Alliance Health Benefit Plan 2002
http:// www.
ahbp. com
Sponsored and administered by: The National Alliance of Postal and
Federal Employees.
Who may enroll in this Plan: All eligible civilian
employees and annuitants who become members or associate members of the National
Alliance of Postal
and Federal Employees (NAPFE).
To become a member
or associate member: At installations and subdivisions where there is a
NAPFE local, you may join as a regular or associate member. If there is no
local, or you are an
annuitant, you will automatically become an associate
member of the NAPFE.
Annuitants (retirees) may enroll in this plan.
Membership dues: $5.00 per month. Members will have the option of
paying dues on an annual or semi-annual basis. Dues paid on an annual basis on
or before March first of the plan year will
receive a 10% discount. NAPFE
will bill new associate members for annual dues when it receives notice of
enrollment. NAPFE will also bill continuing associate members for the annual
membership.
Enrollment codes for this Plan:
1R1 Self Only 1R2 Self and Family
RI 71-003
A fee-for-service plan with a preferred provider organization
Forchangesin
benefits, see page 6. 1
1
Page 2 3
Introduction
................................................................................................................................................................................................
4
Plain Language
...........................................................................................................................................................................................
4
Inspector General Advisory
.......................................................................................................................................................................
4
Section 1. Facts about this fee-for-service plan
......................................................................................................................................
5
Section 2. How we change for 2002
.......................................................................................................................................................
6
Section 3. How you get care
....................................................................................................................................................................
7
Identification cards
..................................................................................................................................................................
7
Where you get covered care
...................................................................................................................................................
7
Covered providers
.........................................................................................................................................................
7
Covered Facilities
..........................................................................................................................................................
7
What you must do to get covered care
..................................................................................................................................
8
How to get approval for
..........................................................................................................................................................
8
Your hospital stay (precertification)
..........................................................................................................................
8-9
Other services
................................................................................................................................................................
9
Section 4. Your costs for covered services
............................................................................................................................................
10
Copayments
.................................................................................................................................................................
10
Deductible
....................................................................................................................................................................
10
Coinsurance
............................................................................................................................................................
10-11
Differences between our allowance and the bill
........................................................................................................
11
Your out-of-pocket
maximum...............................................................................................................................................
12
When government facilities bill us
.......................................................................................................................................
12
If we overpay you
.................................................................................................................................................................
12
When you are age 65 or over and you do not have
Medicare
...........................................................................................
13
When you have Medicare.
....................................................................................................................................................
14
Section 5. Benefits
..................................................................................................................................................................................
15
Overview
...............................................................................................................................................................................
15
(a) Medical services and supplies provided by
physicians and other health care professionals
...................................... 16
(b) Surgical
and anesthesia services provided by physicians and other health care
professionals .................................. 24
(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
Table of Contents
2002 Alliance Health Benefit Plan 2 Table of Contents 2
2 Page 3 4
(g) Special features
..............................................................................................................................................................
38
Flexible benefits option
24 hour nurse line
Services for
deaf and hearing impaired
High risk pregnancies
Centers of
excellence for transplant/ heart surgery/ etc.
Travel benefits for organ
transplant
(h) Dental benefits
...............................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
...........................................................................................................
40
Section 6. General exclusions things we don't
cover
......................................................................................................................
41
Section 7. Filing a claim for covered services
......................................................................................................................................
42
Section 8. The disputed claims process
.................................................................................................................................................
44
Section 9. Coordinating benefits with other
coverage
..........................................................................................................................
46
When you have other health coverage
.................................................................................................................................
46
Original Medicare
.................................................................................................................................................................
46
Medicare managed care plan
................................................................................................................................................
49
TRICARE/ Workers Compensation/ Medicaid
.......................................................................................................................
49
When other Government agencies are responsible for
your care
.......................................................................................
50
When others are responsible for injuries
.............................................................................................................................
50
Section 10. Definitions of terms we use in this
brochure
.......................................................................................................................
51
Section 11. FEHB facts
...........................................................................................................................................................................
55
Coverage
information............................................................................................................................................................
55
No pre-existing condition limitation
...........................................................................................................................
55
Where you get information about enrolling in the FEHB Program
.......................................................................... 55
Types of coverage available for you and your family
...............................................................................................
55
When benefits and premiums start
.............................................................................................................................
55
Your medical and claims records are confidential
.....................................................................................................
56
When you retire
...........................................................................................................................................................
56
When you lose benefits
.....................................................................................................................................................
56
When FEHB coverage ends
........................................................................................................................................
56
Spouse equity coverage
...............................................................................................................................................
56
Temporary Continuation of Coverage (TCC)
............................................................................................................
56
Converting to individual coverage
..............................................................................................................................
57
Getting a Certificate of Group Health Plan Coverage
...............................................................................................
57
Long term care insurance is coming later in 2002
.................................................................................................................................
58
Department of Defense/ FEHB Program Demonstration
Project
............................................................................................................
59
Index
.........................................................................................................................................................................................................
61
Summary of benefits
...........................................................................................................................................................................
62-63
Rates
..........................................................................................................................................................................................
Back Cover
2002 Alliance Health Benefit Plan 3 Table of Contents 3
3 Page 4 5
2002 Alliance Health Benefit Plan 4 Introduction/ Plain Language/
Advisory
Introduction
The Alliance Health Benefit Plan 1628
11 th Street NW
Washington, DC 20001
This brochure describes the
benefits of the Alliance Health Benefit Plan under our contract CS 1164 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, 2002, unless those benefits are also shown in this brochure.
OPM
negotiates benefits and rates with each plan annually.
Benefit changes are effective January 1, 2002, and changes are summarized on
page 6. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and Health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and under-standable
to the public. For instance,
Except for necessary technical terms, we use common words. For instance
"you" means the enrollee or family member; "we" means the Alliance Health
Benefit Plan.
We limit acronyms to ones you know. FEHB is the Federal
Employees Health Benefits Program. OPM is the Office of Personnel Management. If
we use others, we tell you what they mean first.
Our brochure and other
FEHB plans' brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or
suggestions about how to improve the structure of this brochure, let OPM
know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail
OPM at fehbwebcomments@ opm. gov. You may also write to OPM at the Office
of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650.
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 1/ 800-321-0347 and
explain the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
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. 4
4 Page 5 6
2002 Alliance Health Benefit Plan 5 Section 1
Section 1.
Facts about this fee-for-service plan
This Plan is a fee-for-service
(FFS) plan. You can choose your own physicians, hospitals, and other health care
providers.
We reimburse you or your provider for your covered services,
usually based on a percentage of the amount we allow. The type and extent of
covered services, and the amount we allow, may be different from other plans.
Read brochures carefully.
We also have Preferred Provider Organizations (PPO):
Our
fee-for-service plan offers services through a PPO. When you use our PPO
providers, you will receive covered services at reduced cost. Contact us for the
names of PPO providers and to verify their
continued participation. You can also go to our web
page, which you can
reach through the FEHB web site, www. opm. gov/ insure. Do not call OPM or
your agency for our provider directory.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. Provider networks may be more extensive
in some areas than others. We cannot guarantee the availability of every
speciality in all areas. If
no PPO provider is available, or you do not use
a PPO provider, the standard non-PPO benefits apply.
How we pay providers
This Plan has entered into an agreement with
First Health to use The First Health Network, a Preferred Provider
Organization (PPO). This is a group of doctors, hospitals and other providers
who have contracted with First Health to provide medical
services at
reduced cost. This PPO operates in 50 states, plus Puerto Rico and the District
of Columbia. Each time you need medical care you have the choice to use a health
care provider who participates in the network or one who doesn't.
When you use a PPO hospital, your benefits increase from 70% after the $250
inpatient deductible to 90% after the $150 inpatient deductible. When you use a
PPO doctor, your surgery benefits increase to 90% after a $100 deductible and
your office visit
benefits increase to paid in full after a $15 copayment.
Non-PPO benefits for both are 70% after a $300 deductible. Precertification is
required as explained on pages 8 and 9 for all inpatient
hospitalizations. It is your responsibility to complete this prior
notifica-tion;
however, your PPO doctor may initiate precertification
and will file your claims for you. Note: PPO benefits are not payable when the
Alliance Health Benefit Plan is not the primary payer.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get
information about us, our networks, providers, and facilities. OPM's FEHB
website (www. opm. gov/ insure) lists the specific types of information that
we
must make available to you. Some of the required information is listed
below.
Network providers must meet specific criteria including location,
medical specialty, professional skill and proper credentials Years in
existence
Profit status
If you want more information about us, call 1/
800-321-0347 or for calls in the Washington, DC metropolitan area (202)
939-6325, or write to Alliance Health Benefit Plan, 1628
11th Street NW, Washington, DC 20001. You may also contact us by fax at
202-
939-6389 or visit our website at http:// www. ahbp. com. 5
5 Page 6 7
2002 Alliance Health Benefit Plan 6
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a clarification
that does not
change benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Four states are added to the list of medically
underserved areas: Georgia, Montana, North Dakota, and Texas. Louisiana is no
longer medically underserved. (Section 3)
Changes to this Plan
Your share of the non-postal premium will
increase by 10.4% for Self Only or 8.0% for Self and Family.
We clarified
the brochure to better explain that the non-PPO benefits are the standard
benefits of this Plan, that PPO benefits apply only when you use a PPO provider,
and that when no PPO provider is available, non-PPO benefits apply.
We clarified that blood lead level screening for children is covered.
Under the retail prescription drug benefit, you pay 10% coinsurance for the
initial prescription and 50% for all refills.
Occupational and physical
therapy services are limited to 45 visits per calendar year
Speech therapy
services are limited to 45 visits per calendar year
We changed speech
therapy benefits by removing the requirement that services must be required to
restore functional speech. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5(
b)) 6
6 Page 7 8
2002 Alliance Health Benefit Plan 7 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 1/ 800-225-4423.
Where you get covered care You can get care from any "covered
provider" or "covered facility." How much we pay and you pay depends on the
type of covered provider or facility you use. If you
use our preferred
providers, you will pay less.
Covered providers We consider the
following to be covered providers when they perform services within the scope of
their license or certification:
(1) a licensed doctor of medicine (M. D.), or a licensed doctor of osteopathy
(D. O.), and a licensed podiatrist practicing within the scope of their license.
(2) other covered providers include: a Chiropractor, Dentist, Optometrist,
Clinical Psychologist, Clinical Social Worker, Nurse Midwife, Nurse
Practitioner/ Clinical
Specialist, Nurse Anesthetist or Nursing School
Administered Clinic. Charges for Christian Science Nurses and Christian Science
Practitioners who are listed in the
Christian Science Journal will be
covered under this Plan the same as other medical providers.
Medically underserved areas. Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that license
in states OPM
determines are "medically underserved." For 2002, the states
are: Alabama, Georgia, Idaho, Kentucky, Mississippi, Missouri, Montana, New
Mexico, North Dakota, South
Carolina, South Dakota, Texas, Utah, and
Wyoming.
Covered facilities Covered facilities include:
Birthing Center: A free standing facility licensed or certified by the State
in which it functions, or Plan approved, which offers comprehensive maternity
care in a
home-like atmosphere.
Hospice: A facility which
provides short periods of stay for a terminally ill person in a home-like
setting for either direct care or respite. This facility may either be
free-standing or affiliated with a hospital. It must operate as an integral
part of the hospice care program.
Hospital: An institution licensed by the State or conforming to the
standards of, and accredited by, the Joint Commission on Accreditation of Health
Care Organizations
(JCAHO) providing inpatient diagnostic and therapeutic
facilities for surgical and medical diagnosis, treatment and care of injured and
sick persons by or under the
supervision of a staff of licensed doctors of
medicine (M. D.), or licensed doctors of osteopathy (D. O.). The hospital must
provide continuous 24-hour-a-day professional
registered nursing (R. N.)
services and may not be an Extended Care Facility (other than an approved ECF);
nursing home; a place for rest; an institution for exceptional
children, the
aged, drug addicts, or alcoholics; or a custodial or domiciliary institution
having the primary purpose of furnishing food, shelter, training, or non-medical
personal services. This definition includes college infirmaries and Veterans
Administration Hospitals. This also includes Christian Science Nursing
facilities that
are approved by the Commission for the Accreditation of
Christian Science Nursing Organizations/ Facilities, Inc. 7
7 Page 8 9
2002 Alliance Health Benefit Plan 8 Section 3
What you must do to get It depends on the kind of care you want
to receive. You can go to any provider you covered care want, but we must
approve some care in advance.
Transitional care: Speciality care: If
you have a chronic or disabling condition and
lose access to your PPO
specialist because we drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan, or
lose access to your PPO specialist because we terminate our contract with
your specialist for other than cause,
you may be able to continue seeing
your PPO specialist and receiving any PPO benefits 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 PPO specialist based on the above
circumstances, you can continue to see your
specialist and any PPO benefits continue until the end of your postpartum
care, even if it is beyond the 90 days.
Hospital care We pay for covered services from the effective date of
your enrollment. However, if you are in the hospital when your enrollment in our
Plan begins, call our customer
service department immediately at 1/
800-321-0347.
If you changed from another FEHB plan to us, your former plan
will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to benefits of the hospitalized person.
How to Get Approval for...
