Government Employees Hospital Association, Inc. Benefit Plan
http:// www. geha. com
2002 A fee-for-service
plan
with a preferred provider organization
Sponsored and administered by: Government Employees Hospital Association,
Inc.
Who may enroll in this Plan: All Federal employees and annuitants
who are eligible to enroll in the Federal Employees Health Benefits Program may
become members of
GEHA. You must be, or must become a member of Government
Employees Hospital Association, Inc.
To become a member: You join simply by signing a completed Standard
Form 2809, Health Benefits Registration Form, evidencing your enrollment in the
Plan.
Membership dues: There are no membership dues for the Year
2002.
Enrollment codes for this Plan:
311 Self Only – High Option 312 Self and Family – High Option
314 Self Only – Standard Option 315 Self and Family – Standard Option
RI 71-006
For changes in benefits,
see pages 8-9. 1
1 Page 2 3
2002 GEHA Table of Contents 2
Table of Contents
Introduction......................................................................................................................................................................
4
Plain Language..
...........................................................................................................................................................
4
Inspector General
Advisory........................................................................................................................................
5
Section 1. Facts about this fee-for-service plan
.....................................................................................................
6-7
Section 2. How we change for 2002
......................................................................................................................
8-9
Section 3. How you get care
....................................................................................................................................
10
Identification
cards..................................................................................................................................
10
Where you get covered
care..............................................................................................................
10-11
Covered
providers...........................................................................................................................
10
Covered
facilities......................................................................................................................
10-11
What you must do to get covered care..............................................................................................
11-12
How to get approval for
...................................................................................................................
12-14
Your hospital stay (precertification)
.........................................................................................
12-13
Other services
.................................................................................................................................
14
Section 4. Your costs for covered services
.........................................................................................................
15-19
Copayments
....................................................................................................................................
15
Deductible.......................................................................................................................................
15
Coinsurance
..............................................................................................................................
15-16
Differences between our allowance and the bill
.............................................................................
16
Your out-of-pocket
maximum...........................................................................................................
16-17
When government facilities bill us
.........................................................................................................
17
If we overpay you
...................................................................................................................................
17
When you are age 65 or over
and you do not have
Medicare................................................................. 18
When you have Medicare
.......................................................................................................................
19
Section 5.
Benefits.............................................................................................................................................
20-69
Overview.................................................................................................................................................
20
(a) Medical services and supplies provided by
physicians and other health care professionals...... 21-33
(b) Surgical and anesthesia services provided by physicians and
other health care professionals .. 34-42
(c) Services provided by a
hospital or other facility, and ambulance
services................................ 43-49
(d)
Emergency services/
accidents....................................................................................................
50-52
(e) Mental health and substance abuse
benefits...............................................................................
53-60
(f) Prescription drug benefits
..........................................................................................................
61-66
(g) Special
features................................................................................................................................
67
Flexible benefits
option.........................................................................................................
67
Services for deaf and hearing impaired.................................................................................
67
High risk
pregnancies............................................................................................................
67 2
2 Page 3 4
2002 GEHA Table of Contents 3
(h) Dental
benefits
...........................................................................................................................
68-69
(i) Non-FEHB benefits available to Plan
members.........................................................................
70-71
Section 6. General
exclusions --things we don't
cover......................................................................................
72-73
Section 7. Filing a claim for covered
services....................................................................................................
74-75
Section 8. The disputed claims
process..............................................................................................................
76-77
Section 9. Coordinating benefits with other
coverage........................................................................................
78-82
When you have other health
coverage...............................................................................................
78
Original
Medicare........................................................................................................................
78-80
Medicare managed care plan
.............................................................................................................
81
TRICARE/ Workers Compensation/ Medicaid
.............................................................................
81-82
When other Government agencies are responsible
for your care....................................................... 82
When others are responsible for
injuries............................................................................................
82
Section 10. Definitions of terms we use in this
brochure...................................................................................
83-87
Section 11. FEHB
facts......................................................................................................................................
88-90
Coverage
information..............................................................................................................................
88
No pre-existing condition limitation
...............................................................................................
88
Where you get information about enrolling in the
FEHB Program ................................................ 88
Types
of coverage available for you and your
family.....................................................................
88
When benefits and premiums
start..................................................................................................
89
Your medical and claims records are confidential
..........................................................................
89
When you
retire..............................................................................................................................
89
When you lose
benefits...........................................................................................................................
89
When FEHB coverage ends...........................................................................................................
89
Spouse equity
coverage..................................................................................................................
89
Temporary Continuation of Coverage (TCC)
..........................................................................
89-90
Converting to individual
coverage.................................................................................................
90
Getting a Certificate of Group Health Plan
Coverage....................................................................
90
Long Term Care Insurance Is Coming Later in
2002!..............................................................................................
91
Department of Defense/ FEHB Program Demonstration
Project.........................................................................
92-93
Index
.....................................................................................................................................................
94-95
Summary of Standard Option
benefits......................................................................................................................
96
Summary of High Option
benefits............................................................................................................................
97
Rates............................................................................................................................................................
Back cover 3
3 Page
4 5
2002 GEHA 4 Introduction/ Plain Language/ Advisory
Introduction
Government Employees Hospital Association, Inc.
P. O. Box 4665
Independence, Missouri 64051-4665
This brochure describes
the benefits of Government Employees Hospital Association, Inc. under our
contract (CS 1063) 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 and 9. 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 Government Employees
Hospital Association, Inc.
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 GEHA 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) 821-6136 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 GEHA 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 verify their
continued participation. You can
also go to our web page which you can
reach through the FEHB web site, www. opm. gov/ insure. Do not call OPM or
your agency for our provider directory.
We have entered into arrangements with Alliance PPO, Inc.; Community Care
Network, Inc.; FCHN; HealthCare Preferred; Healthlink; MultiPlan; PPO Oklahoma;
PPO USA; Preferred Care Blue; Private Healthcare
Systems; Providence
Preferred; SouthCare; and United Payors & United Providers, Inc. (UP&
UP), which are Preferred Providers or networks of hospitals and/ or doctors in
all states. The doctors and hospitals participating in
these networks have
agreed to provide services to Plan members. You always have the right to choose
a PPO provider or a non-PPO provider for medical treatment.
PPO networks are now available in many metropolitan areas and additional
coverage areas will be added throughout the year. Enrollees residing in a PPO
network area will receive a directory of the PPO providers in their service
area.
These providers are required to meet licensure and certification
standards established by State and Federal authorities, however, inclusion in
the network does not represent a guarantee of professional performance nor does
it constitute
medical advice. To locate a
participating provider in your area, call (800) 296-0776 or visit the GEHA web
site at www. geha. com. When you phone for an appointment, please remember
to verify that the physician is still a PPO
provider.
The non-PPO
benefits are the standard benefits of this Plan. PPO benefits apply 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. However, if the services are rendered at a PPO
hospital, we will pay the services of radiologists,
anesthesiologists and
pathologists who are not preferred providers at the preferred provider rate.
This non-standard benefit does not include the services of emergency room
physicians. In addition, providers outside the United States
will be paid at
the PPO level of benefits.
How we pay providers
Fee-for-service
plans reimburse you or your provider for covered services. They do not typically
provide or arrange for health care. Fee-for-service plans let you choose your
own physicians, hospitals and other health care providers.
The FFS plan reimburses you for your health care expenses, usually on a
percentage basis. These percentages, as well as deductibles, methods for
applying deductibles to families, and the percentage of coinsurance you must pay
vary by
plan.
We offer a preferred provider organization (PPO)
arrangement. This arrangement with health care providers gives you enhanced
benefits or limits your out-of-pocket expenses. 6
6
Page 7 8
2002 GEHA 7 Section 1
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.
Government Employees Hospital Association, Inc. was founded in 1937 as the
Railway Mail Hospital Association. For more than 60 years now, GEHA has provided
health insurance benefits to federal employees and retirees.
GEHA is incorporated as a General Not-For-Profit Corporation pursuant to
Chapter 355 of the Revised Statutes of the State of Missouri.
GEHA's
Preferred Provider Organization includes more than 3,800 hospitals and more than
450,000 physician locations throughout the United States. In circumstances where
there is limited access to PPO providers, GEHA may
negotiate discounts with
some providers which will reduce your overall out-of-pocket expenses.
If you
want more information about us, call (800) 821-6136, or write to GEHA, P. O. Box 4665, Independence, MO 64051. You may
also contact us by fax at (816) 257-3233 or visit our website at www. geha. com.
7
7 Page 8 9
2002 GEHA 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", Georgia, Montana, North Dakota, and Texas.
Lousiana
is no longer underserved. (Section 3)
We changed the address for sending
disputed claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium under
the High Option will increase by 18.4% for Self Only or 16.7% for Self and
Family. Under the Standard Option, your share of the premium will not increase.
We changed speech therapy benefits by removing the requirement that services
must be required to restore functional speech. (Section 5( a))
We now cover
certain intestinal transplants. (Section 5( b))
We changed the PPO networks
for the states of New York, New Jersey and Kansas, outside the Kansas City
metropolitan area.
We changed the Facts about this fee-for-service plan section to allow PPO
benefits for specific non-PPO providers. When you use a PPO hospital, Non PPO
radiologist, anesthesiologist and pathologist services will be
allowed at
the PPO benefit. This non-standard benefit does not include the services of
emergency room physicians. In addition, providers outside the United States will
be paid at the PPO level of benefits. (Section 1)
We changed Other Services by adding Positron Emission Tomography (PET
studies) to the list of services that require precertification. (Section 3)
We changed Physical and occupational therapy to show a combined 60 visit
limit per calendar year. (Section 5( a))
Congenital anomaly surgery is now
limited to children under the age of 18 unless there is a functional deficit.
