APWU Health Plan http:// www. apwuhp. com
2002 A fee-for-service plan
with preferred provider organizations
Sponsored and administered by: American Postal Workers Union, AFL-CIO
Who may enroll in this Plan: All Federal and Postal Service employees
and
annuitants who are eligible to enroll in the FEHB Program may become
members of this Plan. To enroll, you must be, or must become, a member of the
American
Postal Workers Union, AFL-CIO.
To become a member or associate member:
All active Postal Service bargaining unit
employees must be, or must
become, dues-paying members of the APWU, except where exempt by law. In item 1
of Part B of your registration form, enter the number of your APWU Local
immediately after the name of this Plan.
If you are a non-postal
employee/ annuitant, you will automatically become an associate member of APWU
Health Plan upon enrollment in the APWU Health Plan.
Annuitants (retirees) may enroll in this Plan.
Membership dues:
$35 per year for an associate membership. APWU will bill new associate
members for the annual dues when it receives notice of enrollment. APWU will
also bill continuing associate members for the annual membership. Active and
retired Postal Service
employee's membership dues vary by APWU local.
Enrollment codes for
this Plan:
471 High Option -Self Only
472 High Option -Self and Family
For changes in benefits
see page 8.
2002 APWU Health Plan 2 Table of Contents
Table of
Contents
Introduction....................................................................................................................................................................................
4
Plain
Language..............................................................................................................................................................................
4
Inspector General
Advisory.........................................................................................................................................................
5
Section 1. Facts about this fee-for-service plan
..................................................................................................................
6
Section 2. How we change for
2002.....................................................................................................................................
8
Section 3. How you get
care...................................................................................................................................................
9
Identification
cards................................................................................................................................................
9
Where you get covered care
................................................................................................................................
9
Covered providers
.................................................................................................................................
9
Covered
facilities.................................................................................................................................
10
What you must do to get covered care
............................................................................................................
10
How to get approval for
.....................................................................................................................................
11
Your hospital stay
(precertification)................................................................................................
11
Other services
......................................................................................................................................
12
Section 4. Your costs for covered
services........................................................................................................................
14
Copayments..........................................................................................................................................
14
Deductible
............................................................................................................................................
14
Coinsurance..........................................................................................................................................
14
Differences between our allowance and the
bill............................................................................
14
Your out-of-pocket
maximum..........................................................................................................................
15
When government facilities bill
us...................................................................................................................
16
If we overpay
you................................................................................................................................................
16
When you are age 65 or over and you do not have
Medicare .....................................................................
17
When you have Medicare
..................................................................................................................................
18
Section 5. Benefits
.................................................................................................................................................................
19
Overview..............................................................................................................................................................
19
(a) Medical services and supplies provided by
physicians and other health care professionals.......... 20
(b) Surgical and
anesthesia services provided by physicians and other health care
professionals...... 29
(c) Services provided by a
hospital or other facility, and ambulance services
....................................... 35
(d)
Emergency services/
accidents...................................................................................................................
38
(e) Mental health and substance abuse
benefits...........................................................................................
40
(f) Prescription drug benefits
..........................................................................................................................
43
(g) Special
features............................................................................................................................................
46
Flexible benefits option
24 hour nurse line
Services for deaf and hearing impaired 2
2 Page 3 4
2002 APWU Health Plan 3 Table of Contents
Wellness benefit
Review and reward
program
(h) Dental
benefits.............................................................................................................................................
47
(i) Non-FEHB benefits available to Plan members
....................................................................................
48
Section 6. General exclusions — things we don't
cover...............................................................................................
49
Section 7. Filing a claim for covered services
..................................................................................................................
50
Section 8. The disputed claims
process.............................................................................................................................
52
Section 9. Coordinating benefits with other
coverage.....................................................................................................
54
When you have other health
coverage............................................................................................................
54
Original Medicare
...............................................................................................................................................
54
Medicare managed care plan
............................................................................................................................
57
TRICARE/ Workers'
Compensation................................................................................................................
57
Medicaid
...............................................................................................................................................................
58
When other Government agencies are responsible for
your care ............................................................... 58
When others are responsible for injuries
........................................................................................................
58
Section 10. Definitions of terms we use in this
brochure
.................................................................................................
59
Section 11. FEHB
facts...........................................................................................................................................................
62
Coverage information
No
pre-existing condition
limitation................................................................................................
62
Where you get information about enrolling in the
FEHB Program........................................... 62
Types of coverage available for you and your family
.................................................................. 62
When benefits and premiums
start...................................................................................................
63
Your medical and claims records are
confidential........................................................................
63
When you retire
...................................................................................................................................
63
When you lose
benefits......................................................................................................................................
63
When FEHB coverage
ends..............................................................................................................
63
Spouse equity
coverage.....................................................................................................................
63
Temporary Continuation of Coverage (TCC)
................................................................................
63
Converting to individual
coverage...................................................................................................
64
Getting a Certificate of Group Health Plan
Coverage.................................................................. 64
Long term care insurance is coming later in 2002
................................................................................................................
65
Department of Defense/ FEHB Program Demonstration
Project........................................................................................
66
Index..............................................................................................................................................................................................
68
Summary of benefits
..................................................................................................................................................................
70
Rates..............................................................................................................................................................................................
72 3
3 Page 4 5
2002 APWU Health Plan 4 Introduction/ Plain Language/ Advisory
Introduction
APWU Health Plan
12345 New Columbia Pike
Silver Spring, MD 20904
This brochure describes the benefits of APWU Health Plan under our contract
(CS 1370) 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 pages 8. 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 understandable 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 APWU Health 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 4
4 Page 5 6
2002 APWU Health Plan 5 Introduction/ Plain
Language/ Advisory
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 800/ 222-APWU
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. 5
5 Page 6 7
2002 APWU Health
Plan 6 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 website, www. opm.
gov/ insure. Do not call OPM or your agency for our provider directory.
If you need assistance in identifying a participating provider, call the
Plan's PPO administrator for your state: Alliance PPO, Inc. 800/ 342-3289 for
providers in the District of Columbia, Maryland, Virginia and West Virginia;
Beech
Street 800/ 923-3248 for providers in California, Florida, Georgia,
Ohio, Oklahoma, Tennessee, Texas and Washington; MultiPlan 800/ 672-2140 for
providers in New Jersey and New York; MedNet 800/ 556-1144 for
providers in
Maine; PreferredOne 800/ 451-9597 for providers in Minnesota; V. I. Equicare
340/ 774-5779 for providers in the U. S. Virgin Islands; or First Health 800/
447-1704 for all other states. For mental conditions/ substance abuse
providers (all states), call ValueOptions toll-free 888/ 700-7965.
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
specialty
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
PPO Providers: Allowable benefits are based
upon charges and discounts which we or our PPO administrators have negotiated
with participating providers. PPO provider charges are always within our plan
allowance.
Non-PPO providers: We determine our allowance for covered charges by using
health care charge data prepared by the Health Insurance Association of America
(HIAA) or other credible sources, including our own data, when
necessary. We
apply this charge data at the 70 th percentile.
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.
Spectera/ Care, Inc. is the major subcontractor performing hospital
precertification and case management for the Plan and is accredited by American
Accreditation HealthCare Commission/ URAC effective May 24, 1997.
PreferredOne Management Company performs hospital precertification and case
management for members in the State of Minnesota only and is also URAC
accredited effective August 1, 1997.
Value Options performs hospital precertification and outpatient prior
authorization for mental health/ substance
abuse and is also URAC accredited
effective March 1, 1999. 6
6 Page
7 8
2002 APWU Health Plan 7 Section 1
The following PPO
networks are also URAC accredited:
PreferredOne – effective August 1, 1997
MultiPlan – effective August 1, 1998
The American Postal Workers Union Health Plan is a not-for-profit Voluntary
Employee's Beneficiary Association (VEBA) formed in 1972 as the result of a
merger between four predecessor union plans.
We meet applicable State and Federal licensing and accreditation
requirements for fiscal solvency, confidentiality
and transfer of medical
records.
If you want more information about us, call 800/ 222-APWU, or write to APWU
Health Plan, P. O. Box 3279, Silver Spring,
MD 20918. You may also contact us by fax at 301/ 622-5712 or visit our website
at www. apwuhp. com. 7
7 Page
8 9
2002 APWU Health Plan 8 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
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)
We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan
Your share of the Postal premium will increase by 0.1% for Self Only or
–5.4% for Self & Family.
Your share of the non-Postal premium will
increase by 4.4% for Self Only or 1.7% for Self and Family.
We have
eliminated the Point-of-Service (POS) benefit. Last year, a POS benefit was
available to members in certain counties in the State of Texas and in the
Minneapolis/ St. Paul, Minnesota areas. Plan members enrolled in
the POS benefit will be enrolled in the Plan's PPO benefit beginning January
1.
For prescription drugs, you now pay a $7 copayment for up to a 30-day
supply of generic medications obtained from a network
pharmacy. Last year, you paid 25% of the cost of generics with a minimum of
$5 per
prescription. (Section 5 (f))
For prescription drugs, you now pay a
$10 copayment for up to a 90-day supply of generic medications obtained through
our mail order program. Last year, you paid 20% of the
cost of generics with a minimum of $5 per
prescription. (Section 5 (f))
For PPO in-network services and
supplies, you now have a calendar year deductible of $275 per person, $550 per
family. If you use non-PPO providers, your calendar year deductible increases to
a maximum of $350 per person
($ 700 per family). Whether or not you use PPO providers, your calendar year
deductible will not exceed $350 per person ($ 700 per family). Previously, the
deductible was $250 per person, $500 per family for both PPO and
non-PPO
providers. (Section 4)
The separate in-network
calendar year deductible for mental health/ substance abuse treatment has
increased to $275 per person, $550 for family. Previously,
this deductible was $250 per person, $500 per family.
(Section 5 (e))
We no longer limit total blood cholesterol tests to
certain age groups (Section 5 (a))
We now cover
certain intestinal transplants. (Section 5 (b))
We changed speech therapy benefits by removing the requirement that
services must be required to restore functional speech. (Section 5 (a))
You now pay a $40 copayment (no deductible) for treatment of a medical
emergency in a PPO network Urgent Care Center for the
facility charge. Previously, you paid 10% after the calendar year deductible.