Your hospital stay
Precertification is the process by which prior to your inpatient hospital
admission we evaluate the medical necessity of your proposed stay and the
number of days
required to treat your condition. Unless we are misled by the information
given to us, we won't change our decision on medical necessity.
In most cases, your physician or hospital will take care of precertification.
Because you are still responsible for ensuring that we are asked to precertify
your care, you should
always ask your physician or hospital whether they
have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay
by $500 if no one contacts us for precertification. If the stay is not medically
necessary, we will not pay any
benefits.
How to precertify an admission: You, your representative, your
doctor, or your hospital must call us at 1/ 800-225-4423 at least 48 hours
before admission.
If you have an emergency due to a condition that you reasonably believe
puts your life in danger or could cause serious damage to bodily function, you,
your
representative, the doctor, or the hospital must telephone us within
two business days following the day of the emergency admission, even if you have
been
discharged from the hospital.
Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth
date, and phone number; 8
8 Page
9 10
2002 Alliance Health Benefit Plan
9 Section 3
Reason for hospitalization, proposed treatment, or
surgery;
Name and phone number of admitting doctor;
Name of hospital
or facility; and
Number of planned days of confinement.
We will then tell the doctor and/ or hospital the number of approved
inpatient days and we will send written confirmation of our decision to you,
your doctor, and the
hospital.
Maternity care You do not need to
precertify a maternity admission for a routine delivery. However, if your
medical condition requires you to stay more than 48 hours after a vaginal
delivery
or 96 hours after a cesarean section, then your physician or the
hospital must contact us for precertification of additional days. Further, if
your baby stays after you are
discharged, then your physician or the
hospital must contact us for precertification of additional days for your baby.
If your hospital stay If your hospital stay including for maternity
care needs to be extended, you, needs to be extended: your
representative, your doctor or the hospital must ask us to approve the
additional
days.
What happens when you When we precertified the
admission but you remained in the hospital beyond the do not follow the
number of days we approved and did not get the additional days precertified,
then:
precertification rule for the part of the admission that was
medically necessary, we will pay inpatient
benefits, but
for the part
of the admission that was not medically necessary, we will pay only medical
services and supplies otherwise payable on an outpatient basis and will
not pay inpatient benefits.
If no one contacted us, we will decide
whether the hospital stay was medically necessary.
If we determine that the stay was medically necessary, we will pay the
inpatient charges, less the $500 penalty.
If we determine that it was not
medically necessary for you to be an inpatient, we will not pay inpatient
hospital benefits. We will only pay for any covered
medical supplies and
services that are otherwise payable on an outpatient basis.
If we denied
the precertification request, we will not pay inpatient hospital benefits. We
will only pay for any covered medical supplies and services that are otherwise
payable on an outpatient basis.
Exceptions: You do not need
precertification in these cases:
You are admitted to a hospital outside
the United States or Puerto Rico.
You have another group health insurance
policy that is the primary payer for the hospital stay.
Your Medicare part A is the primary payer for the hospital stay. Note: If
you exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days, then we will become the primary payer and you do
need precertification.
Other services Some services require a referral, precertification,
or prior authorization.
Right-sided heart catheterization.
Mental
Health and Substance Abuse services and admissions
Growth Hormone Therapy
9
9 Page 10 11
2002 Alliance Health Benefit Plan 10 Section
4
Section 4. Your costs for covered services
This is what you
will pay out-of-pocket for your covered care:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.
Example: When you see your PPO physician you pay a copayment of $15 per visit
and when you go in a PPO hospital, you pay $150 per admission.
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 them. Copayments do not
count toward any deductible.
The
calendar year deductible is $100 per person for PPO benefits and $300 per person
for Non-PPO benefits. Under a family enrollment, the deductible is satisfied
for all family members when the combined covered expenses applied to the
calendar year deductible for family members reach $300 for PPO benefits and $900
for Non-PPO
benefits.
We also have separate deductibles for:
There is a combined annual $200 deductible per person for mail order and/ or
retail prescription drugs.
There is a Non-PPO $500 deductible per person, per confinement for
inpatient care for mental conditions.
Note: If you change plans during open
season, you do not have to start a new deductible under your old plan between
January 1 and the effective date of your new
plan. If you change plans at
another time during the year, you must begin a new deductible under your new
plan.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. Coinsurance doesn't begin until you meet your
deductible.
Example: You pay 30% of our allowance for non-PPO physician
office visits.
10% for PPO inpatient hospital room/ board, and other
hospital charges;
30% for non-PPO inpatient hospital room/ board, and
other hospital charges;
10% for PPO inpatient and outpatient surgical
benefits, maternity benefits, and other medical benefits;
30% for non-PPO inpatient and outpatient surgical benefits, maternity
benefits, and other medical benefits;
10% for PPO inpatient hospital
charges for treatment of mental conditions;
30% for non-PPO inpatient
hospital charges for treatment of mental conditions;
10% for PPO doctors'
visits for (inpatient) mental conditions;
30% for non-PPO doctors' visits
(inpatient and outpatient) for mental conditions;
10% for PPO inpatient
hospital charges for treatment of substance abuse; 10
10 Page 11 12
EXAMPLE PPO physician Non-PPO physician
Physician's charge $150 $150
Our allowance We set it at: 100 We set
it at: 100
We pay 90% of our allowance: 90 70% of our allowance: 70
You
owe: Coinsurance 10% of our allowance: 10 30% of our allowance: 30
+Difference up to charge? No: 0 Yes: 50
TOTAL YOU PAY $10 $80
2002 Alliance Health Benefit Plan 11 Section 4
30% for non-PPO inpatient hospital charges for treatment of substance
abuse;
50% for non-PPO inpatient and outpatient professional charges for
treatment of substance abuse;
20% for skilled nursing facility
Note: If your provider routinely
waives (does not require you to pay) your copayments, deductibles, or
coinsurance, the provider is misstating the fee and may be
violating the
law. In this case, when we calculate our share, we will reduce the provider's
fee by the amount waived.
For example, if your physician ordinarily charges $100 for a service but
routinely waives your 30% coinsurance, the actual charge is $70. We will pay $49
(70% of the
actual charge of $70).
Differences between Our
"Plan allowance" is the amount we use to calculate our payment for covered
our allowance and services. Fee-for-service plans arrive at their
allowances in different ways, so their
the bill allowances vary. For more information about how we determine
our Plan allowance, see the definition of Plan allowance in Section 10.
Often, the provider's bill is more than a fee-for-service plan's allowance.
Whether or not you have to pay the difference between our allowance and the bill
will depend on
the provider you use.
PPO providers agree to
limit what they will bill you. Because of that, when you use a preferred
provider, your share of covered charges consists only of your
deductible and
coinsurance or copayment. Here is an example about coinsurance: You see a PPO
physician who charges $150, but our allowance is $100. If you have
met your
deductible, you are only responsible for your coinsurance. That is, you just pay
10% of our $100 allowance ($ 10). Because of the agreement, your PPO
physician will not bill you for the $50 difference between our allowance and
his bill.
Non-PPO providers, on the other hand, have no agreement to limit
what they will bill you. When you use a non-PPO provider, you will pay your
deductible and
coinsurance plus any difference between our
allowance and charges on the bill. Here is an example: You see a non-PPO
physician who charges $150 and our
allowance is again $100. Because you've
met your deductible, you are responsible for your coinsurance, so you pay 30% of
the $100 allowance ($ 30). Plus, because
there is no agreement between the
non-PPO physician and us, he can bill you for the $50 difference between our
allowance and his bill.
The following table illustrates the examples of how much you have to pay
out-of-pocket for services from a PPO physician vs. a non-PPO physician. The
table uses our
example of a service for which the physician charges $150 and
our allowance is $100. The table shows the amount you pay if you have met your
calendar year deductible. 11
11 Page 12 13
2002 Alliance Health Benefit Plan 12 Section 4
Your
catastrophic protection For those services with coinsurance, the Plan pays
100% of the plan allowance for the out-of-pocket maximum for remainder of
the calendar year after the calendar year deductible is met when
out-of-deductibles,
coinsurance, pocket expenses for coinsurance in
that calendar year exceed $2,000 under the PPO and copayments benefit.
The Plan pays 100% of the plan allowance, if out-of-pocket expenses for the
coinsurance in that calendar year exceed $3,000 under the non-PPO benefit.
Any expenses incurred through PPO or non-PPO benefits are applied toward both
catastrophic limits.
Out-of-pocket expenses for the purposes of this
benefit are:
The $100 calendar year deductible for PPO benefits;
The
$300 calendar year deductible for non-PPO benefits;
The $150 PPO per
admission inpatient hospital copayment;
The $250 non-PPO per admission
inpatient hospital copayment;
The 10% you pay for PPO hospital, surgical,
maternity and other medical benefits;
The 30% you pay for non-PPO hospital, surgical, maternity and other medical
benefits.
The following cannot be counted toward out-of-pocket expenses:
Expenses
in excess of the plan allowance or maximum benefit limitations;
Expenses
for dental care;
Any amounts you pay because benefits have been reduced for non-compliance with the Plan's cost
containment requirements (see pages 8 and 9);
PPO office visit copayments;
Expenses for prescription drugs
purchased through retail or mail order program; and
Expenses for skilled nursing facility confinements.
Carryover If
you changed to this Plan during open season from a plan with a catastrophic
protection benefit and the effective date of the change was after January 1, any
expenses that would have applied to that plan's catastrophic protection
benefit during the prior year will be covered by your old plan if they are for
care you got in January
before the effective date of your coverage in this
Plan. If you have already met the covered out-of-pocket maximum expense level in
full, your old plan's catastrophic
protection benefit will continue to apply
until the effective date. If you have not met this expense in full, your old
plan will first apply your covered out-of-pocket expenses
until the prior
year's catastrophic level is reached and then apply the catastrophic protection
benefit to covered out-of-pocket expenses incurred from that point until the
effective date. The old plan will pay these covered expenses according to
this year's benefits; benefit changes are effective on January 1.
When government facilities Facilities of the Department of Veterans
Affairs, the Department of Defense, and the bill us Indian Health Service
are entitled to seek reimbursement from us for certain services
and supplies
they provide to you or a family member. They may not seek more than their
governing laws allow.
If we overpay you We will make diligent efforts to recover benefit
payments we made in error but in good faith. We may reduce subsequent benefit
payments to offset overpayments. 12
12 Page 13 14
2002 Alliance
Health Benefit Plan 13 Section 4
When you are age 65 or over
and you do not have Medicare
Under the FEHB law, we must limit our
payments for those benefits you would be entitled to if you had Medicare. And,
your physician and hospital must follow Medicare rules and cannot bill you for
more than they could bill you if you had Medicare. The
following chart has more information about the limits.
If you
are age 65 or over, and
do not have Medicare Part
A, Part B, or both; and
have this Plan as an annuitant or as a former
spouse, or as a family member of an annuitant or former spouse; and
are
not employed in a position that gives FEHB coverage. (Your employing office can
tell you if this applies.)
Then, for your inpatient hospital care,
the law requires us to
base our payment on an amount the "equivalent Medicare amount" set by
Medicare's rules for what Medicare would pay, not on the actual charge;
you are responsible for your applicable deductibles, coinsurance or
copayments you owe under this Plan;
you are not responsible for any
charges greater than the equivalent Medicare amount; we will show that amount on
the explanation of benefits (EOB) form that we send you; and
the law prohibits a hospital from collecting more than the Medicare
equivalent amount.
And, for your physician care, the law requires us to base our payment
and your coinsurance on...
an amount set by Medicare and called the
"Medicare approved amount," or
the actual charge if it is lower than the
Medicare approved amount.
It is generally to your financial advantage to use a physician who
participates with Medicare. Such physicians are permitted to collect only up to
the Medicare approved amount.
Our explanation of benefits (EOB) form will
tell you how much the physician or hospital can collect from you. If your
physician or hospital tries to collect more than allowed by law, ask the
physician or hospital to reduce the charges. If you have paid more
than
allowed, ask for a refund. If you need further assistance, call us.
If your Physician.... Then you are responsible for...
Participates
with Medicare or accepts your deductibles, coinsurance, and copayments; Medicare
assignment for the claim and
is a member of our PPO network,
Participates with Medicare and is not your deductibles, coinsurance,
copayments and in our PPO network, any balance up to the Medicare approved
amount;
Does not participate with Medicare, your deductibles,
coinsurance, copayments, and any balance up to 115% of the Medicare
approved
amount 13
13 Page
14 15
2002 Alliance Health Benefit
Plan 14 Section 4
When you have the Original Medicare Plan
We limit our payment to an amount that supplements the benefits that
(Part A, Part B, or both) Medicare would pay under Medicare Part A
(Hospital insurance) and
Medicare Part B (Medical insurance), regardless of
whether Medicare pays. Note: We pay our regular benefits for emergency services
to an
institutional provider, such as a hospital, that does not participate
with Medicare and is not reimbursed by Medicare.
If you are covered by Medicare Part B and it is primary, your out-of-pocket
costs for services that both Medicare Part B and we cover
depend on whether
your physician accepts Medicare assignment for the claim.
If your physician accepts Medicare assignment, then you pay nothing for
covered charges.