(Section 5( b))
Maternity benefits under the Standard Option have increased to 100% for PPO
providers, including pre and postnatal care. (Section 5( a) and 5( c))
We
have changed hospital emergency room benefits to be subject to the calendar year
deductible and coinsurance. Previously these were payable after a $75 copayment.
Outpatient emergency room treatment of
accidental injuries within 72 hours
of an accident is still covered at 100%. (Section 5( d))
Out of pocket
calendar year maximums have been increased as follows: In Network $4,000 Self
Only, $4,500 Family under Standard Option and $3,000 Self Only, $3,500 Family
under High Option. Out of Network $5,000
Self Only, $5,500 Family under Standard Option and $4,000 Self Only, $4,500
Family under High Option. (Section 4)
The name for our prescription drug Mail Order Drug Program has changed to
Home Delivery Pharmacy service. This service will continue to be performed by
Merck-Medco RX services. (Section 5( f))
Under High Option, we have changed
the prescription drug copayment amounts to a three-tiered copayment structure.
This will add a higher, third level copayment for multi-source brand name drugs
(those for which a
Federally approved generic equivalent is available). When
a Federally approved generic equivalent is available, but you or your physician
specify that the prescription must be filled as written (i. e. with a brand name
drug), you
will pay the multi-source brand name copayment. When a Federally
approved generic equivalent is not available, you will pay the single-source
brand name copayment. (Section 5( f)) 8
8 Page 9 10
2002 GEHA 9
Section 2
If GEHA is your primary insurance, your High Option
prescription drug copayments are:
Network Retail pharmacy (initial fill not
to exceed a 30-day supply, and the first refill) you pay $5 for generic drugs,
$15 for single-source brand name drugs, and $30 for multi-source brand name
drugs. (See
Section 5( f) for the amount you pay on 2 nd and subsequent refills.)
Non-Network Retail pharmacy (initial fill not to exceed a 30-day supply, and
the first refill) you pay $5 for generic drugs, $15 for single-source brand name
drugs, and $30 for multi-source brand name drugs and any
difference between our allowance and the cost of the drug. (See Section 5( f)
for the amount you pay on 2 nd and subsequent refills.)
Home Delivery Pharmacy service (for up to a 90-day supply) you pay $10
generic/$ 35 single-source brand name, and $50 multi-source brand name.
If
Medicare A & B is your primary insurance, your High Option prescription drug
copayments are less. See section 5( f) for the new copayment amounts.
We
changed Dental benefits to show routine and preventative dental care under
Standard Option, payable at 50% of the Plan allowance. Previously we paid 50% of
billed charges. (Section 5( h))
We clarified the following:
Under Your Rights we have explained
how we may negotiate discounts with non-PPO providers in limited access areas.
(Section 1)
We clarified Diagnostic and treatment services by explaining
that facility charges for clinic or office visits are part of the fee charged by
the physician. (Section 5( a))
We clarified that Urgent Care facility fees
are not covered. (Section 5( a))
We clarified Surgical procedures by
explaining that assistant surgeons are allowed when medically necessary.
(Section 5( b))
We clarified Organ/ tissue transplants to show that cornea and kidney
transplants do not require preauthorization. (Section 5( b))
We clarified
Organ/ tissue transplants to show that tandem bone marrow transplants, approved
as one treatment protocol are limited to $100, 000 when not performed at a Plan
designated facility. (Section 5( b))
We clarified our procedures to explain
how we handle claims when others are responsible for injuries. (Section 9) 9
9 Page 10 11
2002 GEHA 10 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)
821-6136.
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:
A licensed doctor of medicine (M. D.) or a licensed doctor of osteopathy (D.
O.). Other covered providers include a chiropractor, nurse midwife,
nurse
anesthetist, dentist, optometrist, licensed clinical social worker, licensed
clinical psychologist, podiatrist, speech, physical and
occupational
therapist, nurse practitioner/ clinical specialist, nursing school administered
clinic and physician assistant.
The term "doctor" includes all of these providers when the services are
performed within the scope of their license or certification. The term
"primary care physician" includes family or general practitioners,
pediatricians, obstetricians/ gynecologists and medical internists.
Medically underserved areas. Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that
license in states OPM determines are "medically underserved". For 2002, the
states are: Alabama, Georgia, Idaho, Kentucky, Mississippi,
Missouri,
Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas, Utah,
and Wyoming.
Covered facilities Covered facilities include:
Freestanding
ambulatory facility A facility which is licensed by the state as an ambulatory
surgery center or has Medicare certification as an ambulatory surgical
center, has permanent facilities and equipment for the
primary purpose of
performing surgical and/ or renal dialysis procedures on an outpatient basis;
provides treatment by or
under the supervision of doctors and nursing
services whenever the patient is in the facility; does not provide
inpatient
accommodations; and is not, other than incidentally, a facility used as an
office or clinic for the private practice of
a doctor or other professional.
10
10 Page 11 12
2002 GEHA 11 Section 3
Hospice A
facility which meets all of the following:
(1) primarily provides inpatient
hospice care to terminally ill persons;
(2) is certified by Medicare as
such, or is licensed or accredited as such by the jurisdiction it is in;
(3)
is supervised by a staff of M. D. 's or D. O. 's, at least one of whom must be
on call at all times;
(4) provides 24 hour a day nursing services under the
direction of an R. N. and has a full-time administrator; and
(5) provides an
ongoing quality assurance program. Hospital
(1) An institution which is
accredited as a hospital under the Hospital Accreditation Program of the Joint
Commission
on Accreditation of Healthcare Organizations (JCAHO); or
(2)
A medical institution which is operated pursuant to law, under the supervision
of a staff of doctors, and with 24
hour a day nursing service, and which is
primarily engaged in providing general inpatient care and treatment
of sick
and injured persons through medical, diagnostic, and major surgical facilities,
all of which facilities must
be provided on its premises or have such
arrangements by contract or agreement; or
(3) An institution which is
operated pursuant to law, under the supervision of a staff of doctors and with
24 hour a
day nursing service and which provides services on the premises
for the diagnosis, treatment, and care of persons
with mental/ substance
abuse disorders and has for each patient a written treatment plan which must
include
diagnostic assessment of the patient and a description of the
treatment to be rendered and provides for follow-up
assessments by or under
the direction of the supervising doctor.
The term hospital does not include a convalescent home or skilled nursing
facility, or any institution or part thereof which
a) is used principally as
a convalescent facility, nursing facility, or facility for the aged; b)
furnishes primarily domiciliary or
custodial care, including training in the
routines of daily living; or c) is operating as a school or residential
treatment facility.
What you must do to It depends on the kind of care you want to
receive. You can go to any get covered care 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 PPO
specialist because we drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll
in another FEHB Plan, or
lose access to your PPO
specialist because we terminate our contract with your specialist for other than
cause,
you may be able to continue seeing your specialist and receiving 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. 11
11 Page 12 13
2002 GEHA 12 Section 3
If you are in
the second or third trimester of pregnancy and you lose access to your PPO
specialist based on the above circumstances, you can
continue to see your
specialist and any PPO benefits continue until the end of your postpartum care,
even if it is beyond the 90 days.
Hospital care: We pay for covered services from the effective date of
your enrollment. However, if you are in the hospital when your enrollment in our
Plan
begins, call our customer service department immediately at (800)
821-6136.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
You are discharged, not merely moved to an
alternative care center; or
The day your benefits from your former plan run
out; or
The 92 nd day after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
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:
For medical and surgical services, you, your representative,
your doctor, or your hospital must call Intracorp before admission. The
toll-free number is (800) 747-GEHA or (800) 747-4342. (See page 55 for
mental health/ substance abuse precertification.)
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
us within two business days following
the day of the emergency admission,
even if you have been discharged from the hospital. 12
12 Page 13 14
2002 GEHA 13 Section 3
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 delivery.
However, if your medical condition requires you to stay more
than 48 hours
after a vaginal delivery or 96 hours after a cesarean section, then your
physician or the hospital must contact us for
precertification of additional
days. Further, if your baby stays after you are discharged, then your physician
or the hospital must contact us for
precertification of additional days for
your baby.
If your hospital stay If your hospital stay --including
for maternity care --needs to be needs to be extended: extended, you,
your representative, your doctor or the hospital must ask
us to approve the
additional days.
What happens when you When we precertified the admission but you
remained do not follow the in the hospital beyond the number of days we
approved and
precertification rules 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. 13
13 Page 14 15
2002 GEHA 14 Section 3
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 a referral, precertification, or
prior authorization. You need to call us at (800) 821-6136 before receiving
treatment care
such as:
Physical therapy Growth hormone therapy (GHT)
Surgical treatment of
morbid obesity Certain prescription drugs
Organ and tissue transplant
procedures Surgical correction of congenital anomalies
In-network Mental
Health and Substance Abuse Benefits (See page 55) Positron Emission Tomography
(Pet Study) 14
14 Page
15 16
2002 GEHA 15 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, under the High Option, you pay a
copayment of $15 per office 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.
The calendar year deductible is $300 per person under
High Option and $450 per person under Standard Option. 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 $600 under High Option and $900 under Standard Option.
We also have a separate deductible for:
Mental health and substance abuse
treatment of $300, per person, under High Option and $450, per person, under
Standard Option. Under a family enrollment, the deductible is satisfied for
all family members when the combined
covered expenses applied to the mental
health and substance abuse treatment deductible for family members reach $600
under High Option and $900 under Standard Option.
Mental health and
substance abuse treatment of $500, per person, per calendar year, for
out-of-network hospital
inpatient and hospital outpatient/ intensive day
treatment
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.
We will base this percentage
on either the billed charge or the Plan Allowance, whichever is less.
Example: Under the High Option, you pay 25% of our allowance for non-PPO
office visits.