(Section 5 (d))
If you do not use preferred providers, the Plan
allowance for surgery, doctor's services, X-ray, lab and therapies
may be
lower than last year because the Plan now uses the 70 th percentile of its
prevailing charge guides. Last year, the 80 th percentile was used. You may have
to pay a larger portion of your bill if you do not use preferred
providers. If you use preferred providers, this change will
not affect you since preferred providers always accept the Plan's allowance
as their charge for services. (Section 10)
We clarified the Infertility benefits to show that we cover fertility
drugs. Last year, these expenses were erroneously listed as non-covered
expenses. (Section 5 (a))
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. 8
8 Page 9 10
2002 APWU Health Plan 9 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
800/
222-APWU.
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. Doctor – A licensed doctor of medicine (M. D.), a licensed doctor of
osteopathy (D. O.), a licensed doctor of podiatry
(D. P. M.), or, for
certain specified services covered by this Plan, a licensed dentist, licensed
chiropractor, or licensed clinical
psychologist practicing within the scope
of the license.
2. Alternate Provider – Alternate providers are covered when
performing certain specified services covered by this Plan and
when such treatment is within the scope of the provider's license. Alternate
providers are limited to licensed physical,
occupational and speech
therapists ; licensed physician's assistants; Registered Nurses (R. N.);
Licensed Practical Nurses
(L. P. N.); Licensed Vocational Nurses (L. V. N.);
and Certified Registered Nurse Anesthetists (C. R. N. A.).
3. Other covered providers include a qualified clinical psychologist,
clinical social worker, optometrist, audiologist,
nurse midwife, nurse
practitioner/ clinical specialist, and nursing school administered clinic. For
purposes of this FEHB
brochure, the term "doctor" includes all of these
providers when the services are performed within the scope of their license or
certification.
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. 9
9 Page 10 11
2002 APWU
Health Plan 10 Section 3
Covered facilities Covered
facilities include:
Freestanding ambulatory facility
An
out-of-hospital facility such as a medical, cancer, dialysis, or surgical center
or clinic, and licensed outpatient facilities accredited
by the Joint Commission on Accreditation of Healthcare Organizations for
treatment of substance abuse.
Hospital
1) An institution which is accredited as a hospital under the
Hospital Accreditation Program of the Joint Commission on
Accreditation of Healthcare Organizations, or
2) Any other institution
which is operated pursuant to law, under the supervision of a staff of doctors
and twenty-four hour a day
nursing service, and which is primarily engaged in providing:
a) general
inpatient care and treatment of sick and injured persons through medical,
diagnostic and major surgical
facilities, all of which must be provided on its premises or under its
control, or
b) specialized inpatient medical care and treatment of sick or injured
persons through medical and diagnostic facilities
(including X-ray and
laboratory) on its premises, under its control, or through a written agreement
with a hospital (as
defined above) or with a specialized provider of those
facilities.
The term "hospital" shall not include a skilled nursing facility, a
convalescent nursing home or institution or part thereof which 1) is
used
principally as a convalescent facility, rest facility, residential treatment
center, nursing facility or facility for the aged or 2)
furnishes primarily
domiciliary or custodial care, including training in the routines of daily
living.
What you must do to get covered care It depends on the kind of care
you want to receive. You can go to any provider you want, but we must approve
some care in advance.
Transitional care Specialty care: If you have a
chronic or disabling condition and
lose access to your 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 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 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 800/
222-APWU. 10
10 Page
11 12
2002 APWU Health Plan 11
Section 3
If you changed from another FEHB plan to us, your former
plan will pay for the hospital stay until:
You are discharged, not merely
moved to an alternative care center; or
The day your benefits from your
former plan run out; or
The 92nd day after you become a member of this
Plan, whichever
happens first
These provisions apply only to the benefits of the hospitalized person.
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 Spectera/ Care at 800/ 580-8771 at least 48 hours before admission.
In Minnesota, call PreferredOne at 800/ 451-9597 to precertify. These numbers
are available 24 hours every day.
If you have an emergency admission 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
the above number 48 hours 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
-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 11
11
Page 12 13
2002
APWU Health Plan 12 Section 3
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
needs to be extended: If your hospital stay
--including for maternity care --needs to be extended, you, your representative,
your doctor or the hospital must ask
us to approve the additional days by
calling Spectera/ Care at 800/ 580-8771 or in Minnesota, call PreferredOne at
800/ 451-9597.
What happens when you
do not follow the
precertification rules
When we precertified the admission but you remained in the hospital beyond
the number of days we approved and did not get the
additional days precertified, then:
-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 and 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 prior approval:
Prior approval
is required for organ transplantation. Before your first evaluation as a
potential candidate, contact Spectera/ Care at
800/ 580-5771 and ask to speak to the transplant case manager.
Prior
approval is required for surgical procedures which may be cosmetic in nature
such as eyelid surgery (blepharoplasty) or
varicose vein surgery (sclerotherapy). Call Spectera/ Care at 800/ 580-8771
before the surgery is done. 12
12 Page 13 14
2002 APWU
Health Plan 13 Section 3
Prior approval is required for
recognized surgery for morbid obesity or for organic impotence. Call Spectera/
Care at 800/ 580-8771
before the surgery is done.
Prior approval is
required for home health care such as nursing visits, infusion therapy, growth
hormone therapy (GHT),
rehabilitative therapy (physical, occupational or speech therapy) and
pulmonary rehabilitation programs. Call Spectera/ Care at
800/ 580-8771.
Prior approval is recommended for durable medical equipment such as
wheelchairs, oxygen equipment and supplies, artificial limbs and
braces. Call Spectera/ Care at 800/ 580-8771.
Prior approval is
required for mental health and substance abuse benefits, inpatient or
outpatient, in-network or out-of-network. Call
ValueOptions at 888/ 700-7965. 13
13 Page 14 15
2002 APWU
Health Plan 14 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.
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.
If you use PPO providers, the calendar year deductible is $275 per person.
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 $550. If
you use non-PPO providers, your
calendar year deductible increases to a maximum of $350 per person ($ 700 per
family).
Whether or not you use PPO providers, your calendar year deductible
will not exceed $350 per person ($ 700 per family).
We also have a separate deductible for mental health and substance
abuse benefits. The in-network deductible is $275 per person. Under a family
enrollment, this deductible is satisfied for all family
members when the combined in-network covered expenses applied to this
deductible for all family members reach $550. The out-of-network
deductible
is $750 per person each calendar year with no family maximum.
Note: If you change plans during open season, you do not have to start a new
deductible under your old plan between January 1 and the effective
date of
your new plan. If you change plans at another time during the year, you must
begin a new deductible under your new plan
And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of
your old
option to the deductible of your new option.
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 office visits to a non-PPO
physician.
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
allowance and the bill Our "Plan allowance" is the amount we use to
calculate our payment for covered services. Fee-for-service plans arrive at
their allowances in
different ways, so their allowances vary. For more information about how we
determine our Plan allowance, see the definition of Plan
allowance in
Section 10. 14
14 Page
15 16
2002 APWU Health Plan 15
Section 4
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 pay just --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
our $100 allowance ($ 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.
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
Your catastrophic protection
out-of-pocket maximum for deductibles,
coinsurance, and
copayments
There is a limit to the amount you must pay out-of-pocket for coinsurance for
the year for certain charges. When you have reached this
limit, and your
calendar year deductible has been met, you pay no coinsurance for covered
services for the remainder of the calendar year.
PPO benefit: Your out-of-pocket maximum is $4,000 for either a Self Only or a
Self and Family enrollment if you are using PPO providers.
Non-PPO benefit:
Your out-of-pocket maximum is $6,000 for either a Self Only or a Self and Family
enrollment if you are using non-PPO
providers.
Out-of-pocket expenses
for the purposes of this benefit are:
The 10% you pay for PPO Inpatient
hospital charges, Surgical, Maternity and Diagnostic and treatment services
The 30% you pay for non-PPO Inpatient hospital charges, Surgical, Maternity
and Diagnostic and treatment services; and
The copayment of $15 for
outpatient visits to PPO physicians 15
15 Page 16 17
2002 APWU Health Plan 16 Section 4
The following cannot be
included in the accumulation of out-of-pocket expenses :
Expenses in
excess of our allowance or maximum benefit limitations
Expenses for
out-of-network mental health or substance abuse or dental care
Any amounts you pay because benefits have been reduced
for non-compliance with this Plan's cost containment
requirements (see
pages 11 and 14)
Covered expenses applied to the
$275 or $350 calendar year deductibles
Covered expenses applied to the $275 deductible for in -network
mental
health or substance abuse care The $200 per admission deductible for non-PPO
Inpatient hospital
charges
Expenses for prescription drugs Expenses
incurred in excess of the $90 per day provided under home
nursing care (see page 27); and
Expenses in excess of hospice care
and preventive care maximums
Carryover If you enrolled in our Plan during Open Season and your
effective date is
after January 1, your previous plan will be responsible
for any medical care you received before your coverage in our Plan began. The
old plan
will pay your covered costs under this year's benefits since benefit changes
start on January 1. If you did not meet your out-of-pocket
maximum under
your old plan last year, your covered out-of-pocket expenses will be applied to
that maximum. If you did meet that
maximum, your old plan's catastrophic
protection benefit will continue to apply until your effective date in our Plan.
When government facilities
bill us
Facilities of the Department of Veterans Affairs, the Department of Defense,
and the 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. 16
16 Page 17 18
2002 APWU
Health Plan 17 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. 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 physiciancare, 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.
If your physician… Then you are responsible for…
Participates with Medicare or accepts Medicare assignment for the claim and
is a member of our PPO network,
your deductibles, coinsurance, and
copayments;
Participates with Medicare and is not in our PPO network, your
deductibles, coinsurance, copayments, and 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
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. 17
17 Page 18 19
2002 APWU Health Plan 18 Section 4
When you have the
Original
Medicare Plan (Part A, Part B, or both)
We limit our payment to an amount that supplements the benefits that 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 payment
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 private contract with a
physician
A physician may ask you to sign a private contract agreeing that you 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. 18
18
Page 19 20
2002 APWU Health Plan 19 Section 5
Section 5. Benefits
--OVERVIEW
(See page 8 for how our benefits changed this year and
pages 70 and 71 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 800/ 222-APWU or at our website at www.
apwuhp. com
(a) Medical services and supplies provided
by physicians and other health care professionals .........................