If your physician does not accept Medicare assignment,
then you pay the difference between our payment combined with Medicare's
payment and the charge.
Note: The physician who does not accept Medicare
assignment may not bill you for more than 115% of the amount Medicare bases its
payments on, called the " limiting charge." The Medicare Summary Notice
(MSN) that Medicare will send you will have more
information about the
limiting charge. If your physician tries to collect more than allowed by law,
ask the physician to reduce the
charges. If the physician does not, report
the physician to your Medicare carrier who sent you the MSN form. Call us if you
need
further assistance.
When you have a Medicare A physician may ask you to sign a private
contract agreeing that you Private Contract with a physician can be
billed directly for services Medicare ordinarily covers. Should
you sign an
agreement, Medicare will not pay any portion of the charges, and we will not
increase our payment. We will still limit our
payment to the amount we would
have paid after Medicare's payment.
Please see Section 9, Coordinating benefits with other coverage, for more
information about how we coordinate benefits with Medicare. 14
14 Page 15 16
2002 Alliance Health Benefit Plan 15 Section 5
Section
5. Benefits OVERVIEW
(See page 6 for how
our benefits changed this year and pages 62-63 for a
benefits summary.)
Note: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To
obtain claims forms, claims filing
advice, or more information about our benefits, contact us at 1/ 800-225-4423 or
at our website at www. ahbp. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .................................................... 16-23
Diagnostic and treatment services Hearing services (testing, treatment,
and supplies) Lab, X-ray, and other diagnostic tests Vision services
(testing, treatment, and supplies)
Preventive care, adult Foot care Preventive care, children Orthopedic
and prosthetic devices
Maternity care Durable medical equipment (DME)
Family planning Home health services
Infertility services Chiropractic
Allergy care Alternative treatments
Treatment therapies Education
classes and programs Physical and occupational therapy
Speech therapy
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................................. 24-28
Surgical procedures Organ/ tissue transplants Reconstructive surgery
Anesthesia
Oral and maxillofacial surgery
(c) Services provided by a hospital or
other facility, and ambulance services
...............................................................................
29-31
Inpatient hospital Hospice care Outpatient hospital or
ambulatory surgical center Ambulance
Extended care benefits/ Skilled nursing care facility benefits
(d)
Emergency services/ Accidents
.....................................................................................................................................................
32-33
Medical emergency Ambulance Accidental emergency
Ambulance
(e) Mental health and substance abuse benefits
...............................................................................................................................
34-35
(f) Prescription drug benefits
............................................................................................................................................................
36-37
(g) Special features
.................................................................................................................................................................................
38
Flexible Benefits Option 24 Hour Nurse
Services for Deaf and Hearing Impaired High Risk Pregnancies
Centers for Excellence for Transplants/ Heart/ Surgery/ Etc. Travel Benefit
for organ transplants
(h) Dental benefits
..................................................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
..............................................................................................................................
40
SUMMARY OF
BENEFITS.................................................................................................................................................................
62-63 15
15 Page
16 17
I M
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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.
Diagnostic and treatment
services
Professional services of physicians PPO: $15 copayment (No
deductible)
In physician's office
Second surgical opinion
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial
examination of newborn child covered under a family enrollment
At home
2002 Alliance Health Benefit Plan 16 Section 5 (a)
Here are some important things you should 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.
The calendar year deductibles are: PPO $100 per person ($ 300 per family);
Non-PPO $300 per person ($ 900 per family). Calendar year deductibles apply to
almost all benefits in this
Section. We added "( No deductible)" to show
when a calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. When no PPO provider is available,
non-PPO benefits apply.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works,
with special sections for members who are age 65 or over. Also
read Section
9 about coordinating benefits with other coverage, including with Medicare.
Section 5 (a). Medical services and supplies provided by physicians and
other
health care professionals
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 16
16 Page 17 18
2002 Alliance Health Benefit Plan 17 Section
5 (a)
Lab, X-ray and other diagnostic tests You pay
Tests,
such as
Blood tests
Urinalysis
Non-routine pap smears
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiograms and EEG
Preventive care, adults
Routine screenings, limited to:
Blood Cholesterol Screening
Chlamydial Infection Screening
Colorectal Cancer Screening, including
Fecal occult blood test annually
for members age 40 and older
Sigmoidoscopy, screening one every five
years starting at age 50
Prostate Specific Antigen (PSA test) one annually for men age 40 and older
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Routine pap test one annually for women age 18
and older PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
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
Routine physical one annually every two years
Note: The maximum PPO
benefit is $150
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster
once every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Not
Covered: All charges
Preventive medical care and services,
including;
Periodic checkups
associated X-ray and lab test
immunizations such as polio, flu, mumps and smallpox, except as
shown
under preventive care, adults and preventive care, children
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
Note: If your PPO
provider uses a non-PPO lab or radiologist, we will pay non-PPO
benefits for
any lab and X-ray charges.
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and
the billed amount
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and
the billed amount
PPO: $15 copayment (No deductible)
Non-PPO: All
charges
PPO: Nothing after office visit copayment
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount 17
17 Page 18 19
2002 Alliance Health Benefit Plan 18 Section 5 (a)
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy PPO: Nothing (No deductible) of Pediatrics
for children under age 22
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and the billed amount
For well-child care charges for routine
examinations, immunizations PPO: $15 copayment (No deductible) and care (to age
6) limited to 12 well care visits.
Non-PPO: 30% of the Plan allowance and Sickle Cell Screening for newborns
for sickle cell anemia any difference between our allowance and
the billed
amount Blood lead level screening
Examinations, limited to: PPO: $15 copayment (No deductible)
Examinations for amblyopia and strabismus limited to one screening (ages 2
through 6)
Examinations done on the day of the immunizations (ages 3 through age 22)
Maternity care
Compete maternity (obstetrical) care, such as: PPO:
10% of the Plan allowance
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 cover an extended stay
if
medically necessary, but you, you representative, your doctor, or your hospital
must precertify.
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 if we cover the infant under a
Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits
(Section 5b)
Not covered: Routine sonograms to determine fetal age, size
or sex All charges
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant)
Injectable contraceptive drugs (such as
Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We
cover contraceptive drugs in Section 5( f).
Not covered: Reversal of voluntary surgical sterilization, genetic
counseling. All charges
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 18
18 Page 19 20
2002 Alliance Health Benefit Plan 19 Section 5 (a)
PPO: 10%
of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and
the billed amount
Infertility services You pay
Diagnosis and treatment of
infertility, except as shown in Not covered. PPO: 10% of the Plan
allowance
(Including fertility drugs) Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
Not covered:
All charges
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as:
artificial insemination
in vitro fertilization
embryo transfer and GIFT
intravaginal
insemination (IVI) intracervical insemination (ICI)
intrauterine insemination (IUI)
Services and supplies
related to ART procedures.
Cost of donor sperm
Cost of
donor egg
Allergy care
Testing and treatment, including materials (such as
allergy serum) PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Allergy injections PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Not covered: provocative food testing and
sublingual allergy desensitization All charges
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed on page 26.
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)
Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy
(GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: We only cover GHT when we preauthorize the treatment. Call 1/
800-225-4423 for preauthorization. We will ask you to submit information
that establishes that the GHT is medically necessary. Ask us to authorize GHT
before you began 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.
Respiratory and inhalation therapies 19
19
Page 20 21
2002
Alliance Health Benefit Plan 20 Section 5 (a)
Physical and
occupational therapies You pay
Physical and Occupational therapy;
Up to 45 visits per calendar year for the services provided by a:
qualified physical therapist; and
occupational therapist
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to illness or injury and when
a
physician:
1) orders the care;
2) identifies the specific professional
skills the patient requires and the medical necessity for skilled services; and
3) indicates the length of time the service is needed.
Not covered:
All charges
Exercise programs
Chelation therapy,
except for acute arsenic, gold, lead, or mercury poisoning.
Massage therapy
Speech therapy
Speech therapy:
Up to 45 visits per calendar year for the services provided by a:
Speech
therapist
Hearing services (testing, treatment, and supplies)
Testing only
when necessitated by accidental injury PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Not covered: All charges
hearing
testing, except for accidental injury
hearing aids, testing and
examinations for them
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment PPO: 10% of the Plan
allowance directly caused by accidental ocular injury or intraocular surgery
(such
as for cataracts) Non-PPO: 30% of the Plan allowance and any difference
between our allowance and
Note: See Preventive care, children for eye exams
for children
Not covered: All charges
Eyeglasses or contact
lenses and examinations for them
Eye exercise and orthoptics
Radial keratotomy and other refractive surgery
PPO: 10% of the Plan allowance and all cost after 45 visits.
Non-PPO: 30%
of the Plan allowance and any difference between our allowance and
the
billed amount and all cost after 45 visits.
PPO: 10% of the Plan allowance and all cost after 45 visits.
Non-PPO: 30%
of the Plan allowance and any difference between our allowance and
the
billed amount and all cost after 45 visits. 20
20
Page 21 22
2002
Alliance Health Benefit Plan 21 Section 5 (a)
Foot care You
pay
Routine foot care when you are under active treatment for a
metabolic or PPO: $15 copayment and/ or 10% of the Plan peripheral vascular
disease, such as diabetes. allowance
See orthopedic and prosthetic devices for information on podiatric shoe
Non-PPO: 30% of the Plan allowance and inserts. difference between our allowance
and
the billed amount
Not covered: All charges
Cutting,
trimming or removal of corns, calluses, or the free edge of toenails, and
similar routine treatment of conditions of the foot, except
as stated above
Treatment of weak, strained or flat feet or
bunions or spurs; and of any instability, imbalance or subluxation of the foot
(unless the treatment is
by open cutting surgery)
Orthopedic and prosthetic devices
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 implants following
mastectomy.
Note: Internal prosthetic devices are paid as hospital
benefits; See Section 5 (c) for payment information. Insertion of the device is
paid as surgery,
see Section 5 (b).
Not Covered: All charges
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
Durable medical equipment (DME)
Durable medical equipment (DME) is
equipment and supplies that:
1. Are prescribed by your attending physician
(i. e., the physician who is treating your illness or injury);
2. Are medically necessary;
3. Are primarily and customarily used only
for a medical purpose;
4. Are generally useful only to a person with an
illness or injury;
5. Are designed for prolonged use; and
6. Serve a
specific therapeutic purpose in the treatment of an illness or injury.
Durable medical equipment (DME) continued on next page
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 21
21 Page 22 23
2002 Alliance Health Benefit Plan 22 Section
5 (a)
Durable medical equipment (DME) (continued) You
pay
We cover rental or purchase, at our option, including repair and
adjustment, of durable medical equipment, such as oxygen and dialysis equipment.
Under this benefit, we also cover:
Hospital beds;
Wheelchairs, to
include medically necessary motorized wheelchairs;
Iron lung;
Certain types of traction equipment;
Oxygen and rental of equipment for
its administration;
Crutches; and
Walkers.
Note: Call us at 1/ 800-225-4423 as soon as your physician prescribes this
equipment. We arrange with a health care provider to rent or sell you
durable medical equipment at discounted rates and will tell you more about
this service when you call.
Not covered: All charges
exercise equipment
whirlpool baths
sun-lamps
heating pads
air conditioners
humidifiers,
dehumidifiers, and purifiers
Home health services
Nursing services:
240 units annually up
to $15 per unit when rendered by a:
Registered Nurse (R. N.), a licensed
practical nurse (L. P. N.), or a Christian Science Nurse who is listed in the
Christian Science Journal
Note: One private duty nursing unit consists of up to one hour of private
duty nursing care.
Home health care services:
60 home health visits per calendar year up
to a maximum plan payment of $40 per visit when:
A home health care visit consists of;
Less than an 8-hour shift of
nursing care; or
One therapy session; or
One social worker visit; or
Less than an 8-hour shift by a home health aide.
Covered home health care services are:
Nursing care provided on a
part-time basis (less than an 8-hour shift) by:
a) a registered nurse (RN); or
b) a licensed practical nurse (LPN); or
c) a Christian science nurse
Physical, occupational or speech therapy provided by a licensed therapist;
Home health services continued on next page
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: all charges after $15 per unit with the maximum of 240 units
Non-PPO: all charges after $15 per unit with the maximum of 240 units
PPO: (No deductible) all charges after we pay $40 per visit
Non-PPO: (No
deductible) all charges after we pay $40 per visit 22
22 Page 23 24
2002 Alliance Health Benefit Plan 23 Section 5 (a)
Home
health services (continued) You pay
Services of a
licensed social worker (but not more than 2 visits);
Home health aide
services provided on a part-time basis (less than an 8-hour shift) that;
a) are performed by a home health aide under the supervision of a registered
nurse (RN); and
b) consist mainly of medical care and therapy provided
solely for the care of the patient.
Note: The home health care services must be furnished:
by a home health
care agency (or by visiting nurses where services of a home health care agency
are not available);
in accordance with a home health care plan, see definition on page 53; and
in the patient's home
Not covered:
All charges
Nursing care requested by, or for the convenience of,
the patient or the patient's family
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or rehabilitative.
Chiropractic
Chiropractor The Plan pays a maximum of $225 per
person annually for outpatient services for:
Manipulation of the spine and extremities
Adjunctive procedures such
as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack
application
Note: No other services of a chiropractor are covered under any other
provision of this Plan.