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. 15
15 Page 16 17
2002 GEHA 16 Section 4
For example,
if your physician ordinarily charges $100 for a service but routinely waives
your 25% coinsurance, the actual charge is $75. We
will pay $56.25 (75% of
the actual charge of $75).
Differences between Our "Plan allowance" is the amount we use to
calculate our payment our allowance and for covered services.
Fee-for-service plans arrive at their allowances in
the bill
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.
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, with High Option 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 with High
Option you pay 25% of our $100
allowance ($ 25). 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 under the
High Option 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 75% of our allowance: 75
You owe: Coinsurance 10% of our
allowance: 10 25% of our allowance: 25
+Difference up to charge? No: 0 Yes:
50
TOTAL YOU PAY $10 $75
Your catastrophic protection For those medical and surgical services
with coinsurance, we pay 100% out-of-pocket maximum for of our allowable
amount for the remainder of the calendar year after
deductibles,
coinsurance, and out-of-pocket expenses for coinsurance exceed:
copayments 16
16 Page
17 18
2002 GEHA 17 Section 4
PPO $3,500 for Self and Family (High Option) or $4,500 (Standard
Option) and $3,000 for Self Only (High Option) or $4,000 (Standard
Option)
if you use PPO Providers. Out-of-pocket expenses from both PPO and Non-PPO
providers count toward this limit. If you
reach this limit, expenses from
Non-PPO providers must reach the Non-PPO out of pocket limit before they are
paid at 100% of our
allowable amount. Non-PPO $4,500 for Self and
Family (High Option) or $5,500 (Standard
Option) and $4,000 for Self Only
(High Option) or $5,000 (Standard Option) if you use non-PPO providers. Any of
the above expenses
for PPO providers also count toward this limit. Your
eligible out of pocket expenses will not exceed this amount whether or not you
use
PPO providers.
Refer to pages 56 and 59 for separate in-and
out-of-network out-of-pocket maximums for mental health and substance abuse.
Out-of-pocket expenses for this benefit are:
The 10% (High Option) or 15%
(Standard Option) you pay for PPO charges under medical services and supplies,
surgical and anesthesia
services and hospital, facility and ambulance
services.
The 25% (High Option) or 35% (Standard Option) you pay for Non-PPO
charges under medical services and supplies, surgical and
anesthesia services and hospital, facility and ambulance services.
The
following cannot be counted toward out-of-pocket expenses:
The $300 (High Option) or $450 (Standard Option) calendar year deductible;
The $15 copayment for doctor's office visits (High Option); or the $10
copayment for primary care physician/$ 25 specialist office visits
(Standard
Option);
Expenses in excess of our allowable amount or maximum benefit
limitations;
Expenses for well child care and immunizations; Expenses for dental and
chiropractic care;
Any amounts you pay because benefits have been reduced for non-compliance
with our cost containment requirements (see pages
12-14);
Expenses for
prescription drugs purchased through retail or Home Delivery Pharmacy service.
When government facilities Facilities of the Department of Veterans
Affairs, the Department of bill us 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. 17
17 Page 18 19
2002 GEHA
18 Section 4
When you are age 65 or over and you do not have
Medicare
Under the FEHB law, we must limit our payments for those
benefits you would be entitled to if you had Medicare. And, your physician and
hospital must follow Medicare rules and cannot bill you for more than they could
bill you if
you had Medicare. The following chart has more information about
the limits.
If you… are age 65 or over, and
do not have Medicare Part A, Part
B, or both; and
have this Plan as an annuitant or as a former spouse, or
as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing
office can tell you if this applies.)
Then, for your inpatient hospital care, the law requires us to base
our payment on an amount --the "equivalent Medicare amount" --set by
Medicare's rules for what Medicare would pay, not on the actual charge;
you are responsible for your applicable deductibles, coinsurance or
copayments you owe under this Plan;
you are not responsible for any charges
greater than the equivalent Medicare amount; we will show that amount on the
explanation of benefits (EOB) form that we send you; and
the law prohibits a hospital from collecting more than the Medicare
equivalent amount.
When inpatient claims are paid according to a Diagnostic
Related Group (DRG) limit (for instance, for admissions of certain retirees who
do not have Medicare), we will pay 30% of the total covered amount as
room and board charges and 70% as other charges and will apply your
coinsurance accordingly.
And, for your physician care, the law
requires us to base our payment and your coinsurance on… an amount set by
Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.
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. 18
18 Page 19 20
2002 GEHA
19 Section 4
When you have the We limit our payment to an
amount that supplements the benefits that Original Medicare Plan Medicare
would pay under Medicare Part A (Hospital insurance) and
(Part A, Part B,
or both) 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 we waive some of
your deductibles,
copayment and coinsurance 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.
Please see Section 9, Coordinating benefits
with other coverage, for more information about how we coordinate benefits
with Medicare.
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 A physician may ask you to sign a private
contract agreeing that you can Private Contract with a be billed directly
for services Medicare ordinarily covers. Should you
physician 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. 19
19 Page 20 21
2002
GEHA
20
Section
5
Section
5.
Benefits
--
OVERVIEW
(See
pages
8
and
9
for
how
our
benefits
changed
this
year
and
pages
96
and
97
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)
821-6136
or
at
our
website
at
www.
geha.
com.
(a)
Medical
services
and
supplies
provided
by
physicians
and
other
health
care
professionals
..............................
...................................................................
21-33
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
.............................
.................................................................
34-42
Surgical
procedures Reconstructive surgery
Oral
and
maxillofacial
surgery
Organ/
tissue
transplants
Anesthesia
(c)
Services
provided
by
a
hospital
or
other
facility,
and
ambulance
services...........................................................
.................................................................
43-49
Inpatient
hospital
Outpatient
hospital
or
ambulatory
surgical
center
Extended
care
benefits/
Skilled
nursing
care
facility
benefits
Hospice
care
Ambulance
(d)
Emergency
services/
Accidents
.............................................................................................................................
.................................................................
50-52
Medical
emergency
Accidental
injury
Ambulance
(e)
Mental
health
and
substance
abuse
benefits
.........................................................................................................
.................................................................
53-60
(f)
Prescription
drug
benefits
.....................................................................................................................................
.................................................................
61-66
(g)
Special
features.....................................................................................................................................................
......................................................................
67
Flexible
benefits
option
Services
for
deaf
and
hearing
impaired
High
risk
pregnancies
(h)
Dental
benefits......................................................................................................................................................
.................................................................
68-69
(i)
Non-
FEHB
benefits
available
to
Plan
members
...................................................................................................
.................................................................
70-71
SUMMARY
OF
BENEFITS
.........................................................................................................................................
.................................................................
96-97
20
20 Page 21 22
2002
GEHA
21
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
$300
per
person
($
600
per
family)
under
the
High
Option
and
$450
per
person
($
900
per
family)
under
the
Standard
Option.
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. The non-PPO
benefits
are
the
standard
benefits
of
this
Plan.
PPO
benefits
apply
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-PPO
benefits
apply.
When
you
use
a
PPO
hospital
the
professionals
who
provide
services
to
you
in
a
hospital
may
not
all
be
preferred
providers.
If
they
are
not,
they
will
be
paid
by
this
plan
as
non-PPO
providers.
However,
if
the
services
are
rendered
at
a
PPO
hospital,
we
will
pay
the
services
of
radiologists,
anesthesiologists
and
pathologists
who
are
not
preferred
providers
at
the
preferred
provider
rate.
This
non-
standard
benefit
does
not
include
the
services
of
emergency
room
physicians.
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
Standard
Option
High
Option
Professional
services
of
physicians
In
physician's
office
Routine
physical
examinations
Office
medical
consultations
Second
surgical
opinions
Note:
The
facility
charge
for
clinic
or
office
visits
is
considered
a
part
of
the
fee
charged
by
the
physician.
PPO:
$10
copayment
for
office
visits
to
primary
care
physicians;
$25
copayment
for
office
visits
to
specialists
(No
deductible) Non-PPO: 35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
PPO:
$15
copayment
(No
deductible) Non-PPO: 25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Diagnostic
and
treatment
services
-
continued
next
page 21
21 Page 22 23
2002
GEHA
22
Section
5( a)
You
pay
Diagnostic
and
treatment
services
(continued)
Standard
Option
High
Option
Professional
services
of
physicians
Emergency
room
physician
care
(non
accidental
injury)
During
a
hospital
stay
At
home
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Urgent care
facilities
except
for
services
of
covered
physicians,
xray
and
laboratory
services.
All
charges
All
charges
Lab,
X-
ray
and
other
diagnostic
tests
Tests,
such
as:
Blood
tests
Urinalysis Non-routine
pap
tests
Pathology X-rays Non-routine
mammograms
CAT
Scans/ MRI
Ultrasound Electrocardiogram
and
EEG
PPO:
15%
of
the
Plan
allowance Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount Note: If your PPO
provider
uses
a
non-PPO
lab
or
radiologist,
we
will
pay
non-PPO
benefits
for
any
lab
and
X-ray
charges.
PPO:
10%
of
the
Plan
allowance Non-PPO:
25%
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. 22
22 Page
23 24
2002
GEHA
23
Section
5( a)
You
Pay
Preventive
care,
adult
Standard
Option
High
Option
Routine
screenings,
limited
to:
Total
Blood
Cholesterol
screenings
Chlamydial
infection
Colorectal
cancer
screening,
including
Annual
coverage
of
one
fecal
occult
blood
test
for
members
age
40
and
older
Sigmoidoscopy Prostate cancer screening Annual coverage
of
one
PSA
(Prostate
Specific
Antigen)
test
for
men
age
40
and
older
Routine
pap
test
Annual
coverage
of
one
pap
smear
for
women
age
18
and
older
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Routine
mammogram Mammograms for
diagnostic
and/
or
routine
screening
Routine
immunizations: Tetanus-diphtheria
(Td)
booster
Influenza/
Pneumococcal
vaccines
Preventive
care,
children
For
dependent
children
under
age
22:
Childhood
immunizations
recommended
by
the
American
Academy
of
Pediatrics
For
well-child
care
charges
for
routine
examinations,
immunizations
and
care
Initial
examination
of
a
newborn
child
covered
under
a
family
enrollment
PPO:
Nothing
(No
deductible)
Non-PPO:
Nothing,
except
any
difference
between
our
Plan
allowance
and
the
billed
amount.