20-28
Diagnostic and treatment services
Lab, X-ray, and other diagnostic
tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy
care
Treatment therapies
Physical and occupational therapy
Speech therapy
Hearing services (testing, treatment, and
supplies) Vision services
(testing, treatment, and
supplies) Foot care
Orthopedic and prosthetic devices
Durable
medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians
and other health care professionals ....................... 29-34
Surgical procedures
Reconstructive surgery
Oral and maxillofacial
surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services.........................................................
35-37
Inpatient hospital
Outpatient hospital or ambulatory
surgical center Extended care benefits/ Skilled nursing
care facility benefits
Hospice care
Ambulance
(d) Emergency services/ Accidents
...................................................................................................................................
38-39
Medical emergency
Accidental injury
Ambulance
(e) Mental health and substance abuse
benefits.............................................................................................................
40-42
(f) Prescription drug
benefits............................................................................................................................................
43-45
(g) Special features
...................................................................................................................................................................
46
Flexible benefits option
24-hour nurse line
Wellness
benefit
Review and reward program
(i) Non-FEHB benefits available to Plan members
............................................................................................................
48
SUMMARY OF BENEFITS
.......................................................................................................................................................
70 19
19 Page
20 21
2002 APWU Health Plan 20 Section 5( a)
Section 5 (a).
Medical services and supplies provided by physicians
and other health care
professionals
I M
P O
R T
A N
T
Here are some important things 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 deductible is: PPO -$275 per
person ($ 550 per family); Non-PPO -$350 per person ($ 700 per family). The
calendar year deductible applies to almost
all benefits in this Section. We added "( No deductible)" to show when the
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.
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.
I M
P O
R T
A N
T
Benefit Description You Pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of
physicians
In physician's office
PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and any difference between our
allowance and the billed amount
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing
facility
Initial examination of a newborn child covered under a family
enrollment
Second surgical opinion
At home
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: Routine physical checkups and related tests All charges
20
20 Page 21
22
2002 APWU Health Plan 21 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
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.
Not covered: Professional fees for automated lab tests All charges
Preventive care, adult
Routine screenings, limited to:
Total Blood Cholesterol – once annually
Chlamydial infection
Colorectal Cancer Screening, including
-Fecal occult blood test, once
annually, ages 40 and older
-Sigmoidoscopy, screening – every five years starting at age 50
Prostate Specific Antigen (PSA test) – one annually for
men age 40 and older
Routine pap test, one annually, women age 18 and older
PPO: 10% of the Plan allowance
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
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years,
ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
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 APWU Health Plan 22 Section 5( a)
Preventive care,
adult – Continued You pay
Not covered:
Adult immunizations other than those listed above
Office visit
associated with preventive care
All charges
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics through age 22 PPO: Nothing (No deductible)
Non-PPO: Any difference between the Plan allowance and the billed
charge (No deductible)
Examinations, limited to:
-Well-child care
charges for physical examinations and laboratory tests through age 12
-Examination for amblyopia and strabismus-limited to one screening
examination (age 2 through 6)
PPO: Nothing (No deductible)
Non-PPO: Any difference between the Plan
allowance and the billed
charge and any amount above $250 per child (ages 0 through 3) each
year
and any amount above $150 per child (ages 4 through 12) each year
(No
deductible)
Maternity care
Complete maternity (obstetrical) care,
such as:
Prenatal care
Delivery
Postnatal care
Note: Here
are some things to keep in mind:
You do not need to precertify your normal
delivery; see
pages 12 and 13 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,
your 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).
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: Amniocentesis if for diagnosing multiple births All charges
22
22 Page 23
24
2002 APWU Health Plan 23 Section 5( a)
Family planning You pay
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 oral contraceptives under the prescription drug benefit.
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: Reversal of voluntary surgical sterilization and
genetic
counseling
All charges
Infertility services
Diagnosis and treatment of infertility,
except as shown in Not covered. PPO: 10% of the Plan allowance and any
amount over $2,500
Non-PPO: 30% of the Plan allowance, any difference between
our allowance
and the billed amount and any amount over $2,500
Not covered:
Infertility services after voluntary
sterilization
Assisted reproductive technology (ART) procedures,
such as:
-artificial insemination (all procedures)
-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
All charges
Allergy care
Testing and treatment, including materials (such as
allergy serum)
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 23
23
Page 24 25
2002 APWU Health Plan 24 Section 5( a)
Treatment
therapies You pay
Chemotherapy and radiation therapy
Note: High
dose chemotherapy in association with autologous bone marrow transplants is
limited to those transplants listed on
page 34.
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 IV/ Infusion therapy and GHT when we preauthorize the
treatment. Call Spectera/ Care at 800/ 580-8771
for preauthorization.
Spectera/ Care will ask you to submit information that establishes that GHT is
medically necessary.
You should ask for preauthorization before you begin
treatment. If you do not ask or if we determine GHT is not medically
necessary, we will not cover GHT or related services and supplies. See Services requiring our prior approval in Section
3.
Respiratory and inhalation therapies
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount
Physical and occupational therapies
Physical therapy and
occupational therapy provided by a licensed registered therapist.
Note: Preauthorization of rehabilitative therapies is required. Call
Spectera/ Care at 800/ 580-8771 for preauthorization.
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 services are needed
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:
Maintenance therapies
Exercise
programs
Physical and occupational therapies without
preauthorization
All charges 24
24 Page 25 26
2002 APWU
Health Plan 25 Section 5( a)
Speech therapy You pay
Speech therapy where medically necessary and provided by a licensed therapist
Note: Preauthorization of speech therapy is required. Call Spectera/ Care at
800/ 580-8771 for preauthorization.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our allowance and the billed amount
Hearing services (testing, treatment, and supplies)
Audiologist to
diagnose a hearing problem 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:
Hearing aids, testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
Internal
(implant) ocular lenses and/ or the first contact lenses required to correct an
impairment caused by accident
or illness. The services of an optometrist are limited to the testing,
evaluation and fitting of the first contact lenses
required to correct an
impairment caused by accident or illness.
Note: See Preventive care, children for eye exams for children
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:
Eyeglasses or contact lenses and examinations
for them
Eye exercises and visual training
Radial
keratotomy and other refractive surgery
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes
See Orthopedic and prosthetic devices for information on podiatric shoe
inserts
PPO: $15 copayment for the office visit (No deductible) plus 10% of
the
Plan allowance for other services performed during the visit
Non-PPO: 30% of the Plan allowance and any difference
between our
allowance and the billed amount
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions
of the foot, except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any
instability, imbalance or subluxation of the foot
(unless the treatment is
by open cutting surgery)
All charges 25
25 Page 26 27
2002 APWU
Health Plan 26 Section 5( a)
Orthopedic and prosthetic devices
You pay
Artificial limbs and eyes; stump hose
Externally worn
breast prostheses and surgical bras,
including necessary replacements
following a mastectomy
Leg, arm, neck and back braces
Internal prosthetic devices, such as
artificial joints,
pacemakers, cochlear implants, and surgically implanted
breast implant following mastectomy. Note: See Section
5( b) for coverage of the surgery to insert the device.
Note: We recommend preauthorization of orthopedic and prosthetic devices.
Call Spectera/ Care at 800/ 580-8771 for
preauthorization.
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:
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
All charges
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
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 equipment such as:
Hospital beds
Wheelchairs
Crutches; and
Walkers
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference
between our allowance and the billed amount 26
26
Page 27 28
2002
APWU Health Plan 27 Section 5( a)
Durable medical equipment
(DME) -Continued You pay
Note: Call Spectera/ Care at 800/
580-8771 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:
Whirlpool equipment
Sun and heat
lamps
Light boxes
Heating pads
Exercise
devices
Stair glides
Elevators
Air
Purifiers
Computer "story boards", "light talkers", or other
communication aids for communication-impaired
individuals
All charges
Home health services You pay
Services for skilled nursing care up
to a maximum plan payment of $90 per day when preauthorized and:
A registered nurse (R. N.), licensed practical nurse (L. P. N.) or licensed
vocational nurse (L. V. N.) provides the services
The attending physician
orders the care
The physician identifies the specific professional skills
required by the patient and the medical necessity for skilled
services; and
The physician indicates the length of time the services
are needed
Note: Skilled nursing care must be preauthorized. Call Spectera/ Care at 800/
580-8771 for preauthorization.
PPO: 10%; all charges after we pay $90 per day
Non-PPO: 30%; all charges
after we pay $90 per day
Not covered:
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
Nursing services without preauthorization
Services of
nurses aides or home health aides
2002 APWU Health Plan 28 Section 5( a)
Chiropractic
Chiropractic treatment limited to 12 visits and/ or manipulations per
year. PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance
and any difference
between our allowance and the billed amount
Alternative treatments
Acupuncture – by a doctor of medicine or
osteopathy PPO: $15 copayment (No deductible) Non-PPO: 30% of the Plan
allowance and any difference between our allowance and the billed
amount
Not covered:
Services of any provider not
listed as covered; see Covered providers on page 9
All charges
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member per
lifetime.
PPO: Nothing
Non-PPO: Nothing 28
28
Page 29 30
2002 APWU Health Plan 29 Section 5( b)
Section 5( b).
Surgical and anesthesia services provided by physicians
and other health
care professionals
I M
P O
R T
A N
T
Here are some important things 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 deductible is: PPO -$275 per
person ($ 550 per family); Non-PPO -$350 per person ($ 700 per family). The
calendar year deductible applies
to almost all benefits in this Section. We added "( No deductible)" to show
when the 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.
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 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.
