Serving: West Central Wisconsin
Enrollment in this Plan is limited;
see page 5 for requirements.
Enrollment codes for this Plan:
WT1 Self Only WT2 Self and Family
Authorized for distribution by the:
COOPERATIVE OF EAU CLAIRE
For changes in benefits
see page 7, 55.
RI 73-555 1
1 Page
2 3
2 Page 3 4
2001 Group Health
Cooperative of Eau Claire 3 Table of Contents
Section 9.
Coordinating benefits with other coverage
...........................................................................................
44
· When you have…
· Other health
coverage...................................................................................................................
44
· Original Medicare
........................................................................................................................
44
· Medicare Managed Care plan
.......................................................................................................
46
TRICARE/ Workers' Compensation/
Medicaid......................................................................................
47
Other Government
agencies.................................................................................................................
47
When others are responsible for injuries
..............................................................................................
47
Section 10. Definitions of terms we use in this
brochure.......................................................................................
48
Section 11. FEHB facts
.......................................................................................................................................
50
Coverage
information........................................................................................................................
50
· No pre-existing condition
limitation...........................................................................................
50
· Where you get information about enrolling in the FEHB Program
.............................................. 50
· Types of coverage
available for you and your
family.................................................................. 50
· When benefits and premiums start
.............................................................................................
51
· Your medical and claims records are
confidential.......................................................................
51
· When you
retire........................................................................................................................
51
When you lose benefits
....................................................................................................................
51
· When FEHB coverage ends
.......................................................................................................
51
· Spouse equity coverage
............................................................................................................
51
· Temporary Continuation of Coverage (TCC)
............................................................................ 51
· Enrolling in
TCC.......................................................................................................................
51
· Converting to individual coverage
............................................................................................
52
· Getting a Certificate of Group Health Plan Coverage
................................................................ 52
Inspector General advisory: Stop health care fraud!
............................................................................. 52
Index
........................................................................................................................................................
53
Summary of benefits
............................................................................................................................................
55
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 Group Health Cooperative of
Eau Claire 4 Introduction/ Plain Language
Introduction
Group HeCould not acquire words on page 5 alth Cooperative of Eau Claire
2503 N. Hillcrest Parkway
Altoona, WI. 54720
This brochure describes the
benefits of Group Health Cooperative of Eau Claire under our contract (CS 2615)
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, 55. Rates are shown at the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and understandable to
the public by requiring agencies to use plain language. In response, a team of
health plan
representatives and OPM staff worked cooperatively to make this
brochure clearer. Except for necessary technical terms, we use common words.
"You" means the enrollee or family member; "we" means Group
Health Cooperative
of Eau Claire.
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
5 Page
6 7
2001 Group Health Cooperative of
Eau Claire 6 Section 1
You may also enroll with us if you live or
work in the following counties: Barron, Buffalo, Chippewa, Clark, Dunn, Eau
Claire, Jackson, Pepin, Rusk, Sawyer, Taylor, Trempealeau, and Washburn. 6
6 Page 7 8
2001 Group Health Cooperative of Eau Claire 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 Group Health plan network will be
the same with regard to copays, and day and visit limitations when you follow a
treatment plan that we approve. Previously, we placed higher patient cost
sharing 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 Group Health Cooperative of Eau Claire
Member Services at (715) 552-4300 or toll-free at (888) 203-7770, or
checking our website http:// www. group-health. com. You can find out more
about
patient safety on the OPM website, www. opm. gov/ insure. To improve
your healthcare, take these five steps:
· · Speak up if you
have questions or concerns.
· · Keep a list of all the
medicines you take.
· · Make sure you get the results of any
test or procedure.
· · Talk with your doctor and health care
team about your options if you need hospital care. · ·
Make
sure you understand what will happen if you need surgery.
· We clarified the language to show that anyone who needs a mastectomy
may choose to have the procedure performed on an inpatient basis and remain in
the hospital up to 48 hours after the procedure. Previously, the
language
referenced only women.
Changes to this Plan · Your share of
the non-Postal premium will increase by 36.4% for Self Only or 28.1% for Self
and Family.
· Emergency Room Care. $25 copayment per visit. Required to call First
Care Nurse Line (prior to Emergency Room visit) for Urgent
Care situations.
7
7 Page 8 9
2001 Group Health Cooperative of Eau Claire 8
Section 3
Section 3. How you get care
Identification cards
We will send you an identification (ID) card when you enroll. You should
carry your ID card with you at all times. You must show it
whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the
Health
Benefits Election Form, SF-2809, your health benefits enrollment confirmation
(for annuitants), or your Employee Express confirmation
letter.
If you
do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 715/ 552-4300.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments
and deductibles, and you will not have to file claims.