(No
deductible)
PPO:
Nothing
(No
deductible)
Non-PPO:
Nothing,
except
any
difference
between
our
Plan
allowance
and
the
billed
amount.
(No
deductible)
Vision
examinations,
limited
to:
Examinations
for
amblyopia
and
strabismus
PPO:
$10
copayment
for
office
visits
to
primary
care
physicians;
$25
copayment
for
office
visits
to
specialists
(No
deductible)
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
PPO:
$15
copayment
(No
deductible) Non-PPO: 25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount 23
23 Page
24 25
2002
GEHA
24
Section
5( a)
You
Pay
Maternity
Care
Standard
Option
High
Option
Complete
maternity
(obstetrical)
care,
such
as:
Prenatal
care
Delivery Postnatal
care
Physician
care
such
as
non-routine
sonograms.
Note:
Here
are
some
things
to
keep
in
mind:
You
do
not
need
to
precertify
your
normal
delivery,
see
page
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.
See
Hospital
benefits
(Section
5c)
and
Surgery
benefits
(Section
5b).
PPO:
Nothing
(No
deductible)
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
PPO:
Nothing
(No
deductible)
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Approved
fetal
monitors
are
covered
the
same
as
other
medical
benefits
for
diagnostic
and
treatment
services
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Routine sonograms
to
determine
fetal
age,
size
or
sex.
Home
uterine
monitoring
devices,
unless
preauthorized
by
our
Medical
Director.
Charges
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
rape
or
incest.
Charges
for
services
and
supplies
incurred
after
termination
of
coverage.
All
charges
All
charges 24
24 Page 25 26
2002
GEHA
25
Section
5( a)
You
Pay
Family
planning
Standard
Option
High
Option
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:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Reversal of
voluntary
surgical
sterilization
Genetic
counseling
All
charges
All
charges
Infertility
services
Diagnosis
and
treatment
of
infertility,
except
as
shown
in
Not
covered.
Note:
Benefits
are
limited
to
a
maximum
of
$3,000
per
calendar
year
per
person.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Infertility
services
after
voluntary
sterilization
Fertility
drugs
Assisted
reproductive
technology
(ART)
procedures,
such
as:
artificial
insemination
in
vitro
fertilization
embryo
transfer
and
GIFT
intravaginal
insemination
(IVI)
intracervical
insemination
(ICI)
intrauterine
insemination
(IUI)
Services
and
supplies
related
to
ART
procedures
Cost
of
donor
sperm
Cost
of
donor
egg
All
charges
All
charges 25
25 Page 26 27
2002
GEHA
26
Section
5( a)
You
Pay
Allergy
care
Standard
Option
High
Option
Testing
and
treatment,
including
materials
(such
as
allergy
serum)
Allergy
testing
is
limited
to
$500
per
person
per
calendar
year.
Allergy
injections
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Clinical
ecology
and
environmental
medicine
Provocative
food
testing
and
sublingual
allergy
desensitization
All
charges
All
charges
Treatment
therapies
Antibiotic
therapy
Chemotherapy
and
radiation
therapy
Note:
High-dose
chemotherapy
in
association
with
autologous
bone
marrow
transplants
is
limited
to
those
transplants
listed
on
page
39.
Dialysis
–
Hemodialysis
and
peritoneal
dialysis
Intravenous
(IV)/
Infusion
Therapy
Growth
hormone
therapy
(GHT)
Note:
–
GHT
is
covered
under
the
prescription
drug
benefit.
We
only
cover
GHT
when
we
preauthorize
the
treatment.
Call
(800)
821-6136
for
preauthorization.
We
will
ask
you
to
submit
information
that
establishes
that
the
GHT
is
medically
necessary.
Ask
us
to
authorize
GHT
before
you
begin
treatment;
otherwise,
we
will
only
cover
GHT
services
from
the
date
you
submit
the
information.
If
you
do
not
ask
or
if
we
determine
GHT
is
not
medically
necessary,
we
will
not
cover
the
GHT
or
related
services
and
supplies.
See
Services
requiring
our
prior
approval
in
Section
3.
Respiratory
and
inhalation
therapies
Note
–
Some
medications
required
for
treatment
therapies
may
be
available
through
the
Home
Delivery
Pharmacy
service
or
a
PAID
Participating
Pharmacy.
Medications
obtained
from
these
sources
are
covered
under
the
Prescription
Drug
Benefits
on
pages
61-66.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Chelation
therapy
except
for
acute
arsenic,
gold
or
lead
poisoning
All
charges
All
charges 26
26 Page 27 28
2002
GEHA
27
Section
5( a)
You
Pay
Physical
and
occupational
therapies
Standard
Option
High
Option
60
visits
per
calendar
year
for
the
combined
services
of
the
following:
qualified
physical
therapists
and
qualified
occupational
therapists.
Prior
to
beginning
physical
therapy
treatments,
you
should
contact
our
Medical
Management
Department,
(800)
821-6136,
to
preauthorize
benefits.
Continuing
physical
therapy
claims
will
be
subject
to
concurrent
review
for
medical
necessity.
Physical
therapy
claims
will
be
denied
if
we
determine
the
therapy
is
not
medically
necessary.
Please
preauthorize.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
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.
Note:
When
you
receive
medically
necessary
physical
or
occupational
therapy
on
an
outpatient
basis
from
a
qualified
professional
therapist
at
a
skilled
nursing
facility,
your
therapy
is
covered
up
to
plan
limits. Not covered: Exercise
programs
Long-
term
rehabilitative
therapy
All
charges
All
charges 27
27 Page 28 29
2002
GEHA
28
Section
5( a)
You
Pay
Speech
therapy
Standard
Option
High
Option
30
visits
per
calendar
year
for
the
services
of
a
qualified
speech
therapist.
Note:
We
only
cover
speech
therapy
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.
Note:
When
you
receive
medically
necessary
speech
therapy
on
an
outpatient
basis
from
a
qualified
speech
therapist
at
a
skilled
nursing
facility,
your
therapy
is
covered
up
to
plan
limits
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Computer
devices
to
assist
with
communications
Computer
programs
of
any
type,
including
but
not
limited
to
those
to
assist
with
speech
therapy
All
charges
All
charges
Hearing
services
(testing,
treatment,
and
supplies)
Diagnostic
hearing
tests
performed
by
an
MD
or
DO
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Hearing testing
conducted
by
audiologists
Hearing
aids,
testing
and
examinations
for
them
All
charges
All
charges 28
28 Page 29 30
2002
GEHA
29
Section
5( a)
You
Pay
Vision
services
(testing,
treatment,
and
supplies)
Standard
Option
High
Option
First
pair
of
contact
lenses
or
ocular
implant
lenses
if
required
to
correct
an
impairment
existing
after
intraocular
surgery
or
accidental
injury.
30
outpatient
vision
therapy
visits
by
an
opthalmologist
or
optometrist
per
person
per
lifetime
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Computer
programs
of
any
type,
including
but
not
limited
to
those
to
assist
with
vision
therapy. Eyeglasses Radial keratotomy
and
other
refractive
surgeries
All
charges
All
charges
Foot
care
Routine
foot
care
only
when
you
are
under
active
treatment
for
a
metabolic
or
peripheral
vascular
disease,
such
as
diabetes.
PPO:
$10
copayment
for
office
visits
to
primary
care
physicians;
$25
copayment
for
office
visits
to
specialists
(No
deductible)
plus
15%
of
the
Plan
allowance
for
other
services
performed
during
the
visit.
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
PPO:
$15
copayment
for
the
office
visit
(No
deductible)
plus
10%
of
the
Plan
allowance
for
other
services
performed
during
the
visit
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Cutting or
trimming
of
toenails
or
removal
of
corns,
calluses,
or
similar
routine
treatment
of
conditions
of
the
foot,
except
as
stated
above.
All
charges
All
charges 29
29 Page 30 31
2002
GEHA
30
Section
5( a)
You
Pay
Orthopedic
and
prosthetic
devices
Standard
Option
High
Option
Artificial
limbs
and
eyes;
stump
hose
Externally
worn
breast
prostheses
and
surgical
bras,
including
necessary
replacements
following
a
mastectomy
Internal
prosthetic
devices,
such
as
artificial
joints,
pacemakers,
cochlear
implants,
and
surgically
implanted
breast
implant
following
mastectomy.
Note:
See
5(
b)
for
coverage
of
the
surgery
to
insert
the
device.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
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
All
charges
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: Hospital
beds;
Wheelchairs; Crutches; and Walkers.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount DME -continued
next
page 30
30 Page 31 32
2002
GEHA
31
Section
5( a)
You
Pay
Durable
medical
equipment
(DME)
-( continued)
Standard
Option
High
Option
Note:
Call
us
at
(800)
821-6136
as
soon
as
your
physician
prescribes
this
equipment.
We
will
arrange
with
a
health
care
provider
to
rent
or
sell
you
durable
medical
equipment
at
discounted
rates
and
will
tell
you
more
about
this
service
when
you
call.
