant services
· Anesthesia services
· Ambulance services (non-emergent)
· Laboratory services
· Routine outpatient radiological and non-radiological diagnostic
imaging services
· Diagnostic and therapeutic services including chemotherapy,
dialysis,
therapeutic radiology, allergy testing and serum injection,
otologic evaluations, complex diagnostic imaging, vascular diagnostic and
therapeutic services, pulmonary diagnostic services, neurological or
psychiatric testing
· Home health services, subject to a maximum
of the lesser of 30 visits or $5,000 per calendar year
· Prescription drugs (prescription drug fee)
· Durable
medical equipment, covered at 50% of plan allowance and a combined HMO/ POS
maximum benefit of $4,000 per member per
calendar year
· Enteral and special food products, subject to a
combined HMO/ POS maximum coverage limit of $2,500 per member per calendar year
· Self management and treatment of diabetes
· Short term
inpatient and outpatient rehabilitation services subject to a combined HMO/ POS
maximum coverage limit of two months per
condition
· Prosthetic and orthotic devices, including repairs,
subject to a combined HMO/ POS maximum coverage limit of $10,000 per calendar
year
· Mental health and substance abuse services 41
41 Page 42 43
2001 Health Plan of Nevada 42 Section 5( i)
Prior Authorization In order for services to be covered under
your Point of Service benefit, you must get prior authorization from the plan.
Failure to comply with the prior
authorization requirements may result in a
reduction of benefits. If you
obtain services without prior authorization
from the plan, payment will be reduced to 50% of plan allowance, up to a maximum
penalty of $500.
Services that require prior authorization under the Point of Service benefit
include:
· All elective inpatient admissions and extensions of stay
beyond the
original certified length of stay to a Hospital or Skilled
Nursing Facility;
· All outpatient surgery provided in any setting if
the charges exceed $200
· All outpatient tests, including technical
and professional services if the
charges exceed $200
· All
outpatient courses of treatment including, but not limited to: allergy testing/
treatment; angioplasty; chemotherapy; dialysis; manual
manipulation; radiation therapy; rehabilitation therapy.
Deductible Your calendar year deductible for point of service coverage
is $250 per member and $750 per family.
Coinsurance After the deductible is met, you pay 20% of the plan's
allowance, except for coverage of durable medical equipment, which is covered at
50% of the
plan's medical expenses. You will be responsible for your
coinsurance plus charges in excess of the Plan's allowance for all services
obtained
under the point of service benefit. The Plan's allowance is established with
reference to:
· The amount most consistently paid to the provider; or
·
The amount paid to other providers of similar qualifications; or
·
The relative value or worth of allowances for similar services comparable
in
severity and nature with reference to other industry and governmental sources
Your coinsurance maximum is limited to $1500 of the plan's allowance per
member per calendar year or $4500 per family per calendar year.
Maximum benefit The Point of service benefit is limited to a maximum
Plan payment of $2,000,000 per member per lifetime 42
42 Page 43 44
2001 Health Plan of Nevada 43 Section 5( i)
Hospital/
extended care For authorized care obtained from a non-participating
hospital, you pay 20% of the plan's allowance. Care accessed from participating
hospitals
using the POS benefit and non-plan doctor will be paid under the
terms of
this point of service benefit. The hospital charge, sometimes
called facility charge, does not cover any charges for doctors' services.
Emergency benefits Emergency care is always covered under the HMO
benefit.
What is not covered · Hospice care ·
Temporomandibular Joint Dysfunction treatment
· Sterilization
· Organ or Tissue Transplants
· Care or treatment of an
illness or injury caused by or arising out of riots,
wary, insurrection,
rebellion, armed invasion or aggression
· Any services for which a
claim is not received by the Plan within 12 months after the date services are
provided
How to obtain benefits Contact the Plan if you want to access services
under your point of service benefits. For services which may need prior
authorization, be prepared to
supply the provider name and number, the
service requested, the service date and your member number. Member services will
assist you in
submission of your prior authorization request. If you need to submit a
claim, follow the instructions for submission of a claim
outlined on page 46 of this brochure. 43
43
Page 44 45
2001
Health Plan of Nevada 44 Section 5( j)
Section 5 (j). Non-FEHB
benefits available to Plan members
The benefits on this page are not
part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB
deductibles or out-of-pocket maximums.