Alternative treatments
Acupuncture by a doctor of medicine or
osteopathy for: PPO: 10% of the Plan allowance
anesthesia when used as an
anesthesic agent for covered surgery. Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
Educational classes and programs
Coverage is limited to:
Cardiac rehabilitation program Outpatient visits must consist of outpatient
cardiac rehabilitative exercise, education, and counseling when:
patient has been diagnosed as having angina pectoris (chest pain); or
patient has been hospitalized for a diagnosed myocardial infarction (heart
attack); or
coronary surgery.
Note: Services must be provided by an approved
hospital-based or hospital-coordinated cardiac rehabilitation program.
Smoking Cessation Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as drugs.
PPO: 10% of the Plan allowance and all cost after $225.
Non-PPO: 30% of
the Plan allowance and any difference between our allowance and
the billed
amount and all cost after the $225
PPO: 30% of the Plan allowance
Non-PPO: 50% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: all charges after benefits stop at $100
Non-PPO: all charges after
benefits stop at $100
PPO: (No deductible) all charges after we pay $40 per visit
Non-PPO: (No
deductible) all charges after we pay $40 per visit 23
23 Page 24 25
Here are some important things you should 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.
The calendar year deductibles are: PPO $100 per person ($ 300 per family);
Non-PPO: $300 per person ($ 900 per family). Calendar year deductibles apply to
almost all benefits in this
section. We added "( No deductible)" to show
when a calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. When no PPO provider is available,
non-PPO benefits apply.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works,
with special sections for members who are age 65 or over. 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
PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the
precertification information shown in Section 3 to be sure which
services require precertification.
I M
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Section 5 (b). Surgery and anesthesia services provided by physicians and
other
health care professionals
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.
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative
care by a surgeon
Correction of amblyopia and strabismus
Endoscopy
procedures
Biopsy procedures
Electroconvulsive therapy
Removal
of tumors and cysts
Correction of congenital anomalies (See Reconstructive
surgery)
Surgical treatment of morbib 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 and
prosthetic devices for device coverage information
Voluntary
sterilization, Norplant (a surgically implanted contraceptive), and intrauterine
devices (IUDs)
Treatment of burns
Assistant surgeons we cover up
to 20% of our allowance for the surgeon's charge
Surgical procedures continued on next page
2002 Alliance Health
Benefit Plan 24 Section 5 (b)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount 24
24 Page 25 26
2002 Alliance Health Benefit Plan 25 Section
5 (b)
PPO: 10% of the Plan allowance for the primary procedure; 10% of
one-half of the
Plan allowance for the secondary procedure( s) and 10% of
one-quarter of the Plan allowance
for procedure( s) thereafter.
Non-PPO:
30% of the Plan allowance for the primary procedure and 30% of one-half
of
the Plan allowance for the secondary procedure( s) and 30% of one-quarter of the
Plan allowance for procedure( s) thereafter and any difference between our
allowance
and the billed amount
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
Surgical procedures (continued) You pay
When
multiple or bilateral surgical procedures performed during the same operative
session add time or complexity to patient care, our benefits are
For the primary procedure
PPO: 90% of the Plan allowance
Non-PPO:
70% of the reasonable and customary charge
For the secondary procedure( s):
PPO: 90% of one-half of the Plan
allowance
Non-PPO: 70% of one-half of the reasonable and customary charge
Note: Multiple and bilateral surgical procedures performed through the same
incision are "incidental" to the primary surgery. That is, the procedure
would not add time or complexity to patient care. We do not pay extra for
incidental procedures.
Not covered: All charges
Reversal of voluntary sterilization
Services of a standby surgeon, except during angioplasty or other high risk
procedures when we determine standbys are medically necessary
Routine treatment of conditions of the foot; see Foot care
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; and webbed fingers and toes.
All stages of breast reconstruction surgery following a mastectomy, such
as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complication, such as lymphedemas;
breast
prostheses; and surgical bras and replacements (see Prosthetic devices for
coverage)
Note: We pay for internal breast prostheses as hospital benefits.
Note:
If you need a mastectomy, you may choose to have the procedure performed on an
inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Not covered: All charges
Cosmetic 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 sexual transformations or sexual dysfunction.
25
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2002 Alliance Health Benefit Plan 26
Section 5 (b)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the
Plan allowance and any difference between our allowance and
the billed
amount
Organ/ tissue transplants continued on next page
Oral and maxillofacial surgery You pay
Oral surgical procedures,
limited to:
Reduction of fractures of the jaw 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
Other surgical procedures that do not involve the teeth or their supporting
structures
Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva and alveolar bone)
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Small
Intestine, including transplant with multiple organs (liver, stomach or
pancreas)
Lung: Single only for the following end-stage pulmonary diseases:
pulmonary fibrosis, primary pulmonary hypertension, or emphysema;
Double
only for patients with cystic fibrosis
Pancreas (when condition is not
treatable by use of insulin therapy)
Allogeneic bone marrow transplants
only for patients with Acute leukemia, Advanced Hodgkins lymphoma, Advanced
non-Hodgkin's
lymphoma, Advanced neuroblastoma (limited to children over age one), Aplastic
anemia, Chronic myelogenous leukemia, Infantile malignant
osteopetrosis,
Severe combined immunodeficiency, Thalassemia major, and Wiskott-Aldrich
syndrome
Autologous bone marrow transplants (autologous stem cell and autologous
peripheral stem cell support) for Acute lymphocytic or
non-lymphocytic
leukemia, Advanced Hodgkin's lymphoma, Advanced non-Hodgkin's lymphoma, Advanced
neuroblastoma, Testicular,
Mediastinal, Retroperitoneal, and Ovarian germ
cell tumors, Breast cancer, Multiple myeloma, and Epithelial ovarian cancer.
The First Health National Transplant Program: 10% of the Plan allowance
PPO: 20% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
the difference between our allowance and
the billed amount. 26
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2002 Alliance Health Benefit Plan 27 Section
5 (b)
Organ/ tissue transplants continued on next page
Organ/ tissue transplants (continued) You pay
First Health National Transplant Program
Covered Transplant
Services:
Pre-transplant evaluation;
Organ procurement;
Transplant procedures and associated hospitalization;
Transplant-related
follow-up care provided by the designated transplant hospital for up to 1 year;
Pharmacy costs provided by the First Health National Transplant Program
for immunosuppressant and other transplant-related
medications while
hospitalized;
Donor expenses, if not covered under any other plan;
Transplant-related services provided by the First Health National Transplant
Program facility that are associated with the transplant
events listed above, including laboratory and other diagnostic services;
Physician services related to the transplant events listed above
Travel and lodging benefit:
If the recipient lives more than 100
miles from a designated transplant facility, the Plan will provide an allowance
for pre-approved travel and
lodging expenses up to $10,000 per transplant. The allowance will not be
subject to the calendar year deductible or coinsurance. The allowance
will
provide coverage of reasonable travel and temporary lodging expenses for the
recipient and one companion (two companions if the
recipient is a minor).
Covered travel and lodging expenses will be established by the Plan's case
manager during the precertification
process. Travel and lodging to a
designated facility for the pre-transplant evaluation is covered under this
benefit even if the transplant is not
eventually certified as medically
necessary.
PPO benefit not designated as National Transplant Program: If
you do not use a First Health National Transplant Program facility,
but you
do use a PPO facility, 80% benefits will be applied to your expenses. Total
benefit payments, including donor expenses, the
transplant procedure itself,
and transplant-related follow-up care for one year at the transplant facility
will be limited to a maximum payment of
$150,000 for a liver transplant and
$100,000 for any other transplant. The travel and lodging allowance will not be
available. Charges incurred
for prescription drugs and follow-up care
outside of the transplant facility/ hospital will not be counted toward this
maximum.
Note: Cornea and pancreas transplants are not available through the First
Health National Transplant Program; therefore, the Travel/ Lodging benefit is
not available.
Precertification: In order to receive benefits for the
transplants listed above, you are
required to call First Health OnCall at 1/
800-225-4423 as soon as the need for a transplant is discussed with your
physician. When you call,
it will be necessary to provide the program with
all information needed to complete the review. In order to receive the highest
level
of benefits, all transplant-related services must be received at one
of the designated hospitals within the First Health National Transplant
Program. All covered transplant benefits, including pre-transplant
evaluation expenses (even if the transplant does not occur) will be
provided
by the Plan.
The First Health National Transplant Program: 10% of the Plan allowance
PPO: 20% of the Plan allowance
Non-PPO: 30% of the Plan allowance and
the difference between our allowance and
the billed amount. 27
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2002 Alliance Health Benefit Plan 28 Section
5 (b)
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan
allowance and any difference between our allowance and
the billed amount
Note: If your PPO provider uses a non-PPO anesthesiologist, we will pay
non-PPO
benefits for the anesthesia charges.
Organ/ tissue transplants (continued) You pay
If
you do not follow the procedures required by the First Health (See above)
National Transplant Program, the Plan's co-payment will be reduced to
the PPO or non-PPO benefit level for all related covered physician/ hospital
expenses, after any applicable deductible. Also, no coverage
will be
provided for transportation or lodging and meal expenses if a transplant
procedure is not performed at a First Health National
Transplant Program
facility. The charges above the maximum payment of $150,000 or $100,000 for
transplants provided outside the
First Health National Transplant Program
do not apply toward your out-of-pocket maximum.
Limitations: (See above)
For the purposes of the maximum total payment,
charges from doctors and hospitals while the patient is confined in a transplant
facility will
be counted toward the maximum. Charges incurred for prescription drugs and
follow-up care outside of the transplant facility/ hospital
will not be
counted toward this maximum.
Note: If the Plan cannot refer a member in need
of a transplant to a First Health National Transplant Program facility, the
$100,000/$ 150,000
maximum will not apply.
Treatment for breast cancer, multiple myeloma,
and epithelial ovarian cancer may be provided in a National Cancer Institute
(NCI) or National
Institute of Health (NIH) approved clinical trial at a Plan-designated center
of excellence and if approved by the Plan's medical director in accordance
with the Plan's protocols.
Note: We cover related medical and hospital
expenses of the donor when we cover the recipient.
Not covered: All charges
Services, supplies, drugs and aftercare
for, or related to, artificial or
non-human organ implants or transplants;
Services that are considered experimental/ investigational or not
medically
necessary;
Expenses for services which are specifically excluded under the Medical
Expenses Not Covered section of this Plan; and
Transplants not listed as covered
Anesthesia
Professional services provided in PPO; 10% of the Plan allowance
Hospital (inpatient)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount
Professional services provided in
Hospital
outpatient department
Skilled nursing facility
Ambulatory surgical
center
Office 28
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2002 Alliance Health Benefit
Plan 29 Section 5 (c)
Here are some important things you
should keep in mind about these benefits:
Please remember that all
your benefits are subject to the definitions, limitations, and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Unlike Sections 5( a) and 5( b), in this Section 5( c) the
calendar year deductible applies to only a few benefits. In that case we added
"( calendar year deductible applies)". The PPO
calendar year deductible is: $100 per person ($ 300 per family) and the
non-PPO calendar year deductible is $300 per person ($ 900 per family).
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. When no PPO provider is available,
non-PPO benefits apply.
When you use a PPO hospital, keep in mind that the
professionals who provide services to you in the hospital, such as radiologists,
emergency room physicians, anesthesiologists, and
pathologists, may not all
be preferred providers. If they are not, they will be paid by this Plan as
non-PPO providers.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works, with special sections for
members who are age 65 or over. 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 in Sections 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL
RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification
information in Section 3 to be sure which services require precertification.
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Section 5 (c). Services provided by a hospital or other facility and
ambulance services
PPO: $150 per admission and 10% of the covered charges
Non-PPO: $250 per
admission and 30% of the covered charges
Note: If you use a PPO provider and
a PPO facility, we may still pay non-PPO
benefits if you receive treatment
from a radiologist, pathologist or anesthesiologist
who is not a PPO
provider
Inpatient hospital continued on next page
Benefit Description You pay
NOTE: The calendar year deductible applies
ONLY when we say below "( calendar year deductible applies)".
Inpatient
hospital
Room and board, such as
ward, semiprivate, or intensive
care accommodations;
general nursing care; and
meals and special
diets.
NOTE: We only cover a private room when you must be isolated to prevent
contagion. Otherwise, we will pay the hospital's average charge for semiprivate
accommodations. If the hospital only has private rooms, we base our payment
on the average semiprivate rate of the most comparable hospital in the area.
NOTE: When the non-PPO hospital bills a flat rate, we prorate the charge to
determine how to pay them, as follows: 30% room and board and 70%
other
charges. 29
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2002 Alliance Health Benefit
Plan 30 Section 5 (c)
Inpatient hospital (continued)
You pay
Other hospital services and supplies, such as: (see
above)
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
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 (Note: calendar year
deductible
applies.)
NOTE: We base payment on whether the facility or a health care
professional bills for the services or supplies. For example, when the hospital
bills for
its nurse anesthetists' services, we pay Hospital benefits and when the
anesthesiologist bills, we pay surgery benefits.
Not covered: All charges
Any part of a hospital admission that is
not medically necessary (see
definition), such as when you do not need acute
hospital inpatient (overnight) care, but could receive care in some other
setting without
adversely affecting your condition or the quality of your medical care.