Precertification/ preauthorization is required for:
-Organ
transplantations
-Procedures which might be cosmetic in nature, such as
eyelid surgery or
varicose vein surgery
-Surgery for morbid obesity, or
-Surgery for organic impotence
I M
P O
R T
A N
T
Benefit Description You Pay After the calendar year deductible
NOTE:
The calendar year deductible applies to almost all benefits in this Section. We
say "( No deductible)"
when it does not apply.
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our
allowance and the billed amount 29
29 Page 30 31
2002 APWU Health Plan 30 Section 5( b)
Surgical
procedures -Continued You Pay
Normal pre -and
post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
(see above)
Biopsy procedures
Electroconvulsive therapy
Removal of tumors
and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment of morbid obesity
Insertion of
internal prosthetic devices. See Section 5( a) for 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
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 or
-Non-PPO: 70% of the Plan allowance
For the secondary procedure( s):
-PPO: 90% of one-half of the Plan allowance or
-Non-PPO: 70% of one-half of the Plan allowance
Note: Multiple or
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.
PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half
of
the Plan allowance for the secondary procedure( s)
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 any
difference between
our payment and the billed amount
Not covered:
Cosmetic surgery and other related expenses if
not preauthorized
Reversal of voluntary sterilization
Services of a standby
surgeon, except during angioplasty or other high risk procedures when we
determine
standbys are medically necessary
Radial keratotomy and other
refractive surgery
2002 APWU Health Plan 31 Section 5( b)
Reconstructive
surgery You pay
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
(including port wine stains); 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 complications, 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.
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:
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 if repair is initiated
within two years of the accident
Surgeries related to sex transformation, sexual dysfunction or
sexual inadequacy except if preauthorized
for organic impotence
All charges 31
31 Page 32 33
2002 APWU
Health Plan 32 Section 5( b)
Oral and maxillofacial surgery
You pay
Oral surgical procedures, limited to:
Reduction of
fractures of the jaws or facial bones
Surgical correction of cleft lip,
cleft plate 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
Extraction of impacted (unerupted) teeth
Alveoplasty, partial
ostectomy and radical resection of
mandible with bone graft unrelated to
tooth structure
Excision of bony cysts of the jaw unrelated to tooth structure
Excision of tori, tumors, and premalignant lesions, and biopsy of hard and soft
oral tissues
Reduction of dislocations and excision, manipulation, arthrocentesis,
aspiration or injection of temporomandibular
joints
Removal of foreign
body, skin, subcutaneous alveolar tissue, reaction-producing foreign bodies in
the musculoskeletal
system and salivary stones
Incision/ excision of salivary glands and
ducts
Repair of traumatic wounds
Sinusotomy, including repair of
oroantral and oromaxillary
fistula and/ or root recovery
Surgical treatment of trigeminal neuralgia
Frenectomy or frenotomy,
skin graft or vestibuloplasty-stomatoplasty unrelated to periodontal disease
Incision and drainage of cellulitis unrelated to tooth structure
Note:
We suggest you call us at 800/ 222-APWU to determine whether a procedure is
covered.
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:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva and
alveolar bone)
Dental bridges, replacement of natural teeth,
dental/ orthodontic/ temporomandibular joint dysfunction
appliances and any related expenses
Treatment of periodontal
disease and gingival tissues, and abscesses
Charges related to orthodontic treatment
All charges 32
32 Page 33 34
2002 APWU
Health Plan 33 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
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
Allogeneic bone marrow transplants are limited to patients
with leukemia, advanced Hodgkin's lymphoma, advanced non-Hodgkin's lymphoma,
aplastic anemia, severe
combined immuno-deficiency disease or Wiskott-Aldrich syndrome
Autologous bone marrow transplants and autologous peripheral stem cell
support are limited to patients with
acute leukemia in remission, relapsed
non-Hodgkin's lymphomas responding to treatment, resistant or recurrent
neuroblastoma, relapsed Hodgkin's disease responding to treatment,
testicular cancer, mediastinal cancer,
retroperitoneal cancer, ovarian germ
cell tumors, epithelial ovarian cancer, breast cancer and multiple myeloma
Intestinal transplants (small intestine) and the small
intestine with
the liver or small intestine with multiple organs such as the liver, stomach,
and pancreas only for
those patients with irreversible intestinal failure who have failed TPN
(total parenteral nutrition)
The Plan uses specific Plan-designated organ/ tissue transplant facilities.
Before your initial evaluation as a potential candidate
for a transplant
procedure, you or your doctor must contact Spectera/ Care at 800/
580-8771 and ask to speak to a Transplant
Case Manager. You will be provided
with information about transplant preferred providers. If you choose a
Plan-designated
transplant facility, you may receive prior approval for
travel and lodging costs.
Limited Benefits – If you don't use a Plan-designated transplant facility,
benefits for pretransplant evaluation, organ procurement,
inpatient
hospital, surgical and medical expenses for covered transplants , whether
incurred by the recipient or donor, are limited
to a maximum of $100,000 for
each listed transplant, including multiple organ transplants.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our allowance and
the billed amount and any amount over $100,000 33
33 Page 34 35
2002 APWU Health Plan 34 Section 5( b)
Organ/ tissue transplants – Continued You pay
Not covered:
Donor screening tests and donor search
expenses, except those performed for the actual donor
Services or supplies for, or related to, surgical transplant procedures
for artificial or human organ transplants not
listed as specifically
covered. Related services include
administration of high dose chemotherapy
when supported by autologous bone marrow transplant
Transplants not listed as covered
All charges
Anesthesia
Professional services for administration of anesthesia
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 any anesthesia charges.
34
34 Page 35 36
2002 APWU Health Plan 35 Section 5( c)
Section 5 (c).
Services provided by a hospital or other facility,
and ambulance services
I M
P O
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A N
T
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.
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 calendar year deductible is; PPO -$275 per person ($ 550 per
family); Non-PPO -$350 per person ($ 700 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 shown in Section 3 to
be sure which services require precertification.
I M
P O
R T
A N
T
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
Meals and special diets
Note: We only cover a private room when you mu st 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 comparable hospitals in the area.
Note: When the non-PPO hospital bills a flat rate, we prorate the charges to
determine how to pay them, as follows: 30%
room and board and 70% other charges.
PPO: 10% of the covered charges
Non-PPO: $200 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. 35
35
Page 36 37
2002 APWU Health Plan 36 Section 5( c)
Inpatient
hospital – Continued You pay
Other hospital services and
supplies, such as:
Operating, recovery, maternity, and other treatment
rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and
X-rays 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
Note: We cover appliances, medical equipment and medical supplies provided
for take-home use under Section 5( a). We cover
prescription drugs and medicines dispensed for take- home use under Section 5( f).
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.
(see above)
Not covered:
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, skilled nursing facilities,
residential treatment facilities, day and
evening care centers, and schools
Personal comfort items such
as radio, television, air conditioners, beauty and barber services, guest meals
and
beds
Services of a private duty nurse that would normally be
provided by hospital nursing staff
All charges 36
36 Page 37 38
2002 APWU
Health Plan 37 Section 5( c)
Outpatient hospital or ambulatory
surgical center You pay
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.
Note: We cover outpatient services and supplies of a hospital or
free-standing ambulatory facility the day of a surgical procedure
(including
change of cast), hemophilia treatment, hyperalimentation, rabies shots, cast or
suture removal, oral
surgery, foot treatment, chemotherapy for treatment of
cancer, and radiation therapy.
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)
Extended care benefits/ Skilled nursing care facility benefits
No
benefit All charges
Hospice care
Hospice is a coordinated program
of home and inpatient supportive care for the terminally ill patient and the
patient's
family provided by a medically supervised specialized team under the
direction of a duly licensed or certified Hospice Care
Program.
We pay
$3,000 annually for outpatient services and $2,000 annually for inpatient
services.
We pay a $200 annual bereavement benefit per family unit.
Any amount over the annual maximu ms shown
Ambulance
Local professional ambulance service when medically
appropriate 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:
Ambulance
service used for routine transport
All charges 37
37 Page 38 39
2002 APWU Health Plan 38 Section 5( d)
Section 5 (d).
Emergency services/ accidents
I M
P O
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A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
The calendar year deductible is: PPO -$275 per person ($ 550 per family);
Non-PPO
-$350 per person ($ 700 per family). The calendar year deductible
applies to almost all benefits in this Section. We added "( No deductible)" to
show when the
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.
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.
I M
P O
R T
A N
T
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, and poisonings.
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. If you
are
unsure of the severity of a condition in terms of this benefit, the Plan
recommends that you first call its 24-hour nurse advisory service (800/
755-2200) or your physician.
Note: If you use an emergency room for other than a recognized medical
emergency, facility fees and supplies will not be covered.
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 24 hours, we cover:
Physician services and supplies
PPO: Nothing (No deductible)
Non-PPO: Only the difference between our allowance and the billed amount
(No deductible) 38
38 Page
39 40
2002 APWU Health Plan 39 Section 5( d)
Accidental
injury– Continued You Pay
Related outpatient hospital
services
Note: We pay Hospital benefits if you are admitted.
(see above)
If you receive care for your accidental injury after 24 hours, we cover:
Physician services and supplies
Note: We pay Hospital benefits if you
are admitted.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our
allowance and the billed amount
Medical emergency
Outpatient facility charges in an Urgent Care
Center PPO: $40 copayment (No deductible)
Non-PPO: 30% of the Plan allowance
and any difference between our
allowance and the billed amount
Outpatient medical or surgical services
and supplies, other than an Urgent Care Center PPO: 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
Air ambulance if medically necessary for transport to
the
closest appropriate facility for treatment
Note: See Section 5( c) for non-emergency service.
PPO: 10% of the Plan allowance
Non-PPO: 30% of the Plan allowance and any
difference between our
allowance and the billed amount 39
39 Page 40 41
2002 APWU Health Plan 40 Section 5( e)
Section 5 (e).
Mental health and substance abuse benefits
I M
P O
R T
A N
T
You may choose to get care In-Network or Out-of-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 Mental health and substance abuse benefits have a separate calendar
year deductible. The In-network deductible is $275 per person, $550 per family.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES . See the instructions
after the benefits descriptions below.
In-Network mental health and substance abuse benefits are below, then
Out-of-Network benefits begin on page 41.