Health Plan of Nevada is pleased to
offer a Supplemental Dental program to FEHBP members with Dentists who have
agreed to participate in our dental program and provide dental care services to
members. You may obtain information
regarding this program by contacting us,
or by obtaining and enrollment packet during open season. Procedures not listed
on the benefit schedule are not covered. You are required to re-enroll every
year into the supplemental dental plan during
the open enrollment period.
Please refer to the supplemental dental information provided by the plan for
further
information on this program, including premiums, what is covered
under the supplemental program and limitations and exclusions.
If you are enrolled in this Plan through FEHBP, have Medicare Part A coverage
and have purchased Part B coverage, you may also enroll in the Health Plan of
Nevada Senior Dimensions program. The Senior Dimensions plan provides all
Medicare covered Part A and Part B benefits, as well as some benefits not
covered by Medicare. It is an arrangement between Medicare and this Plan in
which Medicare pays a specific amount to this plan for each Medicare beneficiary
who
enrolls in the Plan.
Like your FEHBP enrollment in this Plan, you
are required to obtain your services from this Plan's doctors and providers,
except for emergencies and out-of-area urgent care. The rules regarding
enrollment and disenrollment in are fully
explained in the Plan's Evidence
of Coverage. For a copy of these rules and or more information, please contact
Member Services at (702) 242-7300 or (800) 777-1840.
If you choose to enroll in Senior Dimensions, you will be responsible for
paying the Medicare Part B premium. You
must complete an additional
enrollment form in order to be enrolled in Senior Dimensions.
If you are Medicare eligible and are interested in enrolling in a Medicare
HMO sponsored by this Plan without dropping
your enrollment in this Plan's
FEHB plan, call (702) 242-7300 or (800) 777-1840 for information on the benefits
available under the Medicare HMO. 44
44 Page 45 46
2001 Health Plan of Nevada 45 Section 6
Section 6.
General exclusions --things we don't cover
The exclusions in this
section apply to all benefits. Although we may list a specific service as a
benefit, we will not cover it unless your Plan doctor determines it is medically
necessary to prevent, diagnose, or treat your
illness, disease, injury or
condition 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. 45
45
Page 46 47
2001
Health Plan of Nevada 46 Section 7
Section 7. Filing a claim
for covered services
When you see Plan physicians, receive services at
Plan hospitals and facilities, or obtain your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your
identification card and pay your copayment, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form. Facilities will file on
the UB-92 form. For claims
questions and assistance, call us at (702) 242-7300 or (800) 877-1840.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a claim form that includes the information shown below. Bills
<
and receipts should be itemized and show:
· Covered member's name and ID number;
· Name and address
of the physician or facility that provided the service or
supply;
· Dates you received the services or supplies;
· Diagnosis;
· Type of each service or supply;
· The charge for each
service or supply;
· A copy of the explanation of benefits, payments,
or denial from any primary payer --such as the Medicare Summary Notice (MSN);
and
· Receipts, if you paid for your services.
Submit your claims
to: Health Plan of Nevada, Attn: Claims, P. O. Box 15645, Las Vegas, NV
89114-5645
Prescription Drugs To submit claims for drugs, contact the plan at
(702) 242-7300 or (800) 877-1840. We will assist you in completing a Direct
Member Reimbursement
Form and help you process your claim with our Pharmacy
Benefits Manager.
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. 46
46 Page
47 48
2001 Health Plan of Nevada
47 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for services,
drugs, or supplies – including a request for prior authorization:
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: P. O. Box 15645, Las Vegas, NV
89114-5645; and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or if applicable arrange for the health care provider to give you the
care); or
(b) Write to you and maintain our denial --go to step 4; or (c)
Ask you or your medical provider for more information. If we ask your provider,
we will send you a
>
copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
· 90 days after the date of our letter
upholding our initial decision; or
· 120 days after you first wrote
to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division III, P. O. Box 436, Washington, D. C. 20044-0436.