· Plan
providers Plan providers are physicians and other health care professionals
in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our 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 to get Covered care It depends on the type of care
you need. First, you and each family
member must choose a primary care
clinic. This decision is important since your primary care physician, at your
clinic, provides or arranges for
most of your health care. Each member of
the family can choose a different clinic for their care. You may change clinics
twice a year by
calling Member Services at 715/ 552-4300.
· Primary care Your primary care physician can be a family
practitioner, internist, OB/ GYN, or pediatrician. Your primary care physician
will provide most
of your health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary
care physician leaves the Plan, call us. We will help you select a new one.
· Specialty care Your primary care physician will refer you to
a specialist for needed care. However, you may see the Group Health Cooperative
Chiropractors
without a referral.
A woman may see her plan Gynecologist
for her annual routine exam without a referral.
Here are other things you should know about specialty care:
· If
you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician
will develop a
treatment plan that allows you to see your specialist for 8
8 Page 9 10
2001 Group Health Cooperative of Eau Claire 9
Section 3
a certain number of visits. 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 715/ 552-4300 or
888/ 203-7770. If you are new to
the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
· You are discharged, not merely moved to an alternative care center;
or
· The day your benefits from your former plan run out; or
· The 92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person. 9
9 Page 10 11
2001 Group Health Cooperative of Eau Claire 10
Section 3
Circumstances beyond our control Under certain
extraordinary circumstances, such as natural disasters, we may have to delay
your services or we may be unable to provide them.
In that case, we will
make all reasonable efforts to provide you with the necessary care.
Services requiring our prior approval Group Health's primary care
physicians are supported by an extensive
network of more than 500 specialty
and tertiary care physicians to ensure access to the complete continuum of
high-quality healthcare services.
If both you and your primary care physician feel that you require additional
treatment, together you decide about the appropriate type of
referral to a
specialist. A written referral is required for every visit with a specialist.
Your primary care physician will provide you with the referral.
Every
referral you receive will have a limit of days and/ or a specific number of
visits for when you can use that referral. Please make sure that
you see
that specialist within that time allotted.
If you notice that your
appointment falls after the referral end date, please contact your primary care
physician to receive a new referral.
If the specialist believes it is necessary for you to seek additional
treatment, you should contact your primary care physician to discuss the
additional referral. The specialist should not make a direct referral for
you, it must come from your primary care physician. 10
10 Page 11 12
11
11 Page 12 13
2001 Group
Health Cooperative of Eau Claire Section 5 12
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, a specialist, a
chiropractor, or home health services, you pay a copayment of $10 per
office
visit. You would also pay a $25 copayment for Emergency Room visits.
· 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. The only deductible you have
is for Durable Medical Equipment, which is $50 per person per calendar year. 12
12 Page 13 14
2001 Group Health Cooperative of Eau Claire Section
5 13
Section 5. Benefits --OVERVIEW (See page 7 for how our
benefits changed this year and page 55 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 exclusion in Section 6; they apply to the
following benefits
subsection. To obtain more information about our
benefits, contact us at 715/ 552-4300 or 888/ 203-7770 or at our website at www.
group-health. com.
(a) Medical services and supplies provided by physicians
and other health care professionals .................................... 14-21
· 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) · Vision services (one annual
routine exam)
· Foot care · Orthopedic and prosthetic devices
· Durable medical equipment (DME) · Home health services
· Alternative treatments
(b) Surgical and anesthesia services provided by physicians and other health
care professionals...................... 22-26
· Surgical procedures
· Reconstructive surgery · Oral and maxillofacial surgery ·
Organ/ tissue transplants
· Anesthesia
(c) Services provided by a
hospital or other facility, and ambulance services
.................................................. 27-29
· Inpatient
hospital · Outpatient hospital or ambulatory surgical
center
· Extended care benefits/ skilled nursing care facility benefits
· Ambulance
(d) Emergency services/
accidents............................................................................................................
30-32 · Medical emergency · Ambulance
(e) Mental health and
substance abuse
benefits………………………………………………………………….
34-34
(f) Prescription drug benefits
..............................................................................................................................
35
(g) Special features
.............................................................................................................................................
38
(h) Dental benefits
..............................................................................................................................................
39
Summary of benefits
............................................................................................................................................
55 13
13 Page 14
15
14
14 Page 15 16
2001 Group
Health Cooperative of Eau Claire Section 5( a) 13
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.