Note: In this event, we pay benefits for services and supplies other than
room and board and in-hospital physician care at the level they would
have been covered if provided in an alternative setting
Custodial
care; see definition.
Non-covered facilities, such as nursing homes,
schools, rest homes,
places for the aged, convalescent homes, residential
treatment facilities, and any place that is not a hospital
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
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.
Not covered: All services not listed All charges
PPO; 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount (calendar year deductible applies) 30
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2002 Alliance Health Benefit Plan 31 Section
5 (c)
Extended care benefits/ Skilled nursing care facility benefits
You pay
Skilled nursing facility (SNF): We cover semiprivate room,
board, services, PPO: 20% of the Plan allowance supplies in a SNF for up to 60
days confinement when:
1) you are admitted within 14 days from a precertified hospital stay of at
Non-PPO: 20% of the Plan allowance least 3 consecutive days; and
2) you are
admitted for the same condition as the hospital stay; and
3) your skilled
nursing care is supervised by a physician and provided by an R. N., L. P. N., or
L. V. N.; and
4) SNF care is medically appropriate.
Not covered: Custodial care All
charges
Hospice care
Hospice is a coordinated program of maintenance and
supportive care for PPO: Nothing until Plan allowance stops the terminally ill
provided by a medically supervised team under the at $4,500
direction of a Plan approved independent hospice administration. Non-PPO:
Nothing until Plan allowance
We pay $4,500 per lifetime for inpatient and
outpatient services. stops at $4,500
Not covered: All charges
Bereavement counseling
Funeral arrangements
Pastoral counseling
Financial or legal counseling
Homemaker or caretaker services
Ambulance
Local professional ambulance service when medically
appropriate PPO: 10% of the Plan allowance (calendar year deductible applies)
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount (calendar year deductible applies) 31
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2002 Alliance Health Benefit Plan 32 Section
5 (d)
Here are some important things you should keep in mind about
these benefits:
Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure.
The calendar year deductibles are: PPO $100 per person ($ 300 per family);
Non-PPO $300 per person ($ 900 per family). Calendar year deductibles apply to
almost all benefits in this
Section. We added "( No deductible)" to show
when a calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits
apply only when you use a PPO provider. When no PPO provider is available,
non-PPO benefits apply.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works,
with special sections for members who are age 65 or over. Also
read Section
9 about coordinating benefits with other coverage, including with Medicare.
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Section 5 (d). Emergency services/ accidents
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our
allowance and the billed amount
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 is an accidental injury? An accidental injury is a bodily injury
sustained solely through violent, external, and accidental means, such as broken
bones,
animal bites, poisonings and dental care required as a result of
accidental injury to sound natural teeth.
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.
Accidental injury
If
you receive care for your accidental injury within 72 hours, we cover:
Non-surgical physician services and supplies
Related outpatient hospital
services
Note: We pay Hospital benefits if you are admitted.
If you receive care
for your accidental injury after 72 hours, we cover:
Non-surgical
physician services and supplies
Surgical care
Note: We pay Hospital benefits if you are admitted. 32
32 Page 33 34
2002 Alliance Health Benefit Plan 33 Section
5 (d)
Medical emergency You pay
Outpatient medical or
surgical services and supplies in an emergency room. PPO: $25 copayment
Non-PPO: $25 copayment and the difference between our allowance and
the
billed amount
Care in a physician's office PPO: $15 and/ or 10% of the Plan
allowance
Non-PPO: 30% of the Plan allowance and any difference between our allowance
and
the billed amount.
Ambulance
Professional ambulance
service PPO: 10% of the Plan allowance
Note: If hospital treatment requiring special equipment is necessary but not
Non-PPO: 30% of the Plan allowance and locally available, the Plan covers
transportation within the United States any difference between our allowance and
and Canada by professional ambulance, railroad, or scheduled commercial the
billed amount airlines to the nearest hospital equipped to furnish the
treatment.
Note: See 5 (c) for non-emergency service.
Not covered: All charges
Routine transportation necessary to obtain the services of a doctor or
any other practitioner 33
33 Page 34 35
2002 Alliance Health Benefit Plan 34 Section 5 (e)
You may
choose to get care Out-of-Network or In-Network. When you receive In-Network
care, you must get our approval for services and follow a treatment plan we
approve. If you do, cost-sharing
and limitations for In-Network 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.
The calendar year deductibles or, for
facility care, the inpatient deductibles apply to almost all benefits in this
section. We added "( No deductible)" to show when a deductible does not
apply.
Be sure to read Section 4, Your cost 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 descriptions below.
In-Network mental health and substance abuse benefits
are below, then Out-of-Network benefits begin on page 35.
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Section 5 (e). Mental health and substance abuse benefits
In-Network benefits continued on next page
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.
In-Network benefits
All
diagnostic and treatment services contained in a treatment plan that Your cost
sharing responsibilities are no we approve. The treatment plan may include
services, drugs, and supplies greater than for other illnesses or conditions.
described elsewhere in this brochure.
Note: In-Network benefits are
payable only when we determine the care is clinically appropriate to treat your
condition and only when you receive
the care as part of a treatment plan that we approve.
Professional
services, including individual or group therapy by $15 per visit providers such
as psychiatrists, psychologists, or clinical social workers
Medication management
Diagnostic tests 10% of the Plan allowance
Services provided by a hospital or other facility $150 per admission
copayment and 10% of the Plan allowance
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Not
covered: Services we have not approved. All charges.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment plan in favor
of another. 34
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2002 Alliance Health Benefit Plan 35 Section 5 (e)
In-Network benefits (continued)
Preauthorization
To be eligible to receive these enhanced mental health and substance abuse
benefits you must obtain a treatment plan and follow all of the following
network authorization
processes.
Pre-certification: The medical necessity of your admission
to a hospital or other covered facility must be precertified for you to receive
full Plan benefits.
Emergency admissions must be reported within two business days following the
day of the admission even if you have been discharged.
Otherwise, the benefits payable
will be reduced by $500. See page 8 for
details. For precertification call 1/ 800-225-4423
You may obtain a provider directory by calling 1/ 800-321-0347.
Outpatient approval procedures: Covered outpatient services for treatment of
mental conditions or substance abuse require pre-certification.
Pre-certification is required
when treatment continues beyond 2 visits per person, per calendar year. For
precertification call 1/ 800-225-4423
Network limitation If you do not obtain an approved treatment plan, we
will provide only Out-of-Network benefits
Out-of-Network benefits You pay
Inpatient and outpatient professional services to treat mental
conditions. 30% of our allowance and any difference between our allowance and
the billed
amount for up to 45 visits; all charges after 45 visits
Inpatient and outpatient professional services to treat substance abuse 50%
of our allowance and any difference conditions. between our allowance and the
billed
amount and all charges after the $4000 calendar year maximum
Inpatient care to treat mental conditions includes ward or semiprivate After
a $500 deductible per admission to a accommodations and other hospital charges
non-PPO hospital, 30% of charges for up
to 45 days per calendar year; all
charges after 45 days
Inpatient care to treat substance abuse includes room and board and 30% of
Plan allowance and any difference ancillary charges for confinement in a
treatment facility for rehabilitative between our allowance and the billed
treatment of alcoholism or substance abuse amount and all charges after the
$4000 calendar year maximum
Not covered out-of-network: All charges.
Services by pastoral
and marital counselors
Treatment for learning disabilities and
mental retardation
Services rendered or billed by schools,
residential treatment centers or halfway houses or members of their staffs
Lifetime maximum Out-of-Network inpatient care for the treatment of
alcoholism and drug abuse is limited to a 60-day maximum per lifetime.
Precertification The medical necessity of your admission to a
hospital or other covered facility must be precertified for you to receive full
Out-of-Network benefits. Emergency admissions
must be reported within two
business days following the day of admission even if you have been discharged.
Otherwise, the benefits will be reduced by $500. See Section 3
for details.
See these sections of the brochure for more valuable information about these
benefits:
Section 4, Your costs for covered services, for
information about catastrophic protection for these benefits.
Section 7,
Filing a claim for covered services, for information about submitting
out-of-network claims. 35
35 Page 36 37
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 page 37.
All benefits are subject to
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
The combined annual prescription drug deductible is $200 per person for
prescriptions filled through the retail and/ or home delivery pharmacy service
program.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works, with special sections
for members who are age 65 or over. Also
read Section 9 about coordinating
benefits with other coverage, including with Medicare.
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Section 5 (f). Prescription drug benefits
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or licensed dentist
must write the prescription.
Prior authorization. Prior
authorization is required for some drugs. To get a list of these drugs please
call 1/ 800-225-4423.
Where you can obtain them. You may fill the
prescription at a pharmacy participating in the network, a non-network pharmacy,
or by mail. We pay a higher level of benefits when you use a network pharmacy
rather than a non-network
pharmacy.
Network Pharmacy Benefit. After satisfying your
combined annual $200 per person prescription drug deductible, you pay 10%
coinsurance for the initial prescription for up to a 30 day supply of medication
(as prescribed by your doctor) and 50%
for each refill.
Merck-Medco Home Delivery Pharmacy Services.
After satisfying your combined annual $200 per person prescription drug
deductible, you pay 20% of the covered charges per generic medication or per
brand name medication. To order by
mail, send your prescriptions to Merck Medco Home Delivery Pharmacy Services,
Post Office Box 650322, Dallas, TX 75265-0322
Non-Network Pharmacy Benefit. After satisfying your combined annual
$200 per person prescription drug deductible, you pay 10% coinsurance per
prescription for the initial 30 day supply. All refills will require you to pay
50% of the cost of the
prescription drug. You will also be responsible for
any charges in excess of the participating pharmacy charges. You must pay the
full amount of the prescription drug and file a claim with First Health Rx as
indicated below.
We use a formulary. We have an open formulary. If your physician
believes a name brand product is necessary or there is no generic available,
your physician may prescribe a name brand drug from a formulary list. This list
of name brand drugs is
a preferred list of drugs that we selected to meet
patient needs at a lower cost. You may call for the list.
These are the
dispensing limitations. For participating and non-participating pharmacies,
the dispensing limit is a 30 day supply. For home delivery the dispensing limit
is a 90 day supply with the initial home delivery prescription being limited to
a 45 day supply.
Refilling your prescription. To be sure you
never run short of your prescription medication, you should re-order on or after
the refill date indicated on the refill slip or when you have fewer than 14 days
of medication left. Refills sent in prior to
scheduled or authorized refill will not be filled.
Generic
Equivalent. 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 is available, and your physician
has not
specified Dispense as Written for the name brand drug, you have to pay the
difference in cost between the name brand drug and the generic.
Why use generic drugs? Generic drugs contain the same active
ingredients and are equivalent in strength and dosage to the original brand name
product. Generic drugs cost you and your plan less money than a name-brand drug.
When you have to file a claim. If a participating pharmacy is not
available where you reside or if you do not use your prescription drug
identification card, you must pay in full for your medication, obtain a
prescription drug receipt and submit
a claim to: Alliance Health Benefit
Plan, Prescription Drug Program, First Health Rx, Post Office Box 22410, Tucson,
AZ 85734. Reimbursement will be based on Plan cost had you used a participating
pharmacy. The Alliance's cost represents a
negotiated fee. The actual cost
to Alliance may be less than the retail price, so your reimbursement may be
less.
Prescription drug benefits begin on next page.
2002 Alliance Health Benefit Plan 36 Section 5 (f) 36
36 Page 37 38
2002 Alliance Health Benefit Plan 37 Section 5 (f)
Benefit Description You pay After the prescription drug deductible
NOTE: The prescription drug deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
Covered
medications and supplies
Each new enrollee will receive a description of
our prescription drug program, a combined prescription drug/ Plan identification
card, a home
delivery order form/ patient profile and a preaddressed reply envelope
You may purchase the following medications and supplies prescribed by a
physician from either a pharmacy or by mail:
Drugs and medicines (including those administered during a non-covered
admission or in a non covered facility) that by Federal law of the United
States require a physician's prescription for their purchase, except those
listed as Not covered.
Insulin
Diabetic diagnostic supplies used to test blood and urine for
glucose levels
Needles and syringes for the administration of covered
medications
Contraceptive drugs and devices
Not covered: All
charges.
Drugs and supplies for cosmetic purposes
Vitamins,
nutrients and food supplements even if a physician prescribes
or administers
them
Nonprescription medicines
Medical supplies such as dressings and
antiseptics
Medication that does not require a prescription under Federal
law even if your doctor prescribes it or a prescription is required under your
State law
Drugs to aid in smoking cessation except those limited to
the $100
lifetime maximum as part of the smoking
cessation benefit, see page 23
Drugs related to treatment of sexual dysfunction, sexual inadequacy or
sexual transformation
Drugs that are investigational or experimental
Drugs prescribed
for weight loss
Network Retail: 10% generic or brand name for the initial prescription. For
all
refills 50% of Plan cost
Non-Network Retail: 10% generic or brand
name for initial prescription and
any difference between our Plan cost and
the cost of the drug. For all refills, 50%
of the Plan cost and any
difference between our cost and the cost of the drug.