Note:
Benefits
for
durable
medical
equipment
are
limited
to
$10,000
per
person,
lifetime
maximum.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: Computer
devices
to
assist
with
communications
Computer
programs
of
any
type,
including
but
not
limited
to
those
to
assist
with
vision
therapy
or
speech
therapy
Air
purifiers,
air
conditioners,
heating
pads,
whirlpool
bathing
equipment,
sun
and
heat
lamps,
exercise
devices
(even
if
ordered
by
a
doctor),
and
other
equipment
that
does
not
meet
the
definition
of
durable
medical
equipment
(page
84)
Lifts,
such
as
seat,
chair
or
van
lifts
Wigs
All
charges
All
charges
Home
health
services
25
in-home
visits
per
calendar
year,
not
to
exceed
one
visit
up
to
two
hours
per
day
when:
A
registered
nurse
(R.
N.),
licensed
practical
nurse
(L.
P.
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:
Covered
services
are
based
on
our
review
for
medical
necessity.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Home
Health
services
-
continue
on
next
page 31
31 Page
32 33
2002
GEHA
32
Section
5( a)
You
Pay
Home
health
services
-(
continued)
Standard
Option
High
Option
Not
covered: Nursing
care
requested
by,
or
for
the
convenience
of,
the
patient
or
the
patient's
family; Services
primarily
for
hygiene,
feeding,
exercising,
moving
the
patient,
homemaking,
companionship
or
giving
oral
medication;
Home
care
primarily
for
personal
assistance
that
does
not
include
a
medical
component
and
is
not
diagnostic,
therapeutic,
or
rehabilitative.
Custodial
care;
Services
or
supplies
furnished
by
immediate
relatives
or
household
members,
such
as
spouse,
parents,
children,
brothers
or
sisters
by
blood,
marriage
or
adoption;.
Inpatient
private
duty
nursing;
All
charges
All
charges
Chiropractic Chiropractic services
limited
to:
30
visits
per
calendar
year
for
manipulation
of
the
spine
X-rays,
used
to
detect
and
determine
nerve
interferences
due
to
spinal
subluxations
or
misalignments Note: No other benefits
for
the
services
of
a
chiropractor
are
covered
under
any
other
provision
of
this
Plan.
In
medically
underserved
areas,
services
of
a
chiropractor
that
are
listed
above
are
subject
to
the
stated
limitations.
In
medically
underserved
areas,
services
of
a
chiropractor
that
are
within
the
scope
of
his/
her
license
and
are
not
listed
above
are
eligible
for
regular
Plan
benefits.
PPO
and
Non-PPO:
All
charges
in
excess
of
$9
per
visit All charges
in
excess
of
$25
for
X-rays
of
the
spine
Note:
Visits
and
charges
exceeding
these
amounts
are
not
applied
toward
the
calendar
year
deductible.
PPO
and
Non-PPO:
All
charges
in
excess
of
$9
per
visit All charges
in
excess
of
$25
for
X-rays
of
the
spine
Note:
Visits
and
charges
exceeding
these
amounts
are
not
applied
toward
the
calendar
year
deductible.
Not
covered: Any treatment
not
specifically
listed
as
covered.
Adjunctive
procedures
such
as
ultrasound,
electrical
muscle
stimulation,
vibratory
therapy,
and
cold
pack
application.
All
charges
All
charges 32
32 Page 33 34
2002
GEHA
33
Section
5( a)
You
Pay
Alternative
treatments
Standard
Option
High
Option
Acupuncture Benefits are limited
to
20
procedures
per
calendar
year
for
medically
necessary
acupuncture
treatments
if
performed
by
a
Medical
Doctor
(MD)
or
Doctor
of
Osteopathy
(DO).
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Not
covered: All other alternative
treatments,
including
clinical
ecology
and
environmental
medicine. Any treatment
not
specifically
listed
as
covered
Naturopathic
services
(Note:
benefits
of
certain
alternative
treatment
providers
may
be
covered
in
medically
underserved
areas;
see
page
10.)
All
charges
All
charges
Educational
classes
and
programs
Coverage
is
limited
to:
Smoking
Cessation
–
Up
to
$100
to
aid
in
smoking
cessation-per
person
per
lifetime,
including
related
expenses
such
as
drugs.
PPO:
all
charges
in
excess
of
$100 Non-
PPO:
all
charges
in
excess
of
$100
PPO:
all
charges
in
excess
of
$100 Non-
PPO:
all
charges
in
excess
of
$100 33
33 Page
34 35
2002
GEHA
34
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
$300
per
person
($
600
per
family)
under
the
High
Option
and
$450
per
person
($
900
per
family)
under
the
Standard
Option.
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. 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.
The
non-PPO
benefits
are
the
standard
benefits
of
this
Plan.
PPO
benefits
apply
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-PPO
benefits
apply.
When
you
use
a
PPO
hospital
the
professionals
who
provide
services
to
you
in
a
hospital
may
not
all
be
preferred
providers.
If
they
are
not,
they
will
be
paid
by
this
plan
as
non-PPO
providers.
However,
if
the
services
are
rendered
at
a
PPO
hospital,
we
will
pay
the
services
of
radiologists,
anesthesiologists
and
pathologists
who
are
not
preferred
providers
at
the
preferred
provider
rate.
This
non-
standard
benefit
does
not
include
the
services
of
emergency
room
physicians.
I M P O R T A N T 34
34 Page 35 36
2002
GEHA
35
Section
5( b)
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
Standard
Option
High
Option
A
comprehensive
range
of
services,
such
as:
Operative
procedures
Treatment
of
fractures,
including
casting
Normal
pre-
and
post-operative
care
by
the
surgeon
Correction
of
amblyopia
and
strabismus
Endoscopy
procedures
Biopsy
procedures
Electroconvulsive
therapy
Removal
of
tumors
and
cysts
Correction
of
congenital
anomalies
-
limited
to
children
under
the
age
of
18
unless
there
is
a
functional
deficit.
(See
Reconstructive
surgery)
Surgical
treatment
of
morbid
obesity
–
a
condition
in
which
an
individual
weighs
100
pounds
or
100%
over
his
or
her
normal
weight
according
to
current
underwriting
standards;
eligible
members
must
be
age
18
or
over.
Criteria
regarding
complications
of
obesity
and
body
mass
index
must
be
met.
Treatment
must
be
precertified.
Insertion
of
internal
prostethic
devices.
See
5(
a)
–
Orthopedic
and
prosthetic
devices
for
device
coverage
information
Voluntary
sterilization,
Norplant
(a
surgically
implanted
contraceptive),
and
intrauterine
devices
(IUDs)
Treatment
of
burns
Assistant
surgeons
are
covered
up
to
20%
of
our
allowance
for
the
surgeon's
charge
for
procedures
when
it
is
medically
necessary
to
have
an
assistant
surgeon.
Note:
Post
operative
care
is
considered
to
be
included
in
the
fee
charged
for
a
surgical
procedure
by
a
doctor.
Any
additional
fees
charged
by
a
doctor
are
not
covered
unless
such
charge
is
for
an
unrelated
condition.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Surgical
procedures
-
continued
on
next
page 35
35 Page
36 37
2002
GEHA
36
Section
5( b)
You
Pay
Surgical
procedures
(continued)
Standard
Option
High
Option
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
based
on:
Full
Plan
allowance
For
the
secondary
procedure(
s)
based
on:
One-half
of
the
Plan
allowance
For
the
subsequent
procedure(
s)
based
on:
25%
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:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
Not
covered: Reversal of
voluntary
sterilization
Services
of
a
standby
physician
or
surgeon
Routine
treatment
of
conditions
of
the
foot;
see
Foot
care
All
charges
All
charges 36
36 Page 37 38
2002
GEHA
37
Section
5( b)
You
Pay
Reconstructive
surgery
Standard
Option
High
Option
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
-
limited
to
children
under
the
age
of
18
unless
there
is
a
functional
deficit.
Examples
of
congenital
anomalies
are:
cleft
lip;
cleft
palate;
birth
marks;
and
webbed
fingers
and
toes.
All
stages
of
breast
reconstruction
surgery
following
a
mastectomy,
such
as:
surgery
to
produce
a
symmetrical
appearance
on
the
other
breast;
treatment
of
any
physical
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
if
billed
by
a
hospital.
If
included
with
the
surgeon's
bill,
surgery
benefits
will
apply.
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:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
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
promptly
or
as
soon
as
the
member's
medical
condition
permits.
Surgeries
related
to
sex
transformation
or
sexual
dysfunction
Surgeries
to
correct
congenital
anomalies
for
individuals
age
18
and
older
unless
there
is
a
functional
deficit.
All
charges
All
charges 37
37 Page 38 39
2002
GEHA
38
Section
5( b)
You
Pay
Oral
and
maxillofacial
surgery
Standard
Option
High
Option
Oral
surgical
procedures,
limited
to:
Reduction
of
fractures
of
the
jaws
or
facial
bones;
Surgical
correction
of
cleft
lip,
cleft
palate
Excision
of
cysts
and
incision
of
abscesses
unrelated
to
tooth
structure;
Extraction
of
impacted
(unerupted
or
partially
erupted)
teeth;
Alveoloplasty,
partial
or
radical
removal
of
the
lower
jaw
with
bone
graft;
Excision
of
tori,
tumors,
leukoplakia,
premalignant
and
malignant
lesions,
and
biopsy
of
hard
and
soft
oral
tissues;
Open
reduction
of
dislocations
and
excision,
manipulation,
aspiration
or
injection
of
temporo-
mandibular
joints;
Removal
of
foreign
body,
skin,
subcutaneous
areolar
tissue,
reaction-producing
foreign
bodies
in
the
musculoskeletal
system
and
salivary
stones
and
incision/ excision
of
salivary
glands
and
ducts;
Repair
of
traumatic
wounds;
Incision
of
the
sinus
and
repair
of
oral
fistulas;
Surgical
treatment
of
trigeminal
neuralgia;
Repair
of
accidental
injury
to
sound
natural
teeth
such
as:
expenses
for
X-rays,
drugs,
crowns,
bridgework,
inlays
and
dentures.
Masticating
(biting
or
chewing)
incidents
are
not
considered
to
be
accidental
injuries.