· The
calendar year deductible is: There is no calendar year deductible. The durable
medical benefit is the only benefit that has a deductible.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of
physicians and chiropractors
· In physician's office
· In specialist's office
· In chiropractor'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
Nothing
$10 per visit
$10 per visit
$10
per office visit
$10 per visit 15
15 Page 16 17
2001 Group
Health Cooperative of Eau Claire Section 5( a) 14
Preventive care,
adult
Routine physical
Routine screening tests, such as:
· Blood Pressure check
· Total Blood Cholesterol
· Mammogram
· Colorectal Cancer Screening, including
· · Fecal occult blood test
· Sigmoidoscopy,
screening – starting at age 50
· Routine Pap Test
$10 per office visit
Nothing.
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 and EEG
Nothing. 16
16 Page
17 18
2001 Group Health Cooperative of
Eau Claire Section 5( a) 15
Preventive care, adult (Continued)
You pay
Not covered: Physical exams required for obtaining or
continuing employment or insurance, or travel. All charges.
Routine Immunizations, limited to:
· Tetanus-diphtheria (Td)
booster.
· Influenza/ Pneumococcal vaccines.
Nothing.
Preventive care, children You pay
· Childhood immunizations
recommended by the Advisory Committee on Immunization Practices. Nothing.
· 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)
Nothing for one annual eye exam.
Nothing
$10 per office visit
$10
per office visit 17
17 Page
18 19
2001 Group Health Cooperative of
Eau Claire Section 5( a) 16
Maternity care You pay
Complete
maternity (obstetrical) care, such as:
· Prenatal care
·
Delivery
· Postnatal care (one visit)
Note: Here are some things
to keep in mind:
· You do not need to precertify your normal
delivery.
· 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 copayment for first office visit only.
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
· Voluntary sterilization.
· Injectable contraceptive drugs.
$10 per office visit
$10
per office visit
Not covered.
· Reversal of voluntary surgical
sterilization, genetic counseling.
· Surgically implanted
contraceptives.
· Intrauterine devices (IUD's)
· Elective
abortions
All charges.
Infertility services You pay
Diagnosis and treatment of
infertility (if provided at a Group Health primary care clinic), such as:
· Artificial insemination:
· · intravaginal
insemination (IVI)
· · intracervical insemination (ICI)
· · intrauterine insemination (IUI)
$10 per office visit 18
18 Page 19 20
2001 Group
Health Cooperative of Eau Claire Section 5( a) 17
Not covered:
· Assisted reproductive technology (ART) procedures, such as:
· · in vitro fertilization
· ·
embryo transfer and GIFT
· Services and supplies related to
excluded ART procedures
· Fertility drugs
· Cost of donor sperm
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Nothing
Allergy serum Nothing
Not covered: provocative food
testing and sublingual allergy desensitization All charges.
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 25.
· Respiratory and inhalation
therapy
· Dialysis – Hemodialysis and peritoneal dialysis
· Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy
· Growth hormone therapy (GHT) -This requires medical director
approval. Call (715) 552-4300 for pre-authorization or have your
physician
call our office.
Nothing 19
19 Page
20 21
2001 Group Health Cooperative of
Eau Claire Section 5( a) 18
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
·
2 months per condition for combined 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 following a heart transplant, bypass
surgery or a myocardial
infarction, is provided with approved referral.
Nothing.
Not covered:
· long-term rehabilitative therapy
· exercise programs
All charges.
Hearing services (testing, treatment, and supplies)
Not
covered: · cochlear implants
· hearing aids, testing and examinations for them
All charges.
20
20 Page 21
22
2001 Group Health Cooperative of Eau Claire
Section 5( a) 19
Vision services (testing, treatment, and supplies)
You pay
· Annual eye refractions Nothing at participating
providers.
Not covered:
· Corrective lenses or frames
or fitting of contact lenses; except lenses following cataract surgery
· 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 Durable Medical Benefit 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 subluxation
of the foot (unless the
treatment is by open cutting surgery)
All charges. 21
21 Page 22 23
2001 Group
Health Cooperative of Eau Claire Section 5( a) 20
Orthopedic and
prosthetic devices You pay
· Internal prosthetic devices, such as
artificial joints, pacemakers, and surgically implanted breast implant following
mastectomy. Note:
We pay internal prosthetic devices as hospital benefits;
see Section 5 (c) for payment information. See 5( b) for coverage of the surgery
to insert the device.
· Corrective orthopedic appliances for
non-surgical treatment of temporomandibular joint (TMJ) pain dysfunction
syndrome.
Nothing
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
supplied by a plan DME provider, such as oxygen and dialysis equipment. Under
this benefit, we also cover:
· Wheelchairs;
· Hospital beds;
· Crutches;
· Walkers;
· Blood glucose monitors; and
·
Insulin pumps;
· Artificial limbs and eyes; stumphose;
·
Externally worn breast prosthesis and surgical bras, including necessary
replacements, following a mastectomry;
· Custom made foot orthodics and corrective shoes;
·
Corsets, trusses, and other braces and devices;
· Prosthetics.