I M
P O
R T
A N
T
Benefit Description You Pay After the calendar year deductible…
NOTE: The calendar year deductible applies to almost all benefits in
this Section. We say "( No deductible)" when it does not apply.
In-Network benefits
All diagnostic and treatment services
contained in a treatment plan that we approve. The treatment plan may include
services, drugs, and supplies 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.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, licensed
social workers, or licensed
intensive outpatient treatment centers
Medication management
$15 per visit (No deductible)
Diagnostic tests 10% of the Plan allowance
In-Network
benefits-Continued on next page 40
40 Page 41 42
2002 APWU Health Plan 41 Section 5( e)
In-Network
benefits – Continued You pay
Inpatient services provided
by a hospital or other facility
Services in approved partial
hospitalization setting
10% of the covered charges (No deductible)
Not covered: Services we have not approved
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will
generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.
All charges
Preauthorization To be eligible to receive these enhanced mental
health and substance abuse benefits you must obtain a treatment plan and follow
all of the
following network authorization processes:
Inpatient
careYou must get preauthorization of hospital stays; failure to do so will
result in a minimum $500 penalty. Please
refer to the precertification information shown in Section 3. To obtain
preauthorization of an admission for mental conditions or
substance
abuse, call ValueOptions at 888/ 700-7965
Outpatient careYou must get
preauthorization of outpatient
care for mental conditions or substance
abuse. Preauthorization must be obtained by calling ValueOptions at 888/
700-7965
We do not make available provider directories for mental health or
substance abuse providers. ValueOptions will provide you
with a choice of
network providers when you call to preauthorize your care
Out-of-Network benefits
Professional outpatient care to treat
mental conditions and substance abuse After a $750 mental conditions/ substance
abuse calendar year deductible, 50% of our
allowance for up to 15 visits;
all charges after 15 visits
Inpatient care to treat mental conditions includes ward or semiprivate
accommodations and other hospital charges After a $750 mental conditions/
substance abuse calendar year deductible, 50% of
charges for up to 30 days
per calendar year; all charges after 30 days
Inpatient care to treat substance abuse includes room and board and ancillary
charges for confinements in a treatment facility
for rehabilitative
treatment of alcoholism or substance abuse
After a $750 mental conditions/
substance abuse calendar year deductible, 50% of
charges for one treatment
program up to $3,000; all charges over $3,000 per
lifetime 41
41 Page 42 43
2002 APWU Health Plan 42 Section 5( e)
Out-of-Network
benefits -Continued You Pay
Not covered out-of-network:
Treatment for learning disabilities and mental retardation
Services rendered or billed by a school or halfway house or a
member of its staff
Phototherapy for treatment of Seasonal Affective Disorder (SAD)
All charges
Lifetime maximum Out-of-Network inpatient care for the treatment of
alcoholism and drug abuse is limited to one treatment program per lifetime not
to exceed
$3,000.
Precertification Inpatient care – You must get preauthorization of
hospital stays; failure to do so will result in a minimum $500 penalty. Please
refer
to the precertification information shown in Section
3. To obtain preauthorization of an admission for mental conditions or
substance
abuse, call ValueOptions at 888/ 700-7965
Outpatient care –
You must get preauthorization of outpatient care for mental conditions or
substance abuse. Preauthorization must be
obtained by calling ValueOptions at 888/ 700-7965
See these sections of
the brochure for more valuable information about these benefits:
Section
3, How you get care, for information about catastrophic
protection for these benefits.
Section 7, Filing a claim
for covered services, for information about submitting out-of-network
claims. 42
42 Page
43 44
2002 APWU Health Plan 43 Section 5( f)
Section 5 (f).
Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
on page 45.
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 deductible does not apply to prescription drug benefits.
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.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. Any covered provider licensed to
prescribe drugs may write your
prescription.
Where can you obtain them. You can fill the prescription at a PAID
network pharmacy, a non-network pharmacy, or by mail. We pay our highest level
of benefits for mail order and you should use
the mail order program to obtain your maintenance medications.
We
use a formulary. Our formulary is open and voluntary. A formulary is a list
of medications we have selected based on their clinical effectiveness and lower
cost. By asking your doctor to prescribe
formulary medications, you can help reduce your costs while maintaining
high-quality care. Use of a formulary drug is voluntary; there is no financial
penalty if your physician does not prescribe a
formulary drug.
Brand/ Generic Drugs
Why use generic drugs? A generic drug is a chemical equivalent of a
corresponding name brand
drug. The US Food and Drug Administration sets
quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand name drugs. Generic drugs
are less expensive than brand drugs, therefore, you may reduce your
out-of-pocket-expenses by choosing to use a generic drug.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally -approved generic drug is
available, and your physician has
not received a preauthorization, you have to pay the difference in cost between
the name brand drug and the generic, in addition to your coinsurance. However,
if
your doctor obtains preauthorization because it is medically necessary
that a brand name drug be dispensed, you will not be required to pay this cost
difference. Your doctor may seek
preauthorization by calling 800/ 841-5409.
These are the dispensing limitations.
-The PAID Retail Network
–you may obtain up to a 30-day supply plus one 30-day refill for each
prescription purchased from a PAID network pharmacy. After one 30-day refill,
you must obtain a
new prescription and submit it to the mail order program.
If you do not, we will pay the non-network pharmacy benefit level. To receive
maximum savings you must present your card at the
time of each purchase, and
your enrollment information must be current and correct. In most cases, you
simply present the card together with the prescription to the pharmacist.
Refills cannot be
obtained until 75% of the drug has been used. 43
43 Page 44 45
2002 APWU Health Plan 44 Section 5( f)
-Non-network
pharmacy – if you do not use your identification card, if you elect to use a
non-network pharmacy, or if a PAID network pharmacy is not available, you will
need to file a claim
and we will pay at the non-network retail pharmacy
benefit level
-Mail order – through this program, you may receive up to a
90-day supply of maintenance medications for drugs which require a prescription,
ostomy supplies, diabetic supplies and insulin,
syringes and needles for covered injectable medications, and oral
contraceptives. Some medications may not be available in a 90-day supply from
Merck-Medco Home Delivery Pharmacy
even though the prescription is for 90
days.
-Refills for maintenance medications are not considered new
prescriptions except when the doctor changes the strength or 180 days has
elapsed since the previous purchase. Refill orders submitted
too early after the last one was filled are held until the right amount of
time has passed. As part of the administration of the prescription drug program,
we reserve the right to maximize your quality
of care as it relates to the
utilization of pharmacies.
-You may fill your prescription at any pharmacy
participating in the PAID TelePaid system. For the
names of participating
pharmacies, call 800/ 841-2734.
Certain controlled substances and several other prescribed medications may be
subject to other dispensing limitations, such as quantities dispensed, and to
the judgment of the pharmacist.
When you have to file a claim. Use a Prescription Drug Claim Form to
claim benefits for prescription drugs and supplies purchased from a non-network
pharmacy. You may obtain forms by calling
800/ 222-APWU or from our website
at www. apwuhp. com. Your claim must include
receipts that show the prescription number, the National Drug Code (NDC) number,
name of the drug, prescribing
physician's name, date of purchase and
charge for the drug. Mail the claim form and receipt( s) to:
APWU Health
Plan P. O. Box 967
Silver Spring, MD 20910
Prescription drug benefits
begin on next page. 44
44 Page 45 46
2002 APWU
Health Plan 45 Section 5( f)
Benefit Description You Pay
NOTE: The calendar year deductible does not apply to this section.
Covered medications and supplies
Each new enrollee will receive a description of our prescription drug
program, a combined prescription drug/ Plan identification
card, a mail 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 for smoking cessation, for use at home that are obtainable only
upon a
doctor's prescription and listed in official formularies
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 and
reagent strips for known diabetics
Needles and syringes for the
administration of covered medications
Ostomy Supplies
Full range of FDA-approved drugs, prescriptions, and
devices for birth control
Approved drugs for organic impotence subject to prior Plan approval and
limitations on dosage and quantity
Viagra, Retin A and Growth Hormones must have prior approval from Spectera/
Care at 800/ 581-8771
Network Retail: $7 generic/ 25%
brand name
Network Retail Medicare:$ 7 generic/ 25% brand name
Non-Network Retail: 45% of cost
Non-Network Retail Medicare : 45% of
cost
Network Mail Order: $10 generic/ 20% brand name
Network Mail
Order Medicare :
$10 generic/ 20% brand name
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, minerals, nutritional supplements, and enteral formulas
(liquid food supplements)
Medical supplies such as dressings and antiseptics
Nonprescription medicines
All charges 45
45 Page 46 47
2002 APWU
Health Plan 46 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 We offer a 24-hour nurse service for your use. This
program is strictly voluntary and confidential. You may call toll-free at
800/ 755-2200 and reach registered nurses to discuss an existing medical
concern or to receive information about numerous health
care issues.
Services for deaf and hearing impaired We offer a toll-free TDD line
for customer service. The number is 800/ 622-2511. TDD equipment is required.
Wellness benefit We reimburse you up to $250 per Self Only enrollment
and $350 per Self and Family enrollment per calendar year for non-covered
expenses such as vision care, eyeglasses , hearing aids, if received in 2002
and no other benefits for 2002 have been paid. If we paid
claims of less than $350 for a Self and Family enrollment, the difference up
to $350 will be paid.
We will notify you in November if you are eligible for the Wellness benefit.
Submit Wellness claims after January 1, 2003. Wellness
claims are paid after
March 1, 2003. If, after Wellness benefits have been paid, subsequent claims are
received for hospital, medical or
dental expenses, payments made under the
Wellness benefit will be deducted from allowable charges.
Review and reward program If you send us a corrected hospital billing,
we will credit 20% of any hospital charge over $20 for covered services and
supplies that were
not actually provided to a covered person. The maximum
amount payable under this program is $100 per person per calendar year. 46
46 Page 47 48
2002 APWU Health Plan 47 Section 5( h)
Section 5 (h).