Accidental
dental
injury
is
covered
at
100%
for
charges
incurred
within
72
hours
of
an
accident
(see
page
50).
Other
oral
surgery
procedures
that
do
not
involve
the
teeth
or
their
supporting
structures.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
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)
Orthodontic
treatment
Any
oral
or
maxillofacial
surgery
not
specifically
listed
as
covered
Orthognathic
surgery,
even
if
necessary
because
of
TMJ
dysfunction
or
disorder.
All
charges
All
charges 38
38 Page 39 40
2002
GEHA
39
Section
5( b)
You
Pay
Organ/ tissue
transplants
Standard
Option
High
Option
Limited
to:
Cornea Heart Heart/ lung Kidney Kidney/
Pancreas
Liver Lung:
Single
or
double
lung
transplants,
limited
to
patients
for
the
following
end-stage
pulmonary
diseases:
(1)
Pulmonary
fibrosis,
(2)
Primary
pulmonary
hypertension,
(3)
Emphysema,
or
(4)
cystic
fibrosis
Pancreas
(limited
to
patients
whose
condition
is
not
treatable
by
insulin
therapy)
Allogeneic
bone
marrow
transplants
–
only
for
patients
with
acute
leukemia,
advanced
Hodgkin's
lymphoma,
Advanced
non-Hodgkin's
lymphoma,
Advanced
neuroblastoma
(limited
to
children
over
age
one),
Aplastic
anemia,
Chronic
myelogenous
leukemia,
Infantile
malignant
osteopetrosis,
Severe
combined
immunodeficiency,
Thalassemia
major,
or
Wiskott-
Aldrich
syndrome
Intestinal
transplants
(small
intestine),
small
intestine
with
the
liver,
small
intestine
with
multiple
organs
such
as
the
liver,
stomach,
and
pancreas
Autologous
bone
marrow
transplants
(autologous
stem
cell
support)
and
autologous
peripheral
stem
cell
support
-
limited
to
patients
with
Acute
lymphocytic,
or
non-
lymphocytic
leukemia,
Advanced
Hodgkin's
lymphoma,
Advanced
non-Hodgkin's
lymphoma,
Advanced
neuroblastoma
(limited
to
children
over
age
one),
Breast
cancer
or
Testicular,
Mediastinal,
Retroperitoneal
and
Ovarian
germ
cell
tumors,
Multiple
myeloma
or
Epithelial
ovarian
cancer.
Note:
We
cover
related
medical
and
hospital
expenses
of
the
donor
when
we
cover
the
recipient.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Organ/ tissue
transplants
-
continued
on
next
page 39
39 Page
40 41
2002
GEHA
40
Section
5( b)
You
Pay
Organ/ tissue
transplants(
continued)
Standard
Option
High
Option
Note:
All
allowable
charges
incurred
for
a
surgical
transplant,
whether
incurred
by
the
recipient
or
donor
will
be
considered
expenses
of
the
recipient
and
will
be
covered
the
same
as
for
any
other
illness
or
injury
subject
to
the
limits
stated
below.
This
benefit
applies
only
if
the
recipient
is
covered
by
us
and
if
the
donor's
expenses
are
not
otherwise
covered. Transportation
Benefit
We
will
also
provide
up
to
$10,
000
per
covered
transplant
for
transportation
(mileage
or
airfare)
to
a
plan
designated
facility
and
reasonable
temporary
living
expenses
(i.
e.
lodging
and
meals)
for
the
recipient
and
one
other
individual
(or
in
the
case
of
a
minor,
two
other
individuals),
if
the
recipient
lives
more
than
100
miles
from
the
designated
transplant
facility.
Transportation
benefits
are
payable
for
follow-
up
care
up
to
one
year
following
the
transplant.
The
transportation
benefit
is
not
available
for
cornea
or
kidney
transplants.
You
must
contact
Customer
Service
for
what
are
considered
reasonable
temporary
living
expenses.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Limited
Benefits
The
process
for
preauthorizing
organ
transplants
is
more
extensive
that
the
normal
precertification
process.
Before
your
initial
evaluation
as
a
potential
candidate
for
a
transplant
procedure,
you
or
your
doctor
must
contact
our
Medical
Director
so
we
can
arrange
to
review
the
clinical
results
of
the
evaluation
and
determine
if
the
proposed
procedure
meets
our
definition
of
"medically
necessary"
and
is
on
the
list
of
covered
transplants.
Coverage
for
the
transplant
must
be
authorized
in
advance,
in
writing
by
our
Medical
Director.
(Cornea
and
kidney
transplants
do
not
require
preauthorization
by
GEHA's
Medical
Director.)
Organ/ tissue
transplants
-
continued
on
next
page 40
40 Page
41 42
2002
GEHA
41
Section
5( b)
You
Pay
Organ/ tissue
transplants(
continued)
Standard
Option
High
Option
We
will
pay
for
a
second
transplant
evaluation
recommended
by
a
physician
qualified
to
perform
the
transplant,
if:
the
transplant
diagnosis
is
covered
and
the
physician
is
not
associated
or
in
practice
with
the
physician
who
recommended
and
will
perform
the
organ
transplant.
A
third
transplant
evaluation
is
covered
only
if
the
second
evaluation
does
not
confirm
the
initial
evaluation.
The
transplant
must
be
performed
at
a
Plan-designated
organ
transplant
facility
to
receive
maximum
benefits.
If
benefits
are
limited
to
$100,000
per
transplant,
included
in
the
maximum
are
all
charges
for
hospital,
medical
and
surgical
care
incurred
while
the
patient
is
hospitalized
for
a
covered
transplant
surgery
and
subsequent
complications
related
to
the
transplant.
Outpatient
expenses
for
chemotherapy
and
any
process
of
obtaining
stem
cells
or
bone
marrow
associated
with
bone
marrow
transplant
(stem
cell
support)
are
included
in
benefits
limit
of
$100,000
per
transplant.
Tandem
bone
marrow
transplants
approved
as
one
treatment
protocol
are
limited
to
$100,000
when
not
performed
at
a
Plan
designated
facility.
Expenses
for
aftercare
such
as
outpatient
prescription
drugs
are
not
a
part
of
the
$100,000
limit.
PPO:
$10
copayment
for
office
visits
to
primary
care
physicians;
$25
copayment
for
office
visits
to
specialists
(no
deductible) Non-PPO: 35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
If
prior
approval
is
not
obtained
or
a
Plan-designated
organ
transplant
facility
is
not
used,
the
benefits
will
be
limited
to
15%
for
PPO
hospital
expenses,
15%
for
PPO
physician
expenses
or
35%
of
our
allowance
for
non-PPO
hospital
and
surgery
expenses
up
to
a
maximum
of
$100,000
per
transplant.
If
we
cannot
refer
a
member
in
need
of
a
transplant
to
a
designated
facility,
the
$100,000
maximum
will
not
apply.
PPO:
$15
copayment
(no
deductible) Non-PPO: 25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
If
prior
approval
is
not
obtained
or
a
Plan-designated
organ
transplant
facility
is
not
used,
the
benefits
will
be
limited
to
10%
for
PPO
hospital
expenses,
10%
for
PPO
physician
expenses
or
25%
of
our
allowance
for
non-PPO
hospital
and
surgery
expenses
up
to
a
maximum
of
$100,000
per
transplant.
If
we
cannot
refer
a
member
in
need
of
a
transplant
to
a
designated
facility,
the
$100,000
maximum
will
not
apply.
Organ/ tissue
transplants
-
continued
on
next
page 41
41 Page
42 43
2002
GEHA
42
Section
5( b)
You
Pay
Organ/ tissue
transplants(
continued)
Standard
Option
High
Option
Chemotherapy
and
procedures
related
to
bone
marrow
transplantation
must
be
performed
only
at
a
Plan-designated
organ
transplant
facility
to
receive
maximum
benefits.
Simultaneous
transplants
such
as
kidney/
pancreas,
heart/
lung,
heart/
liver
are
considered
as
one
transplant
procedure
and
are
limited
to
$100,000
when
not
performed
at
a
Plan-
designated
organ
transplant
facility.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount.
Not
covered: Services
or
supplies
for
or
related
to
surgical
transplant
procedures
(including
administration
of
high-
dose
chemotherapy)
for
artificial
or
human
organ/
tissue
transplants
not
listed
as
specifically
covered.
Donor
screening
tests
and
donor
search
expenses,
except
those
performed
for
the
actual
donor. Donor
search
expense
for
bone
marrow
transplants.
All
charges
All
charges
Anesthesia Professional
fees
for
the
administration
of
anesthesia
in
Hospital
(inpatient)
Hospital
outpatient
department
Ambulatory
surgical
center
Office
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount 42
42 Page
43 44
2002
GEHA
43
Section
5( c)
Section
5
(c).
Services
provided
by
a
hospital
or
other
facility,
and
ambulance
services
I M P O R T A N T
Here
are
some
important
things
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
$300
per
person
($ 600
per
family)
under
the
High
Option
and
$450
per
person
($
900
per
family)
under
the
Standard
Option.
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).
The
non-PPO
benefits
are
the
standard
benefits
of
this
Plan.
PPO
benefits
apply
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-PPO
benefits
apply.
When
you
use
a
PPO
hospital
the
professionals
who
provide
services
to
you
in
a
hospital
may
not
all
be
preferred
providers.
If
they
are
not,
they
will
be
paid
by
this
plan
as
non-PPO
providers.
However,
if
the
services
are
rendered
at
a
PPO
hospital,
we
will
pay
the
services
of
radiologists,
anesthesiologists
and
pathologists
who
are
not
preferred
providers
at
the
preferred
provider
rate.
This
non-
standard
benefit
does
not
include
the
services
of
emergency
room
physicians.