Note: Call us at (715) 552-4300 or 1-888-203-7770 as soon as your Plan
physician prescribes this equipment. We will arrange with a health
care provider to rent or sell you durable medical equipment at discounted
rates and will tell you more about this service when you call.
Benefits are
limited to a lifetime maximum of $5,000.
$50 deductible per person, per calendar year.
Not covered: · Motorized wheel chairs
·
Replacements for lost or stolen equipment
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.
$10 per home visit 22
22 Page 23 24
2001 Group
Health Cooperative of Eau Claire Section 5( a) 21
Home health
services (Continued) You pay
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
Not covered: ·
naturopathic services
· hypnotherapy · biofeedback
·
acupuncture
All charges.
Educational classes and programs
Not covered. All charges.
23
23 Page 24
25
2001 Group Health Cooperative of Eau Claire
22 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 charge (i. e. hospital,
surgical center, etc.) .
· YOU MUST GET PRECERTIFICATION OF
SURGICAL PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which services require precertification and
identify which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
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
·
Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces
and prosthetic devices for device coverage information.
$10 per office visit
Surgical procedures continued on next page. 24
24 Page 25 26
2001 Group Health Cooperative of Eau Claire 23
Section 5( b)
Surgical procedures (Continued) You
pay
· Voluntary sterilization · Treatment of burns
$10
per office visit.
Not covered: · Reversal of voluntary sterilization
· Norplant (a surgically implanted contraceptive) ·
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.
Nothing.
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.
Nothing.
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 25
25 Page 26 27
2001 Group
Health Cooperative of Eau Claire 24 Section 5( b)
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.
Nothing.
Not covered: · Oral implants and transplants
· Procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva, and alveolar bone)
· Restorations
All charges. 26
26 Page 27 28
2001 Group
Health Cooperative of Eau Claire 25 Section 5( b)
Organ/
tissue transplants You pay
Limited to:
· Cornea
·
Heart
· Heart/ lung
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single –Double
· Pancreas
· Allogeneic (donor) bone marrow transplants
· Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian
germ cell tumors
· We do transplants
on a referral basis. With medical director approval.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical
trial at a Plan-designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing.
Not covered: · Donor screening tests and donor search
expenses, except those
performed for the actual donor ·
Implants of artificial organs
· Transplants not listed as covered
All charges 27
27 Page 28 29
2001 Group
Health Cooperative of Eau Claire 26 Section 5( b)
Anesthesia
You pay
Professional services provided in –
· Hospital
(inpatient)
Nothing.
Professional services provided in –
· Hospital outpatient
department · Skilled nursing facility
· Ambulatory surgical
center · Office
Nothing. 28
28 Page
29 30
2001 Group Health Cooperative of
Eau Claire 27 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.
· Unlike Sections (a) and (b), in this section the calendar year
deductible applies to only a few benefits. In that case, we added "(
calendar year deductible
applies)".
· 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).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as · ward, semiprivate, or intensive care accommodations;
· general nursing care; and · meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 29
29 Page 30 31
2001 Group Health Cooperative of Eau Claire 28
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
Nothing
Not covered: · Custodial care
·
Non-covered facilities, such as nursing homes, extended care facilities,
schools
· Personal comfort items, such as telephone,
television, barber services, guest meals and beds
· Private
nursing care
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.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges 30
30 Page
31 32
2001 Group Health Cooperative of
Eau Claire 29 Section 5( c)
Extended care benefits/ skilled
nursing care facility benefits You pay
Extended Care/ Skilled nursing
facility (SNF) Nothing
Not covered: custodial care All charges
Hospice care
Not covered:
· Independent nursing, homemaker services
·
Hospice Care
All charges
Ambulance
· Local professional ambulance service when
medically appropriate Nothing 31
31 Page 32 33
2001 Group
Health Cooperative of Eau Claire 30 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: A medical emergency is a sudden,
potentially life-threatening situation where immediate medical treatment is
needed. The following are some examples of a
medical emergency. ·
Heart Attack
· Major Trauma · Sudden Unconsciousness
When such a
situation arises, no authorization is necessary and you should proceed directly
to the emergency department. The enclosed Provider Directory has a list of
hospitals that will provide quality
coverage for such emergency care. You
should also look at your Benefit Summary or your Group Health contract policy
and rider that will show if you have a copayment or emergency services.
Emergencies outside our service area: If a true emergency occurs while
you are away from the Group Health service area, treatment for the emergency
will be covered at any facility. Follow up care,
however, whether it is
inpatient or outpatient, must be provided by a contracted provider. To save
yourself some confusion and worry when out of the area, you can call our Member
Service Representatives at (715)
552-4300 or (888) 203-7770 to review your
coverage in case of an emergency.