Dental benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
The calendar year deductible is: PPO -$275 per person ($ 550 per
family); Non-PPO -$350 per person ($ 700 per family). The calendar year
deductible applies to almost all benefits in this Section. We
added "( No deductible)" to show when the calendar year deductible does not
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.
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
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to repair (but not replace) sound natural teeth. The need
for these
services must result from an accidental injury (a blow or fall)
and must be performed within two years of the accident. See
also Section 5(
d), Accidental Injury.
Within 24 hours of accident:
PPO: Nothing (No deductible)
Non-PPO:
Only the difference between our allowance and the billed
amount (No deductible)
More than 24 hours after accident:
PPO: 10% of
the Plan allowance
Non-PPO: 30% of the Plan allowance and any difference
between our
allowance and the billed amount
Dental benefits
Service We pay (scheduled allowance) You pay
Office visits
Restorative care (fillings)
Simple extractions
Note: Office vis its include examinations,
prophylaxis (cleanings), x-rays of all types and
fluoride treatment.
$25 per visit (limit 2 visits per year)
$13 per tooth (single surface)
$18 per tooth (two or more surfaces)
$13 per tooth
All charges in excess of the scheduled amounts
listed to the left (No
deductible) 47
47 Page
48 49
2002 APWU Health Plan 48
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 or
premium, and you cannot file an FEHB disputed claim about them. Fees you
pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Voluntary
Benefits Plan
Dental Plan
The Voluntary Benefits Plan Dental program is an optional program with an
additional premium that supplements the dental benefits in your APWU Health Plan
coverage. All participants of the APWU
Health Plan who enroll in the
Voluntary Benefits Plan Dental Plan through this offer will receive a discount
in the regular premiums for that program. To enroll in this additional coverage,
complete and
sign the Voluntary Benefits Plan Dental Plan enrollment form,
which you can obtain from your APWU Health Plan representative or by calling the
Voluntary Benefits Plan office at the toll-free number listed
below. Please
specify that you are an APWU Health Plan participant.
Availability
The Voluntary Benefits Plan Dental Plan is available to all Active, Retired,
Associate and Transitional
Employee APWU Members in all States and
Territories of the United States.
Coverage
Description This optional dental plan is an indemnity
insurance plan underwritten by the Reliance Insurance Company. You may use any
dentist you choose. Covered services are reimbursed as a percentage of the
"Reasonable
and Customary" charges for that service in the state where the charge is
incurred. Once you have satisfied the continuous coverage limitations of the
program, there are no further waiting periods as long as you
remain continuously insured under the plan. Both you and your eligible
dependents (spouse and unmarried children to age 19 -full-time students to age
25) can be insured under this plan.
Coverage
Schedule
Calendar Year Deductible: $50 per person
-Type I benefits $100 per person -Type II and Type III benefits, combined
Calendar Year Maximum: $1,000 per person for all covered services $500 per
person for all eligible Orthodontic services, if Optional Orthodontic
Coverage is selected
Lifetime Maximum: $1,000 for Orthodontic services,
if Optional Orthodontic Coverage is selected
After the Annual Deductible, this plan will pay: BENEFIT SCHEDULE
HIGH OPTION PLAN LOW OPTION PLAN TYPE I BENEFITS
Preventive Services Exams
X-rays Cleanings
100% of the
Reasonable and Customary charges 100% of the Reasonable and Customary charges
TYPE II BENEFITS
Basic Services Fillings
Oral Surgery Extractions
80% of the Reasonable and Customary charges
(6 month waiting period)
50% of the Reasonable and Customary charges
(6 month waiting period)
TYPE III BENEFITS
Major Services Crowns
Bridges Dentures
Periodontics
50% of the Reasonable and Customary charges
(12 month waiting period)
50% of the Reasonable and Customary charges
(18 month waiting period)
TYPE IV BENEFITS
(Optional Coverage)
Orthodontic
50% of the Reasonable and Customary charges
(24 month waiting period)
50% of the Reasonable and Customary charges
(24 month waiting period)
This is a partial summary of the terms, conditions and limitations of the
Dental Plan policy #G-224,540. For more information regarding the coverage,
rates or to receive an enrollment form, please contact the Voluntary Benefits
Plan office
by calling or writing:
Voluntary Benefi ts Plan
P. O. Box 1471
Waterbury, CT 06721
800/ 422-4492
800/ 237-5536 (In CT) 203/
754-4410 (T. D. D.)
Benefits on this page are not part of the FEHB contract 48
48 Page 49 50
2002 APWU Health Plan 49 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
except for organic impotence as shown on pages 29 and 45
Services, drugs, or supplies you receive from a
provider or facility barred from the FEHB Program
Services, drugs and
supplies for which no charge would be made if the covered individual had no
health insurance coverage
Computer "story boards", "light talkers", or other communication aids for
communication-impaired individuals
Services, drugs and supplies furnished
without charge (except as described on page 58; 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, drugs and supplies furnished by immediate
relatives or household members, such as spouse, parent, child, brother, or
sister by blood, marriage, or adoption
Services and supplies furnished or billed by a noncovered facility, except
that medically necessary prescription drugs and physical, speech and
occupational therapy rendered by a qualified professional therapist on an
outpatient basis are covered subject to plan limits
Services, supplies
and drugs not specifically listed as covered
Services, supplies and drugs
furnished or billed by someone other than a covered provider as defined on page 9
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, we will calculate the
actual provider fee or charge by reducing the fee or charge by the amount
waived
Charges which you or we have 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 pages 17 and 18), doctor charges
exceeding the amount
specified by the Department of Health and Human Services when benefits are
payable under Medicare (limiting charge) (see page 18), or
State premium taxes however applied
Biofeedback; nonmedical self care or self help training, such as
recreational, educational, or milieu therapy; or
Charges that we determine
to be in excess of the Plan allowance 49
49 Page 50 51
2002 APWU Health Plan 50 Section 7
Section 7. Filing a
claim for covered services
How to claim benefits To obtain claim forms
or other claims filing advice or answers about our benefits, contact us at 800/
222-APWU, or at our website at
www. apwuhp.
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 800/ 222-APWU.
When you must file a claim, such as for overseas claims or when another group
health plan is primary, submit it on the 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, address and taxpayer identification number 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 the Medicare Summary Notice (MSN)) with your
claim
Bills for home nursing care must show that the nurse is a
registered
nurse, licensed practical nurse or licensed vocational nurse
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 obtained from a
network pharmacy or through the Mail Service Prescription
Drug Program must
include receipts that include the prescription number, the National Drug Code
(NDC) number, name of drug or
supply, prescribing physician's name, date,
and charge
You should provide an English translation and currency
conversion rate at the time of services for claims for overseas (foreign)
services
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.
50
50 Page 51 52
2002 APWU Health Plan 51 Section 7
Deadline for filing your claim Send us all of the documents for
your claim as soon as possible. You must submit the claim by December 31 of the
year after the year you
received the service, unless timely filing was
prevented by administrative operations of Government or legal incapacity,
provided
the claim was submitted as soon as reasonably possible. 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: APWU Health
Plan, P. O. Bo x 967, Silver Spring, MD 20910. Send any
written inquiries concerning the processing of overseas claims to this
address.
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. 51
51 Page
52 53
2002 APWU Health Plan 52
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on your claim or request for services, drugs, or
supplies – including a request for 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: APWU Health Plan, P. O. Box 3279, Silver
Spring, MD 20918; 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 II, 1900 E Street, NW, Washington, D. C. 20415-3620
Send OPM the following information:
A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms
Copies of all letters you sent to us about the claim
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call 52
52 Page 53 54
2002 APWU
Health Plan 53 Section 8
The disputed claims process
-Continued
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 lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at 800/ 222-APWU 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. 53
53
Page 54 55
2002
APWU Health Plan 54 Section 9
Section 9. Coordinating benefits
with other coverage
When you have other health
coverage
You must tell us if you are covered or a family member is covered under
another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full
as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is primary
according to the National Association of Insurance
Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits
described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older
Some people with disabilities, under 65
years of age
People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant)
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. 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 age 65 or older, you may be able
to buy it. Contact 800/ MEDICARE
(800/ 633-4227) 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 (Part A or Part B) The Original Medicare Plan
(Original Medicare) is available everywhere in the United 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.
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: 54
54 Page 55 56
2002 APWU Health Plan 55 Section 9
The Original
Medicare Plan (Part A or Part B) (Continued) When we are the
primary payer, we process the claim first. In this case, we do not waive any
out-of-pocket costs
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 800/ 222-APWU or contact us at our website at www. apwuhp. 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 service. If you are enrolled in Medicare Part A, the
Plan will waive the deductible, copayment and coinsurance
Medical services
and supplies provided by physicians and other
health care professionals. If
you are enrolled in Medicare Part B, we will waive the deductible and
coinsurance 55
55 Page
56 57
2002 APWU Health Plan 56
Section 9
The following chart illustrates whether Original Medicare
or this Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you tell us
if you or a covered
family member has Medicare coverage so we can administer
these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the Federal government (including when
you or a family member are eligible for Medicare solely
because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The
position is not excluded from FEHB
(Ask your employing office which of these
applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare
based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to
ESRD after Medicare became primary for you under another provision,
C.
When you or a covered family member have FEHB and…
1) Are eligible for
Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee
c) Are a former spouse of an annuitant
d) Are a former spouse of an
active employee 56
56 Page
57 58
2002 APWU Health Plan 57
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
prescriptions drugs. To learn more about enrolling in a Medicare
managed
care plan, contact Medicare at 800/ MEDICARE (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
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 Part A or
Part B
If you do
not have one or both Parts of Medicare, you can still be covered under the 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 the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the
CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your TRICARE
Health Benefits Advisor if you have
questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
You need
because of a workplace-related illness or injury that the
Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they must provide; or 57
57 Page 58 59
2002 APWU
Health Plan 58 Section 9
Workers' Compensation
(continued)
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 are responsible for your care
We do not cover services and supplies when a local, State, or Federal
Government agency directly or indirectly pays for them.