47
47 Page 48 49
2001 Health Plan of Nevada 48 Section 8
The Disputed Claims process (Continued)
Send
OPM the following information:
· A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure;
· Copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms;
· Copies of all letters you sent to us about the claim;
·
Copies of all letters we sent to you about the claim; and
· Your
daytime phone number and the best time to call.
Note: If you want OPM to review 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 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 (702)-242-7300 or
(800)-777-1840 and we will expedite our review; or
(b) We denied your initial request for care or prior authorization, 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 III at
202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 48
48 Page 49 50
2001 Health Plan of Nevada 49 Section 9
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-State 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 may 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 the Original Medicare plan, you still
need to follow the rules in this brochure for us to cover your care.
(Primary payer chart begins on next page.) 49
49 Page 50 51
2001 Health Plan of Nevada 50 Section 9
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
Then the primary payer is… A. When either
you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor afamilymemberare
eligibleforMedicaresolely becauseofadisability), ü
2) Are an annuitant, ü
3) Are a reemployed annuitant with the
Federal government when…
a) The position is excluded from FEHB, or
ü
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you. ü
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), ü
5) Are enrolled in
Part B only, regardless of your employment status, ü (for Part B
services)
ü (for other
services)
6) Are a former Federal
employee receiving Workers' Compensation
and the Office of Workers'
Compensation Programs has determined that you are unable to return to duty,
ü (except for claims
related to Workers' Compensation.)
B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, ü
2) Have completed the 30-month
ESRD coordination period and are still eligible for Medicare due to ESRD, ü
3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, ü
C. When you or a covered family member have FEHB and…
1)
Are eligible for Medicare based on disability, and
a) Are an annuitant, or
ü
b) Are an active employee ü 50
50
Page 51 52
2001 Health Plan of Nevada 51 Section 9
Claims process
--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 (702) 242-7300 or (800) 777-1840. You may also contact us
by fax at (702) 242-9350 or visit our website at
We do not waive any out-of-pocket costs when you have Medicare.
·Medicare Managed Care Plan If you are eligible for Medicare,
you may choose to enroll in and get your Medicare benefits from a Medicare
managed care plan. These are health
care choices (like HMOs) in some areas
of the country. In most Medicare
managed care plans, you can only go to
doctors, specialists, or hospitals that are part of the plan. Medicare managed
care plans 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 our Medicare Managed Care Plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do/ do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
This Plan and another Plan's Medicare Managed Care Plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled
in our FEHB plan. We will still provide benefits when your
Medicare managed
care plan is primary, even out of the managed care plan's network and/ or
service area (if you use our Plan providers), but we will not
waive any of our copayments, coinsurance, or deductibles.
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
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. 51
51 Page 52 53
2001 Health Plan of Nevada 52 Section 9
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.
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 are responsible for your care We do not
cover services and supplies when a local, State, or Federal Government agency
directly or indirectly pays for
them.
When others are responsible for injuries When you receive money to
compensate you for 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. 52
52
Page 53 54
2001 Health Plan of Nevada. 53 Section 10
Section 10.
Definitions of terms we use in this brochure
Calendar year January 1
through December 31 of the same year. For new enrollees, the calendar year
begins on the effective date of their enrollment and ends on
December 31 of
the same year.
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.
Custodial care Care that designed essentially to assist
individuals in meeting activities of daily living. These include personal care
services (help in walking and
getting in or out of bed; assistance in
bathing, dressing, feeding, and using the toilet; preparation of special diets;
and supervision over medication
which can usually be self-administered) that
do not require the continuing
attention of trained medical or paramedical
personnel.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services. See page 11.
Experimental or Investigational services This plan regularly evaluates
for possible coverage new medical technologies and new applications of existing
technologies. New technologies may
include medical procedures, drugs and
devices. The evaluation process
includes a review of information on the
proposed service from appropriate government regulatory bodies as well as from
published scientific evidence.