Urgent Care within our service area: Conditions may arise that require
urgent medical attention but may not be serious enough to go to the ER. Examples
include the following:
· Minor Injuries · Ear Infections
· Fevers Unless the condition is a life-threatening emergency, you
must call your primary care clinic to discuss the
situation with a physician
or triage nurse. They will direct you to the proper setting to receive care. In
some situations, a physician may even be able to provide the appropriate
treatment over the phone. In other
cases, you may be instructed to go to the
emergency room or to an urgent care facility. In order to assure payment of
coverage, you must make the call and receive the authorization before going to
the emergency
room for urgent care services. 32
32
Page 33 34
2001
Group Health Cooperative of Eau Claire 31 Section 5( d)
Urgent
Care outside our service area: Urgent care means that the member cannot
safely return to the Group Health service area before needing treatment. In such
cases, the triage nurse or physician may
advise you to seek care at the
nearest appropriate facility. If it is not possible to contact your primary care
clinic for advice or authorization, you should seek treatment at a physician's
office, urgent care facility, or
Emergency Department depending on the
problem. A coverage decision will be made based on the medical records from you
visit. 33
33 Page
34 35
2001 Group Health Cooperative of
Eau Claire 32 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 at a
hospital, including doctors' services
$10 per office visit.
$10 per office visit.
$25 per office 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
$10 per office visit
$10 per office 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 air and ground ambulance service when
medically appropriate.
See 5( c) for non-emergency service.
Nothing. 34
34 Page 35 36
2001 Group Health Cooperative of Eau Claire 33
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. 35
35 Page
36 37
2001 Group Health Cooperative of
Eau Claire 34 Section 5( e)
Mental health and substance abuse
benefits (Continued) You pay
· Diagnostic tests
Nothing
· Services provided by a hospital or other facility Nothing
Not
covered: Services we have not approved. All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and the following authorization process:
·
You are required to use the Group Health Mental Health providers
listed in
your provider directory. You can obtain a directory or information also from our
Member Services Representatives at (715)
552-4300 or (888) 203-7770.
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following 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 these conditions apply to you, {or, 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. 36
36 Page
37 38
2001 Group Health Cooperative of
Eau Claire 35 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.
· You have a $7.50 copayment per prescription.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
· Who can write your prescription. A plan or referral
physician or licensed dentist must write the prescription.
· Where you can obtain them. You may fill the prescription at a
Group Health contracted pharmacy.
· We use a formulary. Drugs
are prescribed by plan doctors and dispensed in accordance with the plan's drug
formulary. Non formulary drugs will be covered when prescribed by Plan doctor. A
list
of prescription products that are covered by Group Health Cooperative is
available to you. Products are chosen by a Pharmacy & Therapeutics (P&
T) Committee consisting of physicians, pharmacists
and non-physician
clinicians. Inclusion in the formulary is based on medical efficacy and cost
effectiveness. New products are automatically reviewed by the P& T
Committee, while older
products are received at the request of a clinician
or when a substantial number of prior authorizations have been requested for its
use. Members who wish to have a product added to the
formulary should
discuss the reasoning with their primary care physician who may then initiate
the process with the P& T Committee.
· Dispensing limitations. Prescription drugs prescribed by a
Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up
to a 31-day supply, or up to 100 day supply for drugs on the
Group Health
Maintenance List.
Prescription drug benefits begin on the next page. 37
37 Page 38 39
2001 Group Health Cooperative of Eau Claire 36
Section 5( f)
Benefit Description You pay
Covered medications
and supplies
We cover the following medications and supplies prescribed
by a Plan physician and obtained from a Plan pharmacy:
· Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase and are on the Group Health
formulary, except as excluded below. · Contraceptive drugs.
· Insulin · Disposable needles and syringes and other diabetic
supplies for the
administration of covered medications · Drugs for
sexual dysfunction (up to dosage limitation)
· Intravenous fluids and
medication for home use, implantable drugs, and some injectable drugs are
covered under Medical and Surgical
Benefits.
$ 7.50 copayment per prescription.
Nothing. 38
38 Page 39 40
2001 Group Health Cooperative of Eau Claire 37
Section 5( f)
Covered medications and supplies (continued)
You pay
Here are some things to keep in mind about our
prescription drug program:
· A generic equivalent will be dispensed if it is available, unless
your physician specifically requires a name brand. If you receive a
name
brand drug when a Federally-approved generic drug is available, without prior
authorization, you have to pay the
difference in cost between the name brand
drug and the generic.