When others are responsible
for injuries
If you or your dependent's injury or illness is caused by another person or
entity, the Health Plan will pay benefits for that injury or
illness according to the terms of the Brochure in effect at the time services
are provided. If the Health Plan pays any benefits for that
injury or
illness, when you or your dependent receive money or have a right to receive
money from any source, including underinsured and
uninsured automobile
coverage, as a result of this injury or illness, you or your dependent must
reimburse the Health Plan for any
expenses we paid for that injury or
illness. The amount owed to the Health Plan will not be reduced for attorney's
fees or costs nor
because you or your dependent was not fully compensated
for the injury or illness, unless the Plan agrees in writing to a reduction.
If you do not seek damages you must agree to let us try. This includes the
right of the Plan to sue the responsible person or entity in
your or your
dependent's name. This is called subrogation. You must inform the Plan if you or
your dependent's injury or illness is
caused by another person. You must
agree that you will not do anything that would prevent the Plan from being
reimbursed for the
benefits it paid and will cooperate in doing what is
reasonably necessary to assist the Plan in recovering the benefits it paid
because
of that injury or illness. All money recovered and in whatever
manner it is recovered, and regardless of how it is designated, must
first
be used to reimburse the Plan before it is distributed in any form.
If you
need more information, contact us for our subrogation procedures. 58
58 Page 59 60
2002 APWU Health Plan 59 Section 10
Section 10.
Definitions of terms we use in this brochure
Accidental injury An injury
resulting from a violent external force.
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 Your authorization for us to pay benefits directly to the
provider. We reserve the right to pay you 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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. You may also be responsible for additional amounts. See
page 14.
Copayment A copayment is a fixed amount of money
you pay when you receive covered services. See page 14.
Covered services Services we provide benefits for, as described in
this brochure.
Custodial care Treatment or services, regardless of
who recommends them or where they are provided, 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. These activities
include, but are not
limited to:
Personal care such as help in: walking; getting in and out
of bed; bathing; eating by spoon, tube or gastrostomy; exercising; dressing
Homemaking, such as preparing meals or special diets
Moving the
patient Acting as a companion or sitter
Supervising medication that can usually be self administered; or
Treatment or services that any person may be able to perform with minimal
instruction, including but not limited to recording
temperature, pulse, and respirations, or administration and monitoring of
feeding systems
We determine which services are custodial care.
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 14.
Experimental or
investigational services
A drug, device, or biological product is experimental or investigational 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 it is furnished.
Approval means
all forms of acceptance by the FDA. 59
59 Page 60 61
2002 APWU
Health Plan 60 Section 10
Experimental or investigational
services
(Continued)
A medical treatment or procedure, or a drug, device, or biological product is
experimental or investigational if 1) reliable evidence shows
that it is the
subject of ongoing phase I, II, or III clinical trials or under study to
determine its 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 its maximum tolerated dose, its toxicity, its safety, its
efficacy, or its efficacy as compared with the
standard means of treatment
or diagnosis.
Reliable evidence shall mean only published reports and
articles in the authoritative medical and scientific literature; the 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.
Determination of experimental/ investigational
status may require review by a specialty appropriate board-certified health care
provider or
appropriate government publications such as those of the National Institute
of Health, National Cancer Institute, Food and Drug
Administration, Agency
of Health Care Policy & Research, and the National Library of Medicine.
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 other
health care services or supplies, or that pays a specific amount for
each day or period of hospitalization if that specified amount exceeds $200
per day, including extension of any of these benefits through
COBRA.
Home health care agency An agency which meets all of the following:
Is primarily engaged in providing, and is duly licensed or certified to
provide, skilled nursing care and therapeutic services
Has policies established by a professional group associated with the agency
or organization. This professional group must include at
least one
registered nurse (R. N.) to direct the services provided and it must provide for
full-time supervision of each service by a
physician or registered nurse
Maintains a complete medical record on each individual; and
Has a
full-time administrator
Hospice care program A coordinated program of
home and inpatient palliative and supportive care for the terminally ill patient
and the patient's family
provided by a medically supervised specialized team
under the direction of a duly licensed or certified Hospice Care Program.
Maintenance therapy Includes but is not limited to physical,
occupational, or speech therapy where continued therapy is not expected to
result in
significant restoration of a bodily function but is utilized to
maintain the current status. 60
60 Page 61 62
2002 APWU Health Plan 61 Section 10
Medically necessary
Services, drugs, supplies or equipment provided by a hospital or covered
provider of health care services that we determine:
Are appropriate to
diagnose or treat the patient's condition, illness or injury
Are
consistent with standards of good medical practice in the United
States
Are not primarily for the personal comfort or convenience of the
patient, the family, or the provider
Are not a 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 medically necessary.
Plan allowance Our Plan allowance is the amount we use to determine
our payment and your coinsurance for covered services. Fee-for-service plans
determine their allowances in different ways. We determine our allowance as
follows:
For PPO providers, our allowance is based on negotiated rates. PPO providers
always accept the Plan's allowance as their charge for
covered services.
For non-PPO providers, we base the Plan allowance on the reasonable and
customary charge for the service you received. We
determine the reasonable and customary allowance by using health care charges
guides which compare charges of other providers for
similar services in the
same geographical area. For surgery, doctor's services, X-ray, lab and therapies
(physical, speech and
occupational), we use guides prepared by the Health
Insurance Association of America (HIAA) and apply these guides at the 70 th
percentile. We update these charges guides at least once each year. If HIAA
information is not available, we will use other credible
sources including
our own data.
For more information, see Differences
between our allowance and the bill in Section 4.
Rehabilitative care Treatment that reasonably can be expected to
restore and/ or substantially restore a bodily function that was impaired as a
result of
trauma or disease.
Us/ We Us and we refer to APWU Health Plan.
You You refers
to the enrollee and each covered family member. 61
61
Page 62 63
2002
APWU Health Plan 62 Section 11
Section 11. FEHB facts
No
pre-existing condition
limitation
We will not refuse to cover the treatment of a condition that you had before
you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information
about enrolling in the FEHB Program
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal
Employees Health Benefits Plans, brochures for other plans, and
other materials you need to make an informed decision about:
When you may change your enrollment
How you can cover your family
members
What happens when you transfer to another Federal agency, go
on leave without pay, enter military service, or retire
When your enrollment ends; and
When the next open season for
enrollment begins
We don't determine who is eligible for coverage and, in
most cases, cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available
for you and your family
Self Only coverage is for you alone. Self and Family coverage is for you,
your spouse, and your unmarried dependent children under age
22, including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain
circumstances, you
may also continue coverage for a disabled child 22 years of age or older who is
incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your
family. You may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first
day of the pay period in which the
child is born or becomes an eligible family member. When you change to Self and
Family
because you marry, the change is effective on the first day of the
pay period that begins after your employing office receives your
enrollment
form; benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor
will we. Please
tell us immediately when you add or remove family members from your coverage for
any reason, including divorce, or
when your child under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by
another
FEHB plan. 62
62 Page
63 64
2002 APWU Health Plan 63
Section 11
When benefits and
premiums start
The benefits in this brochure are effective on January 1. If you joined this
Plan during Open Season, your coverage begins on the first day of
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.
Your medical and claims
records are confidential
We will keep your medical and claims information confidential. Only the
following will have access to it:
OPM, this Plan, and subcontractors when they administer this contract
This Plan and appropriate third parties, such as other insurance plans and the
Office of Workers' Compensation Programs
(OWCP), when coordinating benefit
payments and subrogating claims
Law enforcement officials when
investigating and/ or prosecuting alleged civil or criminal actions
OPM
and the General Accounting Office when conducting audits
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation
about a
claim
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the
last five years of your Federal service. If you do not meet this requirement,
you may be eligible for other forms of coverage, such as
Temporary
Continuation of Coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
Spouse equity coverage If you are divorced from a Federal employee
or annuitant, you may not continue to get benefits under your former spouse's
enrollment.
But, you may be eligible for your own FEHB coverage under the
spouse equity law. If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get RI
70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary
Continuation of Coverage and Former Spouse Enrollees,
or other
information about your coverage choices.
Temporary Continuation of Coverage (TCC) If you leave Federal
service, or if you lose coverage because you no longer qualify as a family
member, you may be eligible for Temporary
Continuation of Coverage (TCC).
For example, you can receive TCC if you are not able to continue your FEHB
enrollment after you retire,
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. 63
63 Page
64 65
2002 APWU Health Plan 64 Section 11
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.
Converting to individual coverage You may convert to a non-FEHB
individual policy if:
Your coverage under TCC or the spouse equity law
ends (If you canceled your coverage or did not pay your premium, you cannot
convert);
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days
after you
receive this notice. However, if you are a family member who is losing coverage,
the employing or retirement office will not
notify you. You must
apply in writing to us within 31 days after you are no longer eligible for
coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your
health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal 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, or exclusions for health
related conditions
based on the information in the certificate, as long as you enroll within 63
days of losing coverage under this Plan. If you have
been enrolled with us
for less than 12 months, but were previously enrolled in other FEHB plans, you
may also request a certificate from
those plans.
For more information,
get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the
FEHB Program. See also the
FEHB website (www. opm. gov/ insure/ health); refer to the
"TCC and HIPAA" frequently asked questions. These highlight HIPAA rules,
such
as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State agencies
you can contact for more information. 64
64 Page 65 66
2002 APWU Health Plan 65 Long Term Care Insurance
Long
Term Care Insurance Is Coming Later in 2002
Many FEHB enrollees think
that 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 partofitseducational
effort,OPMasksyou toconsiderthesequestions.
What is long term care (LTC) insurance? It's insurance to help pay
for long term care services you may need if you can't takecare
ofyourselfbecauseof anextendedillnessor injury,oranage-related
diseasesuchasAlzheimer's
LTC 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. LTC insurance can supplement care provided by family members,
reducing the burden you place on them.
I'm healthy. I won't need
long term care. Or, will I?
Welcometotheclub! 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 old folks. 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 multiplesclerosis,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,itcanbe 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 protectyour savings.
But won't my FEHB plan,
Medicare or Medicaid cover my long term care?
Not FEHB. Look at the "Notcovered"blocks in Sections 5( a) and 5( c) of your FEHB brochure. Health plans
don't cover custodial care or a stay in an assisted 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.