Home Delivery: 20% of cost for generic or brand name. 37
37 Page 38 39
2002 Alliance Health Benefit Plan 38 Section
5 (g)
Section 5 (g). Special features
Special features
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 1/ 800-225-4423 and talk
with a nurse who will discuss treatment options and
answer your health
questions.
Services for deaf and hearing TDD services are available
at 1/ 800-259-8179. impaired
High risk pregnancies For assistance you should call First Health at
1/ 800-225-4423 during the first trimester of your pregnancy. At this time, a
Case Manager will ask you questions
about your general health and medical
history. This information will be discussed with your physician or practitioner
to help determine the risk factor of your
pregnancy.
Centers of
excellence for For assistance with the First Health National Transplant
Program call us at transplant/ heart surgery/ etc. 1/ 800-225-4423 for
more information.
Travel benefit for organ First Health National Transplant Program:
transplants Travel and lodging must be approved in advance. They include
the cost incurred for
one companion to travel with the patient to receive
services in connection with any approved PPO transplant procedure. Travel and
lodging expenses are covered up to
a $10,000 maximum. 38
38 Page 39 40
2002 Alliance Health Benefit Plan 39 Section
5 (h)
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.
The calendar year deductibles are: PPO $100 per person ($ 300 per family);
Non-PPO $300 per person ($ 900 per family). Calendar year deductibles apply to
the accidental dental injury
benefit only.
Non-PPO dental benefit is
subject to a $25 per person and $50 per family calendar year deductible.
We added "( No deductible)" to show when a dental deductible does not
apply.
Be sure to read Section 4, Your cost for covered services,
for valuable information about how cost sharing works, with special sections
for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including
with Medicare.
Note: 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.
I M
P O
R T
A N
T
I M
P O
R T
A N
T
Section 5 (h). Dental benefits
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair PPO: 10% of the Plan allowance (but
not replace) sound natural teeth. The need for these services must result
from an accidental injury. Services must be received within 12 months from
Non-PPO: 30% of the Plan allowance and the date of the accident. any difference
between our allowance and
the billed amount
Dental benefits
Preventive services:
Cleanings
Exams
Flouride treatments
Sealants
Diagnostic
X-rays
Note: Cleanings, exams, flouride treatments and sealants are limited to two
visits per person annually.
Basic restorative care:
Fillings
Note: The annual benefit maximum per person (Combined In-Network and
Out-of-Network) is $500.
Not covered: All charges
Dental
extractions including the removal of impacted teeth
All dental services
and appliances not listed above
Periodontal prophylaxis
Emergency
exams
Charges in excess of the combined annual benefit maximum
PPO: Nothing "( No deductible)"
Non-PPO: 10% of the Plan allowance and
any difference between our allowance and
the billed amount
PPO: 20% of the Plan allowance "( No deductible)"
Non-PPO: 30% of the
Plan allowance and any difference between our allowance and
the billed
amount. 39
39 Page
40 41
2002 Alliance Health Benefit
Plan 40 Section 5 (i)
Section 5 (i). Non-FEHB benefits
available to Plan members
The benefits on this page are not part of the
FEHB contract 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.
Enrollment in the Alliance Insurance Programs listed below is not a
requirement for participation in the Alliance Health Benefit Plan. These
benefits are offered to Plan members on a voluntary basis through carriers other
than the
Health Plan. The Alliance Health Benefit Plan is not responsible
for any services or representations made by these carriers outside these
Alliance Insurance Programs.
PLAN FEATURES NO CLAIM FORMS!
CIGNA Dental Health Plan No deductibles
No maximums 100% Coverage Diagnostic and Preventive Care (Exams,
X-rays, Cleanings) 50% Coverage Basic Restorative Care (Fillings,
Periodontics,
Endodontics, Simple Extractions) 50% Coverage Major
Restorations (Onlays, Dentures,
Crowns, Bridgework) Call 1/ 800-367-1037
AFLAC (American Family Life Accident/ Sickness/ Disability, Hospital
Intensive Care; Cancer
Assurance Company of Insurance Policy Columbus) These
policies provide benefits paid directly to you, unless assigned,
that can
help you with non-medical expenses. Call 1/ 800-992-3522 and TDD 1/ 800-622-2345
or
espanol 1/ 800-742-3522 For policies available to residents of CT, MA, NJ
and NY, call 1/ 800-366-3436 for more information.
Wal-Mart From the nation's leading discount retailer, discount prescription
Pharmacy Mail services for any family member whether or not a dependent.
Services No annual fees or deductibles. Call 1/ 800-321-0347 for more
information.
Call 1/ 800-321-0347 for General Information
BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 40
40 Page 41 42
2002 Alliance Health Benefit Plan 41 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 we determine it is medically necessary to
prevent, diagnose, or treat your illness, disease, injury, or condition.
We do not cover the following:
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, sexual
dysfunction, or sexual inadequacy;
Services, drugs, or supplies you
receive from a provider or facility barred from the FEHB Program;
Services
and supplies when furnished without charge while in active military service; or
required for illness or injury sustained on or after the effective date of
enrollment (1) as a result of an act of war within the United States, its
territories, or
possessions or (2) during combat
Services and supplies
when furnished by immediate relatives or household members, such as spouse,
parent, child, brother, sister by blood, marriage or adoption;
Services and supplies when furnished or billed by a non-covered facility,
except that medically necessary prescription drugs are covered;
Services
and supplies not specifically listed as covered;
Any portion of a
provider's fee or charge ordinarily due from the enrollee but that has been
waived. If a provider routinely waives (does not require the enrollee to pay) a
deductible, copay or coinsurance, the Plan will calculate the actual provider
fee
or charge by reducing the fee or charge by the amount waived;
Charges the enrollee or Plan has no legal obligation to
pay, such as: excess charges for an annuitant age 65 or older who is not
covered by Medicare Parts A and/ or B (see page 13), doctor charges
exceeding the amount specified by the Department of
Health and Human Services when benefits are payable
under Medicare (limiting charge) (see page 14), or
State premium taxes however applied;
Biofeedback;
Dental services and appliances (except as specified on
page 39);
Exercise equipment, whirlpool baths,
sunlamps, heating pads, air conditioners, humidifiers, dehumidifiers, and
purifiers;
Services and supplies to the extent the charge exceeds
reasonable and customary charges;
Services by practitioners who do not
meet the definition of "covered provider"; or
Charges for a stand-by
doctor. 41
41 Page
42 43
2002 Alliance Health Benefit Plan 42 Section 7
Section
7. Filing a claim for covered services
How to claim benefits To obtain
claim forms or other claims filing advise or answers about our benefits, contact
us at 1/ 800-321-0347, or at our website at www. ahbp.
com.
In most cases, providers and facilities file claims for you. Your physician
must file on the form HCFA-1500 Health Insurance Claim Form. Your facility will
file on the
UB-92 form. For claims questions and assistance, call us at 1/
800-225-4423.
When you must file a claim such as for overseas claims or
when another group health plan is primary submit it on HCFA-1500 or a claim
form that includes the
information shown below. Bills and receipts should be
itemized and show:
Name of patient and relationship to enrollee;
Plan identification number of the enrollee;
Name and address of person or
firm providing the service or supply;
Dates that services or supplies were
furnished;
Diagnosis;
Type of each service or supply; and
The
charge for each service or supply.
Note: Canceled checks, cash register
receipts, or balance due statements are not acceptable substitutes for itemized
bills.
In addition:
You must send a copy of the explanation of benefits (EOB)
from any primary payer (such as Medicare Summary Notice (MSN)) with your claim.
Bills for home nursing care must show that the nurse is a registered or
licensed practical nurse or Christian Science nurse who is listed in the
Christian Science
Journal.
Claims for rental or purchase of durable
medical equipment; private duty nursing; and physical, occupational, and speech
therapy require a written statement from the
physician specifying the
medical necessity for the service or supply and the length of time needed.
Claims for prescription drugs and supplies that are not ordered through the
Merck-Medco Home Delivery Pharmacy Services must include receipts that include
the prescription number, name of drug or supply, prescribing physician's
name, date, and charge. 42
42 Page 43 44
2002 Alliance
Health Benefit Plan 43 Section 7
Records Keep a separate
record of the medical expenses of each covered family member as deductibles and
maximum allowances apply separately to each person. Save copies of
all
medical bills, including those you accumulate to satisfy a deductible. In most
instances they will serve as evidence of your claim. We will not provide
duplicate or
year-end statements.
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 receive 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. Once we pay
benefits,
there is a three-year limitation on the reissuance of uncashed checks.
Overseas claims For covered services you receive in hospitals outside
the United States and Puerto Rico and performed by physicians outside the United
States, send a completed Claim Form
and the itemized bills to: Alliance
Health Benefit Plan, First Health, Post Office Box 22410, Tucson, AZ 85734.
Obtain Claims Forms from this address and send any
written inquiries
concerning the processing of overseas claims to this address. For assistance
call 1/ 800-225-4423
Overseas services claims should include an English translation and charges
should be converted to U. S. dollars using the exchange rate applicable at the
time the expenses
were incurred.
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. 43
43 Page
44 45
2002 Alliance Health Benefit
Plan 44 Section 8
Follow this Federal Employees Health Benefits
Program disputed claims process if you disagree with our decision on your claim
or request for services, drugs, or supplies including a request for
preauthorization/ prior approval:
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:
Alliance Health Benefit Plan, 1628 11th Street NW, Washington, D. C. 20001; 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 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 2, 1900 E Street NW, Washington, DC 20415-3620.
Section 8. The disputed claims process 44
44
Page 45 46
2002
Alliance Health Benefit Plan 45 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
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 include a copy of
your specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control.
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 or from the
year in which you were denied precertification or prior approval. This is the
only deadline that may not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim decision. This information will become part of the
court record.
You may not sue until you have completed the disputed claims
process. Further, Federal law governs your lawsuits, benefits, and payments 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 the 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 1/ 800-321-0347 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 II at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 45
45
Page 46 47
2002
Alliance Health Benefit Plan 46 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 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. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if
you are 65 or older, you may
be able to buy it. Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement
check.
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+ Choice plan
you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere in the United (Part A or Part B)
States. It is the way everyone used to get Medicare benefits and is the way
most
people get their Medicare Part A and Part B benefits now. You may go to
any doctor, specialist, or hospital that accepts Medicare. The Original Medicare
Plan pays its share
and you pay your share. Some things are not covered
under Original Medicare, like prescription drugs. 46
46 Page 47 48
2002 Alliance Health Benefit Plan 47 Section 9
When you are
enrolled in Original Medicare along with this Plan, you still need to follow the
rules in this brochure for us to cover your care.
Claims process when you
have the Original Medicare Plan You probably will never have to file a
claim form when you have both our Plan and the Original
Medicare Plan.
When we are the primary payer, we process the claim first.
When Original
Medicare is the primary payer, Medicare processes your claim first. In most
cases, your claims will be coordinated automatically and we will 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 1/ 800-225-4423 or
at our
website at www. ahbp. com.
We waive some costs when you have the Original Medicare Plan When
Original Medicare is the primary payer, we will waive some out-of-pocket costs
as follows:
Inpatient Hospital Benefits: If you are enrolled in Medicare
Part A, the Plan will waive the deductible and coinsurance.
Surgical
Benefits: If you are enrolled in Medicare Part B, the Plan will waive the
deductible and coinsurance.
Mental Conditions/ Substance Abuse Benefits:
If you are enrolled in Medicare Part A, the Plan will waive the deductible and
coinsurance for inpatient care. If you are
enrolled in Medicare Part B, the
Plan will waive the deductible and coinsurance for outpatient care.
Other Medical Benefits: If you are enrolled in Medicare Part B, the Plan
will waive the deductible and coinsurance for medical benefits. 47
47 Page 48 49
2002 Alliance Health Benefit Plan 48 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
A. When either you or your covered spouse are
age 65 Then the primary payer is 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 3
because of a disability),
2) Are an annuitant, 3
3) Are a reemployed
annuitant with the Federal government when
a) The position is excluded from
FEHB, or . . . . . . . . . . . . . . . . . . . . . . . 3
b) The position is
not excluded from FEHB . . . . . . . . . . . . . . . . . . . . . . . 3
(Ask
your employing office which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if 3
your covered spouse is this type of judge),
5) Are enrolled in Part B
only, regardless of your employment status, 3 3 (for Part B (for other
services) services)
6) Are a former Federal employee receiving Workers'
Compensation 3 and the Office of Workers' Compensation Programs has determined
(except for claims
that you are unable to return to duty, 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, 3
2) Have
completed the 30-month ESRD coordination period and are still eligible for
Medicare due to ESRD, 3
3) Become eligible for Medicare due to ESRD after
Medicare became primary for you under another provision, 3
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 . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 3
b) Are an active employee .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
c) Are
a former spouse of an annuitant . . . . . . . . . . . . . . . . . . . . . . . .
. . 3
d) Are a former spouse of an active employee . . . . . . . . . . . . .
. . . . . . . . 3 48
48 Page
49 50
2002 Alliance Health Benefit Plan 49 Section 9
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan 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 provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www. medicare.
gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care
plan: You may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB
plan. We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed care plan's
network and/ or service area, but we will not waive
any of our copayments,
coinsurance, or deductibles. If you enroll in a Medicare managed care plan, tell
us. We will need to know whether you are in the Original
Medicare Plan or in
a Medicare managed care plan so we can correctly coordinate your benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a
Medicare managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your Medicare managed care plan premium.) For information
on
suspending your FEHB enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next Open Season
unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.