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 43
43 Page 44 45
2002
GEHA
44
Section
5( c)
Benefit
Description
You
pay
NOTE:
The
calendar
year
deductible
applies
ONLY
when
we
say
below:
"(
calendar
year
deductible
applies)".
Inpatient
Hospital
Standard
Option
High
Option
Room
and
board,
such
as
Ward,
semiprivate,
or
intensive
care
accommodations;
General
nursing
care;
and
Meals
and
special
diets.
NOTE:
We
only
cover
a
private
room
if
we
determine
it
to
be
medically
necessary.
Otherwise,
we
will
pay
the
hospital's
average
charge
for
semiprivate
accommodations.
The
remaining
balance
is
not
a
covered
expense.
If
the
hospital
only
has
private
rooms,
we
will
cover
the
private
room
rate.
NOTE:
When
the
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:
15%
of
the
Plan
allowance
(calendar
year
deductible
applies)
Non-PPO:
35%
of
the
Plan
allowance
(calendar
year
deductible
applies)
PPO:
Nothing Non-PPO: Nothing
Other
hospital
services
and
supplies,
such
as:
Operating,
recovery
and
other
treatment
rooms
Prescribed
drugs
and
medicines
Diagnostic
laboratory
tests
and
X-rays
Blood
or
blood
plasma,
if
not
donated
or
replaced
Dressings,
splints,
casts,
and
sterile
tray
services
Medical
supplies
and
equipment,
including
oxygen
Anesthetics,
including
nurse
anesthetist
services
Take-home
items
Medical
supplies,
appliances,
medical
equipment,
and
any
covered
items
billed
by
a
hospital
for
use
at
home
(Note:
calendar
year
deductible
applies.)
NOTE:
We
base
payment
on
whether
the
facility
or
a
health
care
professional
bills
for
the
services
or
supplies.
For
example,
when
the
hospital
bills
for
its
nurse
anesthetists'
services,
we
pay
Hospital
benefits
and
when
the
anesthesiologist
bills,
we
pay
Surgery
benefits.
PPO:
15%
of
the
Plan
allowance
(calendar
year
deductible
applies)
Non-PPO:
35%
of
the
Plan
allowance
(calendar
year
deductible
applies)
PPO:
10%
of
the
Plan
allowance Non-PPO:
25%
of
the
Plan
allowance
Inpatient
hospital
-
continued
on
next
page 44
44 Page
45 46
2002
GEHA
45
Section
5( c)
Inpatient
hospital
(continued)
You
Pay
Standard
Option
High
Option
Maternity
Care
–
Inpatient
Hospital
Room
and
board,
such
as
ward,
semiprivate,
or
intensive
care
accommodations
general
nursing
care;
and
meals
and
special
diets
Note:
Here
are
some
things
to
keep
in
mind:
You
do
not
need
to
precertify
your
normal
delivery;
see
page
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
must
precertify.
Other
hospital
services
and
supplies,
such
as:
Delivery
room,
recovery,
and
other
treatment
rooms;
Prescribed
drugs
and
medicines;
Diagnostic
laboratory
tests
and
X-rays
Blood
or
blood
plasma,
if
not
donated
or
replaced
Dressings
and
sterile
tray
services
Medical
supplies
and
equipment,
including
oxygen
Anesthetics,
including
nurse
anesthetist
services
Take-home
items
Medical
supplies,
appliances,
medical
equipment,
and
any
covered
items
billed
by
a
hospital
for
use
at
home
(Note:
calendar
year
deductible
applies.)
We
cover
routine
nursery
care
of
the
newborn
child
during
the
covered
portion
of
the
mother's
maternity
stay.
PPO:
Nothing Non-PPO: 35%
of
the
Plan
allowance
(calendar
year
deductible
applies).
PPO:
Nothing Non-PPO: Nothing
for
room
and
board;
25%
of
the
Plan
allowance
for
other
hospital
services
Inpatient
hospital
-
continued
on
next
page 45
45 Page
46 47
2002
GEHA
46
Section
5( c)
You
Pay
Inpatient
hospital
(continued)
Standard
Option
High
Option
Maternity
Care
–
Inpatient
Hospital
-
continued
We
will
cover
other
care
of
an
infant
who
requires
non-routine
treatment
if
we
cover
the
infant
under
a
Self
and
Family
enrollment.
PPO:
15%
of
the
Plan
allowance
(calendar
year
deductible
applies). Non-PPO:
35%
of
the
Plan
allowance
(calendar
year
deductible
applies).
PPO:
Nothing
for
room
and
board;
10%
of
the
plan
allowance
for
other
hospital
services Non-PPO:
Nothing
for
room
and
board;
25%
of
the
Plan
allowance
for
other
hospital
services
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,
schools
Personal
comfort
items,
such
as
telephone,
television,
barber
services,
guest
meals
and
beds
Private
nursing
care
All
charges
All
charges 46
46 Page 47 48
2002
GEHA
47
Section
5( c)
You
Pay
Outpatient
hospital
or
ambulatory
surgical
center
Standard
Option
High
Option
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.
PPO:
15%
of
the
Plan
allowance
(calendar
year
deductible
applies) Non-PPO:
35%
of
the
Plan
allowance
(calendar
year
deductible
applies)
PPO:
10%
of
the
Plan
allowance
(calendar
year
deductible
applies) Non-PPO:
25%
of
the
Plan
allowance
(calendar
year
deductible
applies)
Not
covered: Urgent care
facilities
except
for
services
of
covered
physicians,
xray
and
laboratory
services.
All
charges
All
charges
Maternity
Care
–
Outpatient
hospital
Delivery
room,
recovery,
and
other
treatment
rooms;
Prescribed
drugs
and
medicines;
Diagnostic
laboratory
tests
and
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
and
sterile
tray
services
Medical
supplies,
including
oxygen
Anesthetics
and
anesthesia
services;
PPO:
Nothing. Non-PPO: 35%
of
the
Plan
allowance
(calendar
year
deductible
applies).
PPO:
Nothing
.
Non-PPO:
25%
of
the
Plan
allowance
(calendar
year
deductible
applies).
Extended
care
benefits/
Skilled
nursing
care
facility
benefits
No
benefits.
All
charges.
All
charges. 47
47 Page 48 49
2002
GEHA
48
Section
5( c)
You
Pay
Hospice
care
Standard
Option
High
Option
Hospice
is
a
coordinated
program
of
maintenance
and
supportive
care
for
the
terminally
ill
provided
by
a
medically
supervised
team
under
the
direction
of
a
Plan-approved
independent
hospice
administration.
We
pay
$2000
for
hospice
care
on
an
outpatient
basis.
We
pay
$150
per
day
for
room
and
board
and
care
while
an
inpatient
in
a
hospice
up
to
a
maximum
of
$3,000.
These
benefits
will
be
paid
if
the
hospice
care
program
begins
after
a
person's
primary
doctor
certifies
terminal
illness
and
life
expectancy
of
six
months
or
less
and
any
services
or
inpatient
hospice
stay
that
is
part
of
the
program
is:
Provided
while
the
person
is
covered
by
this
Plan;
Ordered
by
the
supervising
doctor;
Charged
by
the
hospice
care
program;
and
Provided
within
six
months
from
the
date
the
person
entered
or
re-entered
(after
a
period
of
remission)
a
hospice
care
program.
Remission
is
the
halt
or
actual
reduction
in
the
progression
of
illness
resulting
in
discharge
from
a
hospice
care
program
with
no
further
expenses
incurred.
A
readmission
within
three
months
of
a
prior
discharge
is
considered
as
the
same
period
of
care.
A
new
period
begins
after
three
months
from
a
prior
discharge
with
maximum
benefits
available.
PPO:
Nothing
up
to
the
Plan
limits
(calendar
year
deductible
applies)
Non-PPO:
Nothing
up
to
the
Plan
limits
(calendar
year
deductible
applies)
PPO:
Nothing
up
to
the
Plan
limits
(calendar
year
deductible
applies)
Non-PPO:
Nothing
up
to
the
Plan
limits
(calendar
year
deductible
applies)
Not
covered: Charges
incurred
during
a
period
of
remission,
charges
incurred
for
treatment
of
a
sickness
or
injury
of
a
family
member
that
are
covered
under
another
Plan
provision,
charges
incurred
for
services
rendered
by
a
close
relative,
bereavement
counseling,
funeral
arrangements,
pastoral
counseling,
financial
or
legal
counseling,
homemaker
or
caretaker
services
All
charges
All
charges 48
48 Page 49 50
2002
GEHA
49
Section
5( c)
You
Pay
Ambulance
–
accidental
injury
Standard
Option
High
Option
Ambulance
service
within
72
hours
of
an
accident
is
covered
as
follows:
Local
ambulance
service
(within
100
miles)
to
the
first
hospital
where
treated,
from
that
hospital
to
the
next
nearest
one
if
necessary
treatment
is
unavailable
or
unsuitable
at
the
first
hospital,
then
to
either
the
home
(if
ambulance
transport
is
medically
necessary)
or
other
medical
facility
(if
required
for
the
patient
to
receive
necessary
treatment
and
if
ambulance
transport
is
medically
necessary).
Air
ambulance
to
nearest
facility
where
necessary
treatment
is
available
is
covered
if
no
emergency
ground
transportation
is
available
or
suitable
and
the
patient's
condition
warrants
immediate
evacuation.
PPO:
Nothing
up
to
the
Plan
allowance Non-PPO:
Nothing
up
to
the
Plan
allowance
PPO:
Nothing
up
to
the
Plan
allowance Non-PPO:
Nothing
up
to
the
Plan
allowance
Ambulance
–
non-accidental
injury
Local
ambulance
service
(within
100
miles)
to
the
first
hospital
where
treated,
from
that
hospital
to
the
next
nearest
one
if
necessary
treatment
is
unavailable
or
unsuitable
at
the
first
hospital,
then
to
either
the
home
(if
ambulance
transport
is
medically
necessary)
or
other
medical
facility
(if
required
for
the
patient
to
receive
necessary
treatment
and
if
ambulance
transport
is
medically
necessary).