Medicareonlycoversskilled nursinghomecare(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
oncovered services and where they can be
received. Long term care insurance can provide choices of care and
preserve yourindependence.
When will I get more
information on how to apply for this new
insurance coverage? Employees will get more information from their
agencies during the LTC open enrollment period in the late summer/ early fall of
2002.
Retirees will receive information at home.
How can I find out more
about the program NOW? Ourtoll-free teleservice center will begin in
mid-2002. In the meantime, you can learn more about the program on our website
at www. opm. gov/ insure/ ltc. 65
65 Page 66 67
2002 APWU Health Plan 66 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 the 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 under
the DoD/ FEHBP Demonstration Project.
The demonstration areas
Dover, AFB, DE
Fort Knox, KY
Dallas, TX
New Orleans, LA
Adair County, IA area
Commonwealth of Puerto Rico
Greensboro/ Winston Salem/ High Point,
NC
Humboldt County, CA area
Naval Hospital, Camp Pendleton, CA
Coffee County, GA area
When you can join You may enroll under the FEHB/ DoD Demonstration
Project during the 2001 open season, November 12, 2001, through December 10,
2001. Your
coverage will begin January 1, 2001. 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 877/ DOD-FEHB (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 website 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 website at
www. opm. gov. 66
66 Page
67 68
2002 APWU Health Plan 67 DoD/ FEHB Demonstration Project
Temporary Continuation of
Coverage eligibility
See Section 11, FEHB Facts; it explains temporary
continuation of coverage (TCC). Under this 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. 67
67 Page 68 69
2002 APWU Health Plan 68 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 31, 38, 39, 47, 59 Acupuncture
................................. 28
Allergy
care.................................. 23 Allogeneic bone marrow transplant
................................................... 33 Alternative
treatments ................. 28
Ambulance ....................... 35, 37, 39
Anesthesia.............................. 34, 37
Artificial
limbs....................... 13, 26 Autologous bone marrow transplant
....................................... 24, 33, 34 Autologous peripheral
stem cell
support...................................... 33 Biopsies
.................................. 30, 32
Blood and blood plasma .......
36, 37 Breast prosthesis .................... 26, 31
Casts
............................................. 37 Catastrophic
protection......... 15, 16
Changes for 2002........................... 8
Chemotherapy.................. 24, 34, 37
Chiropractic.............................. 9, 28 Cholesterol
tests........................... 21
Coinsurance......... 14, 15, 17, 55, 59
Colorectal cancer screening........ 21
Congenital anomalies............ 30,
31 Contraceptive devices and drugs23,
30, 45 Coordination of benefits 54,
55, 56,
57, 58 Copayment ... 14, 15, 20, 25, 28, 55,
59 Covered charg es
.................... 18, 55
Covered providers ......................... 9
Crutches........................................ 26
Deductible ....
14, 15, 16, 20, 29, 35, 38, 40, 41, 45, 47, 55, 59
Definitions........................ 59, 60, 61 Dental care ................
15, 32, 47, 48
Diagnostic services................ 21, 37 Disputed claims
review......... 52, 53
Doctor............................................. 9
Donor expenses (transplants) 33, 34
Dressings................................ 37, 45 Durable medical equipment.
13, 26,
27, 50 Educational classes and programs
................................................... 28 Effective date of
enrollment... 9, 49
Emergency................ 11, 18, 38, 39 Enteral
formulas .......................... 45
Experimental or investigational 49,
59, 60
Eyeglasses .............................. 25, 46 Family
planning........................... 23
Fecal occult blood
test................. 21 Flexible benefits option............... 46
Foot care....................................... 25 Freestanding ambulatory
facilities
............................................. 10, 37 General
exclusions....................... 49
Hearing services
.................... 25, 46 Home health services............. 13, 27
Home
nursing care .... 13, 16, 27, 50 Hospice care.................... 16, 37, 60
Hospital.... 5, 10, 11, 12, 17, 18, 20, 22, 29, 31, 33, 35, 36, 37, 39, 41,
42, 46, 55, 59, 61 Immunizations........................ 21, 22
Infertility....................................... 23 Inhospital physician
care............. 20
Inpatient hospital benefits.... 12, 15, 16, 35, 36
Insulin ........................................... 45 Laboratory and
pathological
services .................. 21, 22, 36, 37 Long Term Care
........................... 65
Magnetic reasonance imagings
(MRIs)....................................... 21
Mail order prescription
drugs43, 45 Mammograms .............................. 21
Maternity benefits
........... 11, 12, 22 Medicaid....................................... 58
Medical emergency................ 38, 39 Medically necessary 11, 12, 20, 26,
29, 35, 36, 39, 43, 47, 49, 61 Medically underserved areas .. 9, 28
Medicare 12, 17, 18, 29, 35, 38, 40, 43, 45, 47, 54, 55, 56, 57, 66
Mental health............. 13, 40, 41, 42 Newborn care
......................... 20, 22
Non-FEHB benefits ..................... 48
Nurse................ 9, 13, 27, 36, 50, 60
Licensed Practical Nurse... 9,
27, 50
Licensed Vocational Nurse9, 27, 50
Nurse
Anesthestist...................... 9 Nurse Midwife............................ 9
Nurse Practitioner....................... 9 Registered Nurse..... 9, 27, 50,
60
Nursing school administered clinic
..................................................... 9
Obstetrical
care............................ 22 Occupational therapy. 9, 13, 24, 50,
60 Office visits ..................... 20, 25, 47
Oral and maxillofacial
surgery ... 32 Organic impotence.... 13, 29, 45, 49
Orthopedic devices
................ 25, 26 Out-of-pocket expenses......... 15, 16
Overseas
claims ..................... 50, 51 Oxygen....................... 13, 26, 36, 37
Pap test.......................................... 21 Physical and
occupational therapies
...................................................
24 Physical examination................... 22
Physical therapy .... 9, 13,
24, 50, 60 Physician.. 5, 11, 14, 17, 18, 20, 24,
27, 29, 36, 38, 39, 43,
44, 45, 50, 57, 60
Precertification ... 11, 12, 35, 41, 42 Preferred
Provider Organizations
(PPO)........................................... 6
Prescription drugs .... 16, 36, 43, 44,
45, 49, 50 Preventive care,
adult............ 21, 22
Preventive care, children ............. 22 Prior
approval12, 13, 24, 33, 52, 53
Prostate cancer screening............ 21
Prosthetic devices...... 25, 26, 30, 31
Psychologist.................................... 9 Radiation
therapy.................. 24, 37
Reagent strips
............................... 45 Renal dialysis
................................ 24
Review and reward program....... 46 Room
and board .................... 35, 36
Second surgical
opinion............... 20
Sigmoidoscopy............................. 21
Skilled nursing facility care. 10, 20,
36, 37 Smoking cessation................. 28, 45
Social
worker.................................. 9 Speech therapy...... 9, 13, 25, 50,
60
Subrogation................................... 58 Substance abuse. 10,
13, 15, 40, 41,
42 Surgery ... 12, 13, 25, 29, 30, 31, 32,
33, 35, 37,
39 Anesthesia ............. 29, 34, 36, 37
Assistant surg
eon..................... 30 Multiple procedures ................. 30
Oral
..................................... 32, 37 Outpatient .....................
10, 37, 39
Reconstructive.......................... 31
Syringes......................................... 45
Temporary
continuation of coverage....................... 63, 64, 67
Transplants.......... 12, 24, 32, 33, 34 Treatment
therapies...................... 24
Tricare
........................................... 57 Vision services
...................... 25, 46
Well child care
............................. 22
Wellness benefit...........................
46 Wheelchairs ........................... 13, 26
Workers' compensation............... 57
X-rays......................... 21, 36, 37, 47 68
68 Page 69 70
2002 APWU Health Plan 69 Notes
Notes 69
69 Page
70 71
2002 APWU Health Plan 70 Summary
Summary of benefits for
the APWU Health 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 calendar year
deductible, $275 (PPO) or $350 (Non-PPO).
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 (No
deductible); 10% of
Plan allowance
Non-PPO: 30% of our allowance plus amount over our allowance
Services provided by a hospital:
Inpatient......................................................................................................
Outpatient*.................................................................................................
PPO: 10% of Plan allowance
Non-PPO: $200 copay and 30% of our
allowance plus amount over our
allowance
PPO: 10% of Plan allowance
Non-PPO: 30% of our allowance
plus amount over our allowance
35
37
Emergency benefits:
Accidental injury
.......................................................................................
Medical
emergency*................................................................................
PPO: Nothing
Non-PPO: Any amount over our allowance
Regular benefits
38
39
Mental health and substance abuse treatment
............................................ In-Network: Regular cost
sharing. Out-of-Network: Benefits are limited. 40
Prescription drugs:
Network pharmacy
...................................................................................
Network pharmacy Medicare
..................................................................
Non-network pharmacy
...........................................................................
Non-network pharmacy Medicare
.........................................................
Mail
order...................................................................................................
Mail order Medicare
.................................................................................
$7 generic/ 25% brand name
$7 generic/ 25% brand name
45% of cost
45% of cost
$10 generic/ 20% brand name
$10 generic/ 20% brand name
43
Summary of benefits-Continued on next page 70
70 Page 71 72
2002 APWU Health Plan 71 Summary
Summary of benefits
(continued)
Benefits You Pay Page
Dental Care
..........................................................................................................
Any difference between our allowance
and the billed amount for covered
services
47
Special features: Flexible benefits option, 24-hour
nurse line, Services for deaf and hearing-impaired, Wellness benefit, Review and
reward program……………………………………………………………………………….. 46
Protection against catastrophic costs (your out-of-pocket
maximum) ...... PPO: Nothing after $4,000/ Self Only or Family enrollment
per year
Non-PPO: Nothing after $6,000/ Self Only or Family enrollment per
year
Some costs do not count toward this protection
15 71
71 Page
72
2002 APWU Health Plan 72
2002 Rate Information
for
APWU Health 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 70-21N).
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.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only 471 $97.86 $48.84 $212.03 $105.82 $115.52 $31.18
Self and
Family 472 $223.41 $98.54 $484.06 $213.50 $263.75 $58.20 72