Private Contract with your physician A physician may ask you to sign
a private contract agreeing that you can be billed directly for services
ordinarily covered by Original Medicare. Should you sign an
agreement,
Medicare will not pay any portion of the charges, and we will not increase our
payment. We will still limit our payment to the amount we would have paid after
Original Medicare's payment.
If you do not enroll in Medicare If you do not have one or both
Parts of Medicare, you can still be covered under the Part A or Part B
FEHB Program. We will not require you to enroll in Medicare Part B and, if
you can't
get premium-free Part A, we will not ask you to enroll in it.
TRICARE TRICARE is a 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 Advsior if you have questions about TRICARE coverage. 49
49 Page 50 51
2002 Alliance Health Benefit Plan 50 Section
9
Workers' Compensation We do not cover services that:
you
need because of a workplace-related illness or injury that the Office of
Workers' Compensation Programs (OWCP) or a similar Federal or State agency
determines they must provide; or
OWCP or a similar agency pays for
through a third party injury settlement or other similar proceeding that is
based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State or Federal Government are responsible for your care
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries or for injuries illness caused
by another person, you must reimburse us for any expense 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. Subrogation applies when you are sick or injured as a result of the
act or omission of
another person or party. Subrogation means the Plan's
right to recover any benefit payments made to you or your dependent by a third
party's insurer, because of an
injury or illness caused by the third party.
Third party means another person or organization.
If you or your dependent receive Plan benefits and have a right to recover
damages from a third party, the Plan is subrogated to this right. All recoveries
from a third party
(whether by lawsuit, settlement, or otherwise) must be
used to reimburse the plan for benefits paid. Any remainder will be yours or
your dependent's. The Plan's share of
the recovery will not be reduced
because you or your dependent has not received full damages claimed, unless the
Plan agrees in writing to a reduction.
You must promptly advise the Plan whenever a claim is made against a third
party with respect to any loss for which the Plan benefits have been paid or
will be paid.
You or your dependent must execute any assignments, liens, or
other documents and provide information as the Plan requests. Plan benefits may
be withheld until
documents or information is received.
If you need more
information, contact us for our subrogation procedures. 50
50 Page 51 52
2002 Alliance Health Benefit Plan 51 Section 10
Section
10. Definitions of terms we use in this brochure
Accidental injury An
injury caused by an external force such as a blow or a fall and which requires
immediate medical attention. Also included are animal bites, poisonings and
dental care
required as a result of accidental injury to sound natural
teeth. An injury to teeth while eating is not considered to be an accidental
injury.
Admission The period from entry (admission) into a hospital or other
covered facility until discharge. In counting days of inpatient care, the date
of entry and the date of
discharge are counted as the same day.
Assignment An authorization by an enrollee or spouse for the Plan to
issue payment of benefits directly to the provider. The Plan reserves the right
to pay a member directly for all
covered services.
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.
Christian Science Nurses
and Christian Science Nurses and Practitioners are those who are listed in
Practitioners the Christian Science Journal.
Christian Science Nursing facility Christian Science Nursing facility
is a nursing facility that is approved by the Commission for the Accreditation
of Christian Science Nursing Organizations/
Facilities, Inc.
Congenital anomaly A condition existing at or from birth which is a
significant deviation from the common form or norm. For purposes of this Plan,
congenital anomalies include protruding ear
deformities, cleft lips, cleft
palates, birthmarks, webbed fingers or toes and other conditions that the Plan
may determine to be congenital anomalies. In no event will the
term
"congenital anomaly" include conditions relating to teeth or intra-oral
structures supporting the teeth.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. You may also be responsible for additional amounts. See pages 10 and 11.
Copayment A copayment is a
fixed amount of money you pay when you receive covered services. See page 10.
Cosmetic surgery Any operative procedure
or any portion of a procedure performed primarily to improve physical appearance
and/ or treat a mental condition through change in bodily form.
Covered
services Services we provide benefits for, as described in this brochure.
Custodial care Treatment or services that could be rendered safely
and reasonably by a person not medically skilled, or that are designed mainly to
help the patient with daily living
activities. Such as:
help in
walking, getting in and out of bed, bathing, eating by spoon, tube or
gastrostomy, exercising, dressing;
homemaking;
moving the patient;
acting as a companion or
sitter;
supervising medication that can usually be self administered; or
treatment of any services that any person may be able to perform with
minimal instruction, such as recording temperature, pulse, and respirations, or
administration
and monitoring of feeding systems.
The Plan determines which services are
custodial care. 51
51 Page
52 53
2002 Alliance Health Benefit Plan 52 Section 10
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 10.
Durable
medical equipment Equipment and supplies that: 1) are prescribed by your
attending doctor;
2) are medically necessary;
3) are primarily and
customarily used for a medical purpose;
4) are generally useful only to a
person with an illness or injury;
5) are designed for prolonged use; and
6) serve a specific therapeutic purpose in the treatment of an illness or
injury.
Effective date The date the benefits described in this brochure are
effective:
Benefits described in this brochure are effective January 1 for
continuing enrollments. For new enrollees in this Plan the effective date of
enrollment is determined by the
employing office or retirement system of the
enrollee.
Experimental or A drug, device or biological product is experimental
or investigational: investigational services
1) If the drug, device
or biological product cannot be lawfully marketed without approval of the U. S.
Food and Drug Administration (FDA) and approval for
marketing has not been
given at the time the drug or device is furnished. Approval means all forms of
acceptance by the FDA.
2) An FDA-approved drug, device or biological product (for use other than its
intended purposes and labeled indications), or medical treatment or procedure is
experimental or investigational if 1) reliable evidence shows that it is
subject to ongoing phase I, II, or III clinical trials or under study to
determine maximum
tolerated dose, its toxicity, its safety, its efficacy, or
its efficacy as compared with the standard means of treatment or diagnosis; or
2) reliable evidence shows that the
consensus of opinion among experts
regarding the drug, device, or biological product or medical treatment or
procedure is that further studies or clinical trials are
necessary to
determine maximum tolerated dose, its toxicity, its safety, its efficacy, or its
efficacy as compared with the standard means of treatment or diagnosis.
3) Reliable evidence shall mean only published reports and articles in the
authoritative medical and scientific literature; written protocol or protocols
used by the treating
facility or the protocol( s) of another facility
studying substantially the same drug, device or medical treatment or procedure;
or the written informed consent used by
the treating facility or by another
facility studying substantially the same drug, device, or medical treatment or
procedure.
FDA-approved drugs, devices, or biological products used for their intended
purposes and labeled indications and those that have received FDA approval
subject to
postmarketing approval clinical trials, and devices classified by
the FDA as category B, Non-experimental/ Investigational Devices are not
considered experimental or
investigational.
Determination of
experimental/ investigational status may require review of appropriate
government publications such as those of the National Institute of Health,
National
Cancer Institute, Agency for Health Care Policy and Research, Food
and Drug Administration, and National Library of Medicine.
Independent evaluation and opinion by Board Certified Physicians may be
obtained for their expertise in subspecialty areas. 52
52 Page 53 54
2002 Alliance Health Benefit Plan 53 Section
10
Group health coverage Health care coverage that a member is
eligible for because of employment by, membership in, or connection with, a
particular organization or group that provides
payment for hospital, medical
or health care services or supplies, or that pays a specific amount for each day
or period of hospitalization if the specified amount exceeds $200
per day,
including extension of any of these benefits through COBRA.
Home health care A plan of continued care and treatment of an injured
or sick person who is under the care of a doctor, and whose doctor certifies
that without the home health care,
confinement in a hospital or skilled
nursing facility would be required.
Home health care agency A public agency or private organization that
is licensed as a Home Health Care Agency by the state and is certified as such
under Medicare.
Hospice care program Professional inpatient and outpatient care
rendered by a licensed or certified hospice to terminally ill patients for
personal care and relief of pain using technical and related
medical
procedures.
Initial emergency treatment Initial emergency treatment is care
rendered by a hospital or doctor for an accidental injury. Initial emergency
treatment does not include benefits for ambulance
transportation or
treatment an enrollee receives as a result of an inpatient admission. Once an
enrollee is admitted to the hospital, inpatient benefits will be applied.
Medical emergency 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. Medical
emergencies include heart attacks, poisonings, loss of consciousness or
respiration, convulsions, and such other acute
conditions.
Medical necessity Services, drugs, supplies or equipment provided by a
hospital or covered provider of health care services that the Plan determines
are:
appropriate to diagnose or treat the patient's condition, illness or
injury;
consistent with standards of good medical practice in the United
States;
not primarily for the personal comfort or convenience of the
patient, the family, or the provider;
not part of or associated with the scholastic education or vocational
training of the patient; and
in the case of inpatient care, cannot be
provided safely on an outpatient basis.
The fact that a covered provider has
prescribed, recommended, or approved a service, supply, drug or equipment does
not, in itself, make it a medical necessity.
Mental conditions/ Conditions and diseases listed in the most recent
edition of the International substance abuse Classification of Disease
(ICD) as psychoses, neurotic disorders, or personality
disorders; other
nonpsychotic mental disorders listed in the ICD, to be determined by the Plan;
or disorders listed in the ICD requiring treatment for abuse of or dependence
upon substances such as alcohol, narcotics, or hallucinogens.
Plan allowance Our Plan allowance is the amount we use to determine
our payments and your coinsurance for covered services. Fee-for-service plans
determine their allowances in
different ways. We determine our allowance as
follows:
Often, the provider's bill is more than a fee-for-service plan's
allowance. Whether or not you have to pay the difference between our allowance
and the bill will depend on
the provider you use. 53
53 Page 54 55
2002 Alliance Health Benefit Plan 54 Section
10
PPO providers agree to limit what they will bill you.
Because of that, when you use a preferred provider, your share of covered
charges consists only of your
deductible, copayment and/ or coinsurance.
Here is an example: You see a PPO physician who charges $150, but our allowance
is $100. If you have met your
deductible, you are only responsible for your
coinsurance. That is, you just pay 10% of our $100 allowance ($ 10). Because
of the agreement, your PPO physician
will not bill you for the $50
difference between our allowance and his bill.
Non-PPO providers,
on the other hand, have no agreement to limit what they will bill you. When
you use a non-PPO provider, you will pay your deductible and
coinsurance
plus any difference between our allowance and charges on the bill. Here
is an example: You see a non-PPO physician who charges $150 and our
allowance is again $100. Because you've met your deductible, you are
responsible for your coinsurance, so you pay 30% of the $100 allowance ($ 30).
Plus, because
there is no agreement between the non-PPO physician and us, he
can bill you for the $50 difference between our allowance and his bill.
The Plan allowance for any non-PPO service or supply is the charge
determined by the Plan on a semiannual basis to be in the 90th percentile of the
prevailing charges
made for a service or supply by providers in the
geographic area where it is furnished. The prevailing charges data are obtained
from prevailing health care
charge guides such as that prepared by the
Health Insurance Association of America (HIAA) and the Plan's administrator,
First Health. In determining the plan
allowance for a service or supply that
is unusual, or not often provided in the area, or provided by only a small
number of providers in the area, the Plan may take into
account factors such
as: the complexity; the degree of skills needed; the type of speciality of the
provider; the range of services or supplies provided by a facility;
and the
prevailing charge of other areas. When a PPO provider is used, the fee that has
been negotiated between the Plan and the PPO provider is considered the plan
allowance.
For more information see Differences between our allowance
and the bill in Section 4.
Sound natural teeth A tooth that is whole or properly restored and is
without impairment, periodontal or other condition and is not in need of
treatment provided for any reason other than an
accidental injury.
Us/ We Us and we refer to the Alliance Health Benefit Plan.
You
You refers to the enrollee and each covered family member. 54
54 Page 55 56
2002 Alliance Health Benefit Plan 55 Section 11
Section
11. FEHB facts
No pre-existing condition We will not refuse to cover the
treatment of a condition that you had before you limitation 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 can answer about
enrolling in the your questions, and give you a Guide to Federal
Employees Health Benefits Plans,
FEHB Program 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 you, your spouse, for you and your family 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.
When benefits and The benefits in this brochure are effective on
January 1. If you joined this Plan during premiums start Open Season,
your coverage begins on the first day of the your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing
office will tell you the
effective date of coverage. 55
55 Page 56 57
2002 Alliance Health Benefit Plan 56 Section 11
Your
medical and claims We will keep your medical and claims information
confidential. Only the following records are confidential 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 continue to get coverage benefits under the 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.
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no longer qualify as of Coverage (TCC) 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, if you lose your Federal job, if you are a covered
dependent child and you turn 22 or marry, etc.