Not covered:
· Drugs and supplies for cosmetic purposes
· Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
· Nonprescription medicines
· Drugs used to
control or reduce weight
· Nicotine patches
·
Fertility drugs
All Charges 39
39 Page 40 41
2001 Group
Health Cooperative of Could not acquire words on page 45 Eau Claire 38
Section 5( g)
Section 5 (g). Special Features
Feature
Description
Flexible benefits option Under the flexible benefits option,
we determine the most effective way to provide services.
· We may
identify medically appropriate alternatives to traditional care and coordinate
other benefits as a less costly alternative
benefit.
· Alternative benefits are subject to our ongoing review.
· By approving an alternative benefit, we cannot guarantee you will
get it in the future.
· The decision to offer an alternative benefit is solely ours, and we
may withdraw it at any time and resume regular contract benefits.
·
Our decision to offer or withdraw alternative benefits is not subject to OPM
review under the disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call the First Care Nurse Line to talk with a registered
nurse who will discuss treatment options and answer your health questions. The
phone number will be on your ID card when you join Group Health. 40
40 Page 41 42
2001 Group Health Cooperative of Eau Claire 39
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 physician or dentist must provide or arrange your care.
· We cover hospitalization for dental procedures only when a
nondental physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient; 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 the initial emergency visit necessary to promptly repair (but
not replace) sound natural teeth. The need for these services must result
from an accidental injury. (Excludes restorations).
Nothing 41
41 Page 42 43
2001 Group Health Cooperative of Eau Claire Section
6 40 42
42 Page
43 44
2001 Group Health Cooperative of
Eau Claire Section 6 41
Section 6. General exclusions --things we
don't cover
The exclusions in this section apply to all benefits.
Although we may list a specific service as a benefit, we will not cover it
unless your Plan doctor determines it is medically necessary to prevent,
diagnose, or
treat your illness, disease, injury, or condition.
We
do not cover the following:
· Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
· Services, drugs, or supplies you receive while you are not enrolled
in this Plan;
· Services, drugs, or supplies that are not medically
necessary;
· Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice;
· Experimental or investigational procedures, treatments, drugs or
devices; (refer to pg. 48)
· 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. 43
43 Page 44 45
2001 Group Health Cooperative of Eau Claire Section
7 42
Section 7. Filing a claim for covered services
When you
see Plan physicians, receive services at Plan hospitals and facilities, or
obtain your prescription drugs at Plan pharmacies, you will not have to file
claims. Just present your identification card and pay your copayment or
deductible.
Group Health Cooperative members should not receive a bill
for medical services provided, except when an applicable copayment or deductible
applies. Routine office visits, hospitalizations, and specialist services will
be
covered according to your contract if you stay within the Group Health
network and obtain a written referral when required. 44
44 Page 45 46
45 Page 46 47
2001 Group
Health Cooperative of Eau Claire 44 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, drugs, or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the
disputed claims process. Further, Federal law governs your lawsuit, benefits,
and payment of benefits. The Federal court will base its review on the record
that was
before OPM when OPM decided to uphold or overturn our decision. You
may recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at (715) 552-4300 or
1-888-203-7770 and we will expedite our review; or
(b) We denied your
initial request for care or preauthorization/ prior approval, then:
·
· If we expedite our review and maintain our denial, we will inform OPM
so that they can give your claim expedited treatment too, or
· · You can call OPM's Health Benefits Contracts Division III
at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 46
46 Page 47 48
2001 Group Health Cooperative of Eau Claire 45
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-Stage Renal Disease (permanent kidney failure requiring dialysis
or a transplant).
Medicare has two parts:
· · Part A (Hospital Insurance).
Most people do not have to pay for Part A.
· · Part B (Medical
Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various health
plan
choices available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits with Medicare, depending on the
type of
Medicare managed care plan you have.
· The Original Medicare Plan The Original Medicare Plan is
available everywhere in the United States. It is the way most people get their
Medicare Part A and Part B benefits. You
may go to any doctor, specialist,
or hospital that accepts Medicare. Medicare pays its share and you pay your
share. Some things are not covered under
Original Medicare, like
prescription drugs.
When you are enrolled in this Plan and Original
Medicare, you still need to follow the rules in this brochure for us to cover
your care. Your care
must continue to be authorized by your Plan PCP, as
required.
We will waive your office visit copayments if you have both Part A
and Part B of Medicare. 47
47 Page 48 49
2001 Group
Health Cooperative of Eau Claire 46 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) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely because of a disability), ü
2) Are an annuitant, ü
3) Are a reemployed annuitant with the
Federal government when…
a) The position is excluded from FEHB 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 48
48 Page
49 50
2001 Group Health Cooperative of
Eau Claire 47 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 our Member Services Representatives at
(715)
552-4300 or (888) 203-7770, or visit our web site at http:// www. group-health.
com.