Medical Necessity Medical Necessity means a service is needed to
improve a specific health condition or to preserve your health. Medical
necessity is present when the
Plan determines that the care requested is:
Consistent with the diagnosis and
treatment of your illness or injury; the
most appropriate level of service which can be safely provided to you; and, not
provided solely for your
convenience or that or your provider or hospital. When applied to inpatient
services, "Medically Necessary" further means that your condition
requires treatment in a hospital rather than any other setting. Services and
accommodations are not automatically considered to be Medically Necessary
because a physician prescribes them.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Fee-for-service plans
determine their
allowances in different ways. We determine our allowance
based upon the
reasonable and customary charges as determined by the Plan.
Participating plan providers accept the plan allowance as payment in full.
Us/ We Us and we refer to Health Plan of Nevada
You You
refers to the enrollee and each covered family member. 53
53 Page 54 55
2001 Health Plan of Nevada 54 Section 11
Section 11.
FEHB facts
No pre-existing condition limitation We will not refuse to
cover the treatment of a condition that you had before you enrolled in this Plan
solely because you had the condition before you
enrolled.
Where you can get information about enrolling in the
FEHB Program
See www. opm. gov/ insure. Also, your
employing or retirement office can answer your questions, and give you a
Guide to Federal 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 for you and your family Self Only coverage
is for you alone. Self and Family coverage is for 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. 54
54 Page
55 56
2001 Health Plan of Nevada 55 Section 11
When benefits
and premiums start The benefits in this brochure are effective on January 1.
If you are 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 records are confidential We will keep your
medical and claims information 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 coverage If you are divorced from a Federal
employee or annuitant, you may 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.
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. 55
55 Page 56 57
2001 Health Plan of Nevada 56 Section 11
·Converting to individual coverage You may convert to an
individual policy if: ·· Your coverage under TCC or the spouse
equity law ends. If you canceled
your coverage or did not pay your premium,
you cannot convert;
·· You decided not to receive coverage
under TCC or the spouse equity law; or
·· You are not eligible for coverage under TCC or the spouse
equity law.
If you leave Federal service, your employing office will notify
you of your right to convert. You must apply in writing to us within 31 days
after you
receive this notice. However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You
must apply in writing to us within 31 days after you are no longer eligible for
coverage.
Your benefits and rates will differ from those under the FEHB
Program; however, you will not have to answer questions about your health, and
we will
not impose a waiting period or limit your coverage due to
pre-existing conditions.
Getting a Certificate of Group Health Plan Coverage If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us. You can use this
certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting periods, limitations, or
exclusions for health related
conditions based on the information in the certificate, as long as you enroll
within 63 days
of losing coverage under this Plan.
If you have been enrolled with us for less than 12 months, but were
previously
enrolled in other FEHB plans, you may also request a certificate
from those plans.
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 (702)
242-7300 or (800) 777-1840 and explain the situation.
· If we do not resolve the issue, call THE HEALTH CARE FRAUD
HOTLINE--202/ 418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud Hotline,
1900 E Street, NW, Room 6400, Washington, DC 20415.
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. 56
56 Page 57
58
2001 Health Plan of Nevada 57 Index
Index
Do not rely on this page; it is for your convenience
and does not explain your benefit coverage.