You may not elect TCC if
you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, from your
employing or retirement office or from www. opm.
gov/ insure. It explains what you have to do to enroll. 56
56 Page 57 58
2002 Alliance Health Benefit Plan 57 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 The Health Insurance Portability and
Accountability Act of 1996 (HIPPA) is a Federal Group Health Plan Coverage
law that offers limited Federal protections for health coverage availability
and
continuity to people who lose employer group coverage. If you leave the
FEHB Program, we will give you a Certificate of Group Health Plan Coverage that
indicates
how long you have been enrolled with us. You can use this
certificate when getting health insurance or other health care coverage. Your
new plan must reduce or eliminate
waiting periods, limitations, exclusions
for health related conditions based on the information in the certificate, as
long as you enroll within 63 days of losing coverage
under this Plan. If you
have been enrolled with us for less than 12 months, but were previously enrolled
in other FEHB plans, you may also request a certificate from those
plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm. gov/ insure/ health); refer to
the "TCC and HIPPA" frequently asked questions. These highlight HIPPA rules,
such as the requirement that Federal
employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health coverage
under the HIPPA, and have information about Federal and
State agencies you
can contact for more information. 57
57 Page 58 59
2002 Alliance Health Benefit Plan 58 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
Many FEHB
enrollees think their health plan and/ or Medicare will cover their long-term
care needs. Unfortunately, they are WRONG!
How are you planning to
pay for the future custodial or chronic care you may need? You should consider
buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality long
term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is
long term care It's insurance to help pay for long term care services you
may need if you can't (LTC) insurance? take care of yourself because of
an extended illness or injury, or an age related
disease such as
Alzheimer's.
Long term care insurance can provide broad, flexible benefits
for nursing home care, care in an assisted living facility, care in your home,
adult day care, hospice
care, and more. Long term care insurance can supplement care provided by
family members, reducing the burden you place on them.
I'm healthy. I won't need Welcome to the club! long term care.
Or, will I?
76% of Americans believe they will never need long term
care, but the facts are that about half of them will. And it's not just the
elderly. About 40% of people needing
long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital
to their
financial and retirement planning.
Is long term care expensive? Yes, it can be very expensive. A year
in a nursing home can exceed $50,000. Home care for only three 8-hour shifts a
week can exceed $20,000 a year. And that's
before inflation!
Long term
care can easily exhaust your savings. Long term care insurance can protect
your savings.
But won't my FEHB plan, Not FEHB. Look at the "Not covered"
blocks in sections 5( a) and 5( c) of your Medicare or Medicaid cover
FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted
my long term care? living facility or a continuing need for
a home health aide to help you get in and out of bed and with other activities
of daily living. Limited stays in skilled nursing
facilities can be covered
in some circumstances.
Medicare only covers skilled nursing home care (the
highest level of nursing care) after a hospitalization for those who are blind,
age 65 or older or fully disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
When will I get more information Employees will get more information
from their agencies during the LTC on how to apply for this new open
enrollment period in the late summer/ early fall of 2002.
insurance
coverage? Retirees will receive information at home.
How can I find out more about the Our toll-free teleservice center
will begin in mid-2002. In the meantime, you
program NOW? can learn more about the program on our web site at www.
opm. gov/ insure/ ltc. 58
58 Page 59 60
2002 Alliance Health Benefit Plan 59 DoD/ FEHB Demonstration
Project
Department of Defense/ FEHB Demonstration Project
What is
it? The Department of Defense/ FEHB Demonstration Project allows some active
and retired uniformed service members and their dependents to enroll in the FEHB
Program. The demonstration will last for three years and began with the 1999
open season for year 2000. Open season enrollments will be effective January 1,
2002. DoD
and OPM have set up some special procedures to implement the
Demonstration Project, noted below. Otherwise, the provisions described in this
brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired
uniformed service member and are eligible for Medicare;
You are a
dependent of an active or retired uniformed service member and are eligible for
Medicare;
You are a qualified former spouse of an active or retired
uniformed service member and you have not remarried; or
You are a survivor
dependent of a deceased active or retired uniformed service member; and
You live in one of the geographic demonstration areas.
If you are eligible
to enroll in a plan under the regular Federal Employees Health Benefits Program,
you are not eligible to enroll in the DoD/ FEHB Demonstration
Project.
The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico
Fort Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX
Humboldt County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair County, IA area Coffee County, GA area
When you can join You may enroll under the DoD/ FEHB Demonstration
Project during the 2001 open season, November 12, 2001, through December 10,
2001. Your coverage will begin
January 1, 2002. DoD has set-up an
Information Processing Center (IPC) in Iowa to provide you with information
about how to enroll. IPC staff will verify your eligibility
and provide you
with FEHB Program Information, plan brochures, enrollment instructions and
forms. The toll-free phone number for the IPC is 1-877/ DOD-FEHB
(1-877/
363-3342).
You may select coverage for yourself (Self Only) or for you and
your family (Self and Family) during open season. Your coverage will begin
January 1, 2002.
If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll and when your coverage
will begin.
DoD has a web site devoted to the Demonstration Project. You can
view information such as their Marketing/ Beneficiary Education Plan, Frequently Asked Questions,
demonstration area locations and zip code lists at www. tricare. osd.
mil/ fehbp. You can also view information about the demonstration project,
including "The 2002 Guide to
Federal Employees Health Benefits Plans Participating in the DoD/ FEHB Demonstration Project," on
the OPM web site at www. opm. gov. 59
59 Page 60 61
2002
Alliance Health Benefit Plan 60 DoD/ FEHB Demonstration Project
Temporary Continuation See Section 11, FEHB Facts; it explains
temporary continuation of coverage (TCC). of Coverage (TCC) Under the
DoD/ FEHB Demonstration Project the only individual eligible for TCC is
one who ceases to be eligible as a "member of family" under your self and
family enrollment. This occurs when a child turns 22, for example, or if you
divorce and your
spouse does not qualify to enroll as an unremarried former
spouse under title 10, United States Code. For these individuals, TCC begins the
day after their enrollment in
the DoD/ FEHB Demonstration Project ends. TCC
enrollment terminates after 36 months or the end of the Demonstration Project,
whichever occurs first. You, your
child, or another person must notify the
IPC when a family member loses eligibility for coverage under the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/ FEHB Demonstration Project
area, you cancel your coverage, or your coverage is terminated for any reason.
TCC is not
available when the demonstration project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project. 60
60 Page 61 62
2002 Alliance Health Benefit Plan 61 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury 32, 39 Allergy tests 19
Alternative treatment 23
Allogenetic (donor) bone marrow
transplant 26 Ambulance 31, 33
Anesthesia 23, 28 Autologous bone marrow
transplants 26
Biopsies
24 Birthing center 7
Blood and blood plasma 17, 30 Breast cancer
screening 17
Carryover 12 Casts 30
Catastrophic protection 12 Changes for 2002
6
Chemotherapy 19 Childbirth 18
Chiropractic 23 Christian Science
facilities 7, 51
Christian Science nurse 7, 51 Christian Science providers
7, 51
Cholesterol tests 17 Circumcision 13
Claims 36, 42, 44 Coinsurance
10, 11, 51
Colorectal cancer screening 17 Congenital anomalies 25
Contraceptive devices and drugs 18, 37 Coordination of benefits 46
Covered charges 51 Covered providers 7
Crutches 22
Deductible
10, 52 Definitions 51-54
Dental care 39 Diagnostic services 16, 30
Disputed claims review 44, 55 Donor expenses (transplants) 27
Dressings
30, 37 Durable medical equipment 21, 22, 52
Educational classes and programs 23 Effective date of enrollment 52
Emergency 32, 53 Experimental or
investigational 52 Eyeglasses 20
Family planning 18 Fecal occult blood test 17
Flexible benefits
option 38
Foot care 21 Freestanding ambulatory
facilities 28, 30
General
Exclusions 41
Hearing services 20 Home health services 22, 23, 53
Home nursing care 22, 53 Hospice care 31, 53
Hospital 8, 29
Immunizations 17, 18 Independent laboratories 17
Infertility 19
Inhospital physician care 16
Inpatient Hospital benefits 29, 30 Insulin 37
Laboratory and pathological services 17
Machine diagnostic
tests 17 Magnetic Resonance Imagings (MRIs)
17 Mail Order Prescription Drugs
36, 37
Mammograms 17 Maternity Benefits 9, 18
Medicaid 50 Medically
necessary 30, 53
Medically underserved areas 7 Medicare 13, 14, 46-69
Members 1 Mental Conditions/ Substance Abuse
Benefits 34-35
Neurological testing 17 Newborn care 18
Non-FEHB Benefits 40
Nurse
Licensed Practical Nurse 22, 23 Nurse Anesthetist 23, 28, 30
Nurse
Midwife 7 Nurse Practitioner 7, 22, 23
Psychiatric Nurse 34 Registered Nurse
22, 23
Nursery charges 18 Nursing School Administered Clinic 7
Obstetrical care 18 Occupational therapy 20
Ocular injury 20
Office visits 16
Oral and maxillofacial surgery 26 Orthopedic devices 21
Ostomy and catheter supplies 30 Out-of-pocket expenses 12
Outpatient facility care 30 Overseas claims 43
Oxygen 22, 30
Pap
test 17 Physical examinations 17
Physical therapy 20 Physician 16
Pre-surgical testing 30 Precertification 8, 9, 27, 28, 35
Preferred
Provider Organization (PPO) 5, 11
Prescription drugs 36, 37 Preventive care,
adult 17
Preventive care, children 18 Prior approval 8
Prostate cancer
screening 17 Prosthetic devices 21
Psychologist 7, 34 Psychotherapy 34
Radiation therapy 19 Renal dialysis 19
Room and board 29
Second surgical opinion 16 Skilled nursing facility care 31
Smoking cessation 23 Social Worker 7
Speech therapy 20 Splints 30
Sterilization procedures 18, 19 Subrogation 50
Substance Abuse 34, 35
Surgery
Anesthesia 28 Assistant surgeon 24
Multiple procedures 25
Oral 26
Outpatient 30 Reconstructive 25
Syringes 37
Temporary Continuation of Coverage 56, 60
Transplants 26-28
Treatment therapies 19
Vision services 20
Well child care 18 Wheelchairs 22
Workers' compensation 50
X-rays 17 61
61 Page 62 63
2002 Alliance Health Benefit Plan 62 Summary
Summary of
benefits continued on next page
Summary of benefits for the Alliance Health Benefit Plan -2002
Do not rely on this chart alone. All benefits 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.
Below, an asterisk (*) means the item is subject to the $100 or $300 calendar
year deductible. And, after we pay, you generally pay any difference between our
allowance and the billed amount if you use a Non-PPO physician or other health
care
professional.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office ......... PPO:
$15 copay per visit and/ or 10%* of the Plan allowance
Non-PPO: 30%* of the Plan allowance 16
Services
provided by a hospital: PPO: $150 per admission copay and 10% of the Plan
allowance
Inpatient
......................................................................................
Non-PPO: $250 per admission copay and 30%
of the Plan allowance
PPO:
10%* of the Plan allowance Outpatient
....................................................................................
Non-PPO: 30%* of the Plan allowance 29
Emergency
benefits: Accidental
injury.........................................................................
Within 72 hours: Nothing for non-surgical
outpatient care
Medical
emergency .....................................................................
$25 copay, emergency room 32
Mental health and substance abuse treatment ...............................
In-Network: Regular cost sharing.*
Out-of-Network: Benefits are limited.* 34
Prescription drugs
...........................................................................
After the combined annual deductible of $200 per person:
In-Network: 10% of the generic or brand name for the initial prescription.
For all
refills, 50% of Plan cost.
Non-Network: 10% of the generic or
brand name for the initial prescription and any
difference between our Plan
cost and the cost of the drug. For all refills, 50% of Plan cost
and any
difference between our cost and the cost of the drug.
Mail order: 20% of prescription drug cost. 36 62
62 Page 63 64
2002 Alliance Health Benefit Plan 63 Summary
Summary of benefits Continued
Benefits You Pay
Page
Dental
care.......................................................................................
PPO: Nothing for preventive services
Non-PPO: After $25 deductible per person or $50 per family, 10% for
preventive services 39
Special features:
Flexible benefits option
24 hour nurseline
Services for deaf and hearing impaired
High risk pregnancies
Centers for excellence for transplant/ heart surgery/ etc.
Travel benefit
for organ transplants 38
Protection against
catastrophic costs PPO: Nothing after $2,000/ Self Only or (your out-of-pocket
maximum)...................................................... $2,000/ Family
enrollment per year.
Non-PPO: Nothing after $3,000/ Self Only or $3,000/ Family enrollment per
year.
Some costs do not count toward this protection. 12
63
63 Page 64
2002 Alliance Health Benefit Plan
Non-Postal Premium
Postal Premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your Enrollment Code Share Share Share
Share Share Share
Self Only 1R1 $ 97.86 $ 60.22 $212.03 $130.48 $115.52 $42.56
Self and
Family 1R2 $223.41 $111.72 $484.06 $242.06 $263.75 $71.38
2002 Rate Information for Alliance Health Benefit Plan
Non-Postal
rates apply to most non-Postal enrollees. If you are in a special enrollment
category, refer to the FEHB Guide for that category or contact the agency that
maintains your health
benefits enrollment.
Postal rates apply to
career Postal Service employees. Most employees should refer to the FEHB Guide
for United States Postal Service Employees, RI 70-2. Different postal rates
apply and
special FEHB guides are published for Postal Service Nurses, 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 who are not career postal
employees. Refer to the applicable
FEHB Guide. 64