· 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. 49
49
Page 50 51
2001
Group Health Cooperative of Eau Claire 48 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 We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital for injuries care for injuries or illness caused
by another person, you must reimburse
us for any expenses we paid. However,
we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation
procedures. 50
50 Page
51 52
2001 Group Health Cooperative of
Eau Claire 49 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.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Provision of room and board, nursing care,
or personal care designed to assist an individual who, in the opinion of a plan
physician, has reached
the maximum level of recovery. In the case of
confinement in a Hospital or nursing facility, Custodial Care also includes room
and board, nursing
care, or such other care which is provided to an
individual for whom it cannot reasonably be expected, in the opinion of the plan
physician, that
the medical or surgical treatment will enable that person to
live outside an institution. Custodial Care also includes rest cures, respite
care, and
home care provided by family members.
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 Section 4.
Experimental or Is a health service, treatment, or supply used for an
illness or injury investigational services which, at the time it is used,
meets one or more of the following criteria:
· Is subject to approval
by an appropriate governmental agency for the purpose it is being used for such
as, but notlimited to the
Food and Drug Administration (FDA), which has not
granted that approval;
· Is not a commonly accepted medical practice
in the American medical community;
· Is the subject of a written
investigational or research protocol; · Requires a written
investigational or research protocol;
· Requires a written informed
consent by a treating facility that makes reference to it being experimental,
investigative,
educational, for a research study, or posing an uncertain
outcome, or having an unusual risk;
· Is the subject of an outgoing
FDA Phase I, II, III clinical trial; · Is undergoing review by an
institutional review board;
· Lacks recognition and endorsement of
supporting medical literature published in an established, peer reviewed
scientific
journal; · Has unacceptable failure rates and side effects
or poses
uncertain risks and outcomes; · Is being used in place of
other more conventional and proven
methods of treatment; · Has been
disapproved by the GHC Technology Assessment
Committee.
Medical necessity A service, treatment, procedure, equipment, drug,
device or supply provided by a hospital, physician or other health care provider
that is
required to identify or treat a participant's illness or injury and
which is, 51
51 Page
52 53
2001 Group Health Cooperative of
Eau Claire 50 Section 10
as determined by the plan: 1. consistent
with symptoms or diagnosis and treatment of the participants; 2. appropriate
under the standards of
acceptable medical practice to treat that illness or
injury; 3. not solely for the convenience of the participant, physician,
hospital or other health
care provider; 4. the most appropriate service,
treatment, procedure, equipment, drug, device or supply which can be safely
provided to the
participant and accomplishes the desired end result in the
most economical manner.
Us/ We Us and we refer to Group Health Cooperative of Eau Claire
You You refers to the enrollee and each covered family member. 52
52 Page 53 54
2001 Group Health Cooperative of Eau Claire 51
Section 11
Section 11. FEHB facts
No pre-existing condition
We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the
condition
before you enrolled.
Where you can get information See
www. opm. gov/ insure. Also, your employing or retirement office about
enrolling in the can answer your questions, and give you a Guide to
Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
· When you may change your enrollment;
· How you can cover
your family members;
· What happens when you transfer to another
Federal agency, go on leave without pay, enter military service, or retire;
· When your enrollment ends; and
· When the next open
season for enrollment begins.
We don't determine who is eligible for
coverage and, in most cases, cannot change your enrollment status without
information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances,
you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period
in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please
tell us immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child
under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by another
FEHB plan. 53
53 Page
54 55
2001 Group Health Cooperative of
Eau Claire 52 Section 11
When benefits and The benefits in
this brochure are effective on January 1. If you are new premiums start
to this Plan, your coverage and premiums begin on the first day of your
first pay
period that starts on or after January 1. Annuitants' premiums
begin on January 1.
Your medical and claims We will keep your medical
and claims information confidential. Only records are confidential the
following will have access to it:
· OPM, this Plan, and subcontractors when they administer this
contract;
· This Plan, and appropriate third parties, such as other
insurance plans and the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
· Law
enforcement officials when investigating and/ or prosecuting alleged civil or
criminal actions;
· OPM and the General Accounting Office when conducting audits;
· Individuals involved in bona fide medical research or education
that does not disclose your identity; or
· OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the
FEHB Program. Generally, you must have been enrolled in the FEHB Program for the
last five years of your
Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such as temporary
continuation of coverage (TCC).
When you lose benefits
· When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
· · Your enrollment ends, unless you cancel your enrollment, or
· · You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
· Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage 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. 54
54
Page 55 56
2001
Group Health Cooperative of Eau Claire 53 Section 11
·
Converting to You may convert to a non-FEHB individual policy if:
individual coverage · · Your coverage under TCC or the
spouse equity law ends. If you
canceled your coverage or did not pay your
premium, you cannot convert;
· · You decided not to receive coverage under TCC or the spouse
equity law; or
· · You are not eligible for coverage under TCC
or the spouse equity law.