Accidental injury 40
Allergy tests 18, 41, 42
Alternative treatment 23 Ambulance 29, 31, 33
Anesthesia 25, 28 Autologous bone marrow transplant
19, 28 Biopsies
25
Blood and blood plasma 30 Breast cancer screening 39
Casts 30
Catastrophic protection 12
Changes for 2001 7 Chemotherapy 19, 41, 42
Childbirth 17 Cholesterol tests 15
Claims 13, 36, 46, 47, 51, 55
Coinsurance 11, 42, 53
Colorectal cancer screening 15 Congenital anomalies
25, 26
Contraceptive devices and drugs 17, 26, 37
Coordination of
benefits 49 Covered charges 51
Covered providers 8
Crutches 23
Deductible 11
Definitions 53 Dental care 40, 44
Diagnostic services 14 Disputed claims review 47
Donor expenses
(transplants ) 28 Dressings 30
Durable medical equipment (DME) 23
Educational classes and programs 24 Effective date of enrollment 8
Emergency 32 Experimental or investigational 45,
53 Eyeglasses 21
Family planning 17
Fecal occult blood test 15 General Exclusions 45
Hearing
services 20 Home health services 23
Hospice care 31 Home nursing care 23
Hospital 9 Immunizations 16
Infertility 18 Inhospital physician
care 14
Inpatient Hospital Benefits 29 Insulin 37
Laboratory and
pathological services 30, 41
Magnetic Resonance Imagings (MRIs) 15
Mail
Order Prescription Drugs 36 Mammograms 16
Maternity Benefits 17 Medicaid 52
Medically necessary 10 Medicare 49
Members 4 Mental Conditions/
Substance
Abuse Benefits 34 Neurological testing 41
Newborn care
14, 17 Non-FEHB Benefits 44
Nurse Licensed Practical Nurse 23
Nurse
Anesthetist 30 Registered Nurse 23
Nursery charges 17 Obstetrical
care 17
Occupational therapy 20 Ocular injury 21
Office visits 5
Oral and maxillofacial surgery 27
Orthopedic devices 22 Out-of-pocket
expenses 12
Outpatient facility care 25 Oxygen 23
Pap test 15 Physical examination 5
Physical therapy 20 Physician 8
Point of service (POS) 5 Precertification 17
Preventive care, adult 15
Preventive care, children 16
Prescription drugs 36 Preventive services 5
Prior authorization 10 Prostate cancer screening 15
Prosthetic devices
22 Psychologist 34
Radiation therapy 19 Rehabilitation therapies 20
Renal dialysis 49 Room and board 29
Second surgical opinion 14
Skilled nursing facility care 31
Smoking cessation 24 Speech therapy 20
Splints 30 Sterilization procedures 17
Subrogation 52 Substance abuse 34
Surgery 25 · Anesthesia 28
· Oral 27 · Outpatient
30
· Reconstructive 26 Syringes 37
Temporary continuation
of coverage 55
Transplants 28 Treatment therapies 19
Vision
services 21 Well child care 41
Wheelchairs 23 Workers'
compensation 52
X-rays 15 57
57 Page 58 59
2001 Health
Plan of Nevada, Inc. 58
NOTES: 58
58
Page 59 60
2001 Health Plan of Nevada, Inc. 59 Summary
Summary of
benefits for the Health Plan of Nevada -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; $10 specialist
14
Services provided by a hospital:
·
Inpatient.......................................................................................................
·
Outpatient....................................................................................................
$100 per day up to $200
$50 per surgical center
29
30
Emergency benefits:
·
In-area.........................................................................................................
·
Out-of-area.................................................................................................
$25 per visit
$25 per visit
33
33
Mental health and substance abuse treatment
........................................... Regular cost sharing. 34
Prescription drugs
..........................................................................................
$5 generic preferred
$20 brand preferred
$35 non-preferred
Dental Care
..................................................................................................
No benefit. 40
Vision Care
..................................................................................................
$10 per visit for one refraction annually 21
Special features: 39
Point of Service benefits
--Yes 41
Protection against catastrophic costs
(your out-of-pocket
maximum)................................................................
Nothing after $3,300/ Self Only or
$7,804/ Family enrollment per year for
HMO benefits or $1,500/ Self
Only or $4,800/ Family for POS
benefits
Some costs do not count toward this protection
12 59
59 Page 60
2001 Health Plan of Nevada 60
Rate Information
2001 Rate Information for Health Plan of
Nevada
Non-Postal rates apply to most non-Postal enrollees. If you are
in a special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal
rates apply to career Postal Service employees. Most employees should refer
to the FEHB Guide for United States Postal Service Employees, RI 70-2. Different
postal rates apply and special FEHB guides are
published for Postal Service
Nurses and Tool & 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 Enrollment Code Gov't Share Your Share Gov't Share Your Share
USPS Share Your Share
Location Information
High Option Self Only NM1 $67.95 $22.65 $147.23
$49.07 $80.41 $10.19
High Option Self & Family NM2 $173.96 $57.99 $376.92 $125.64 $205.86 $26.09 60