If you leave Federal service, your employing
office will notify you of your right to convert. You must apply in writing to us
within 31 days
after you receive this notice. However, if you are a family member who is
losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of If you leave the FEHB Program, we will give
you a Certificate of Group Group Health Plan Coverage 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 (715) 552-4300
or 1-888-203-7770 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. 55
55 Page 56 57
2001 Group
Health Cooperative of Eau Claire 54 Index
Index
Do not
rely on this page; it is for your convenience and does not explain your benefit
coverage.
Accidental injury 39 Allergy tests 17
Alternative
treatment 21 Ambulance 29
Anesthesia 12, 26 Autologous bone marrow
transplant 25 Biopsies 22
Blood and blood plasma 28 Breast cancer
screening 14
Changes for 2001 7 Chemotherapy 17
Cholesterol tests 14
Claims 41
Copayments 11 Colorectal cancer screening 14
Congenital
anomalies 22 Contraceptive devices and drugs 16,
36 Coordination of benefits
44
Covered charges 8 Covered providers 8
Crutches 20 Deductible
11, 20
Definitions 48 Dental care 39
Diagnostic services 13 Disputed
claims review 42
Donor expenses (transplants) 25 Dressings 28
Durable
medical equipment (DME) 11, 20
Educational classes and programs 21
Effective date of enrollment 51
Emergency 33, 32 Experimental or
investigational
48 Eyeglasses 19
Family planning 16 Fecal occult blood test 14
General
Exclusions 40 Hearing services 18
Home health services 20 Hospice
care 29
Home nursing care 20, 21 Hospital 9, 27
Immunizations 15
Infertility 16
Inpatient Hospital Benefits 27, 28
Insulin 20, 36
Laboratory and pathological
services 14 Magnetic Resonance Imagings
(MRIs) 14 Mammograms 14
Maternity Benefits 16 Medicaid 47
Medically
necessary 48 Medicare 44
Mental Conditions/ Substance Abuse Benefits 33
Newborn care 16 Nurse
Nurse Midwife 5 Nurse Practitioner 5
Registered Nurse 38 Nursery charges 16
Obstetrical care 16
Occupational therapy 18
Office visits 13 Oral and maxillofacial surgery 24
Orthopedic devices 20 Outpatient facility care 28
Oxygen 20 Pap
test 14
Physical examination 14 Physical therapy 18
Preventive care, adult 14
Preventive care, children 15
Prescription drugs 35 Preventive services 14,
15
Prior approval 10 Prosthetic devices 20
Psychologist 33 Radiation
therapy 17
Rehabilitation therapies 18 Renal Dialysis 17
Room &
Board 27 Second surgical opinion 13
Skilled nursing facility care 29
Smoking cessation 37
Speech therapy 18 Splints 28
Sterilization
procedures 16, 23
Subrogation 47 Substance abuse 33
Surgery 22 ·
Anesthesia 26
· Oral 24 · Outpatient 28
·
Reconstructive 23 Syringes 36
Temporary continuation of coverage 51
Transplants 25 Vision services 15, 19
Well child care 15
Wheelchairs 20
Workers' compensation 47 X-rays 14 56
56 Page 57 58
2001 Group Health Cooperative of Eau Claire 55
NOTES: 57
57 Page
58 59
2001 Group Health Cooperative of
Eau Claire 56 Summary
Summary of benefits for the
Group Health Cooperative of Eau Claire -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, $10
chiropractic
13
Services provided by a hospital:
· Inpatient
.......................................................................................
·
Outpatient.....................................................................................
Nothing Nothing
27
28
Emergency benefits:
·
In-area.........................................................................................
· Out-of-area
..................................................................................
$25 copayment per visit
$25 copayment per visit
30
30
Mental health and substance abuse
treatment.................................... Regular cost sharing. 33
Prescription drugs
.............................................................................
$7.50 copay per prescription 35
Dental
Care....................................................................................
No benefit. 39
Vision
Care....................................................................................
Nothing for one annual exam. 19 58
58 Page 59 60
2001 Group
Health Cooperative of Eau Claire 57 Section 4
2001 Rate
Information for
Group Health Cooperative of Eau Claire
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
Fill in Location Here
Self Only WT1 $86.59 $48.63 $187.61 $105.37
$102.22 $33.00
Self and Family WT2 $195.82 $153.12 $424.28 $331.76 $231.17 $117.77 59
59 Page 60
2001 Group Health Cooperative of Eau Claire 58 Section 4
60