Air
ambulance
to
nearest
facility
where
necessary
treatment
is
available
is
covered
if
no
emergency
ground
transportation
is
available
or
suitable
and
the
patient's
condition
warrants
immediate
evacuation.
PPO:
15%
of
the
Plan
allowance
(calendar
year
deductible
applies). Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
PPO:
10%
of
the
Plan
allowance
(calendar
year
deductible
applies). Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies).
Not
covered: Transportation
by
ambulance
is
not
covered
when
the
patient
does
not
require
the
assistance
of
medically
trained
personnel
and
can
be
safely
transferred
(or
transported)
by
other
means.
All
charges
All
charges 49
49 Page 50 51
2002
GEHA
50
Section
5( d)
Section
5
(d).
Emergency
services/
accidents
I M P O R T A N T
Here
are
some
important
things
to
keep
in
mind
about
these
benefits:
Please
remember
that
all
benefits
are
subject
to
the
definitions,
limitations,
and
exclusions
in
this
brochure.
The
calendar
year
deductible
is
$300
per
person
($
600
per
family)
under
the
High
Option
and
$450
per
person
($
900
per
family)
under
the
Standard
Option.
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. The non-PPO
benefits
are
the
standard
benefits
of
this
Plan.
PPO
benefits
apply
when
you
use
a
PPO
provider.
When
no
PPO
provider
is
available,
non-PPO
benefits
apply.
When
you
use
a
PPO
hospital
the
professionals
who
provide
services
to
you
in
a
hospital
may
not
all
be
preferred
providers.
If
they
are
not,
they
will
be
paid
by
this
plan
as
non-PPO
providers.
However,
if
the
services
are
rendered
at
a
PPO
hospital,
we
will
pay
the
services
of
radiologists,
anesthesiologists
and
pathologists
who
are
not
preferred
providers
at
the
preferred
provider
rate.
This
non-
standard
benefit
does
not
include
the
services
of
emergency
room
physicians.
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.
Benefit
Description
You
pay
NOTE:
The
calendar
year
deductible
applies
to
almost
all
benefits
in
this
Section.
We
say
"(
No
deductible)"
when
it
does
not
apply.
Accidental
injury
Standard
Option
High
Option
If
you
receive
care
for
your
accidental
injury
within
72
hours,
we
cover:
Treatment
outside
a
hospital
or
in
the
outpatient/
emergency
room
department
of
a
hospital
Related
outpatient
physician
care
Note:
Emergency
room
charges
associated
directly
with
an
inpatient
admission
are
considered
"Other
charges"
under
Inpatient
Hospital
Benefits
(see
page
44)
and
are
not
part
of
this
benefit,
even
though
an
accidental
injury
may
be
involved.
Expenses
incurred
after
72
hours,
even
if
related
to
the
accident,
are
subject
to
regular
benefits
and
are
not
paid
at
100%.
This
provision
also
applies
to
dental
care
required
as
a
result
of
accidental
injury
to
sound
natural
teeth.
Masticating
(chewing)
incidents
are
not
considered
to
be
accidental
injuries.
PPO:
Nothing
(No
deductible)
Non-PPO:
Only
the
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
PPO:
Nothing
(No
deductible)
Non-PPO:
Only
the
difference
between
our
allowance
and
the
billed
amount
(No
deductible)
Accidental
injury
-
continued
on
next
page 50
50 Page
51 52
2002
GEHA
51
Section
5( d)
You
Pay
Accidental
injury
(continued)
Standard
Option
High
Option
If
you
receive
care
for
your
accidental
injury
after
72
hours,
we
cover:
Non-
surgical
physician
services
and
supplies
Surgical
care
Note:
We
pay
Hospital
benefits
if
you
are
admitted.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Medical
emergency Outpatient medical or surgical
services
and
supplies
billed
by
a
hospital
for
emergency
room
treatment. Note: We pay Hospital
benefits
if
you
are
admitted.
PPO:
15%
of
the
Plan
allowance
Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
PPO:
10%
of
the
Plan
allowance
Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
Ambulance
–
accidental
injury
Ambulance
service
within
72
hours
of
an
accident
is
covered
as
follows:
Local
ambulance
service
(within
100
miles)
to
the
first
hospital
where
treated,
from
that
hospital
to
the
next
nearest
one
if
necessary
treatment
is
unavailable
or
unsuitable
at
the
first
hospital,
then
to
either
the
home
(if
ambulance
transport
is
medically
necessary)
or
other
medical
facility
(if
required
for
the
patient
to
receive
necessary
treatment
and
if
ambulance
transport
is
medically
necessary).
Air
ambulance
to
nearest
facility
where
necessary
treatment
is
available
is
covered
if
no
emergency
ground
transportation
is
available
or
suitable
and
the
patient's
condition
warrants
immediate
evacuation.
PPO:
Nothing
up
to
the
Plan
allowance Non-PPO:
Nothing
up
to
the
Plan
allowance
PPO:
Nothing
up
to
the
Plan
allowance Non-PPO:
Nothing
up
to
the
Plan
allowance Ambulance -continued
on
next
page 51
51 Page
52 53
2002
GEHA
52
Section
5( d)
You
Pay
Ambulance
–
non-accidental
injury
Standard
Option
High
Option
Local
ambulance
service
(within
100
miles)
to
the
first
hospital
where
treated,
from
that
hospital
to
the
next
nearest
one
if
necessary
treatment
is
unavailable
or
unsuitable
at
the
first
hospital,
then
to
either
the
home
(if
ambulance
transport
is
medically
necessary)
or
other
medical
facility
(if
required
for
the
patient
to
receive
necessary
treatment
and
if
ambulance
transport
is
medically
necessary).
Air
ambulance
to
nearest
facility
where
necessary
treatment
is
available
is
covered
if
no
emergency
ground
transportation
is
available
or
suitable
and
the
patient's
condition
warrants
immediate
evacuation.
PPO:
15%
of
the
Plan
allowance
(calendar
year
deductible
applies). Non-PPO:
35%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies)
PPO:
10%
of
the
Plan
allowance
(calendar
year
deductible
applies). Non-PPO:
25%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount
(calendar
year
deductible
applies).
Not
covered: Transportation
by
ambulance
is
not
covered
when
the
patient
does
not
require
the
assistance
of
medically
trained
personnel
and
can
be
safely
transferred
(or
transported)
by
other
means.
All
charges
All
charges 52
52 Page 53 54
2002
GEHA
53
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
Out-of-
Network
or
In-Network.
When
you
receive
In-Network
care,
you
must
get
our
approval
for
services
and
follow
a
treatment
plan
we
approve.
If
you
do,
cost-sharing
and
limitations
for
In-Network
mental
health
and
substance
abuse
benefits
will
be
no
greater
than
for
similar
benefits
for
other
illnesses
and
conditions.
Here
are
some
important
things
to
keep
in
mind
about
these
benefits:
All
benefits
are
subject
to
the
definitions,
limitations,
and
exclusions
in
this
brochure.
The
separate
calendar
year
mental
health/
substance
abuse
deductible
applies
to
almost
all
benefits
in
this
Section.
We
added
"( No
deductible)"
to
show
when
a
deductible
does
not
apply.
Be
sure
to
read
Section
4,
Your
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
57.
I M P O R T A N T
Benefit
Description
You
pay
After
the
mental
health/ substance
abuse
calendar
year
deductible…
NOTE:
The
mental
health/
substance
abuse
calendar
year
deductible
applies
to
almost
all
benefits
in
this
Section.
We
say
"(
No
deductible)"
when
it
does
not
apply.
In-Network
benefits
Standard
Option
High
Option
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.
Your
cost
sharing
responsibilities
are
no
greater
than
for
other
illness
or
conditions.
In-
Network
benefits
-
continued
on
next
page 53
53 Page
54 55
2002
GEHA
54
Section
5( e)
You
Pay
In-Network
benefits
(continued)
Standard
Option
High
Option
Professional
services,
including
individual
or
group
therapy
by
providers
such
as
psychiatrists,
psychologists,
or
clinical
social
workers
Medication
management
$25
copayment
per
office
visit
(No
deductible)
$15
copayment
per
office
visit
(No
deductible)
Inpatient
professional
fees
Diagnostic
tests
Laboratory
tests
to
monitor
the
effect
of
drugs
prescribed
for
your
condition
15%
of
the
Plan
allowance
10%
of
the
Plan
allowance
Inpatient
hospital
Room
and
board,
such
as
ward,
semiprivate,
or
intensive
care
accommodations;
general
nursing
care;
and
meals
and
special
diets.
NOTE:
We
only
cover
a
private
room
if
we
determine
it
to
be
medically
necessary.
Otherwise,
we
will
pay
the
hospital's
average
charge
for
semiprivate
accommodations.
The
remaining
balance
is
not
a
covered
expense.
If
the
hospital
only
has
private
rooms,
we
will
cover
the
private
room
rate
NOTE:
When
the
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.
15%
of
the
Plan
allowance
Nothing
(No
deductible)
Other
hospital
services
and
supplies
Services
provided
by
a
hospital
or
other
facility
Services
in
approved
alternative
care
settings
such
as
partial
hospitalization,
half-way
house,
residential
treatment,
full-day
hospitalization,
and
facility-based
intensive
outpatient
treatment
15%
of
the
Plan
allowance
10%
of
the
Plan
allowance
(No
deductible
for
inpatient
services)
In-
Network
benefits
-
continued
on
next
page 54
54 Page
55 56
2002
GEHA
55
Section
5( e)
You
Pay
In-Network
benefits
(continued)
Standard
Option
High
Option
Outpatient
hospital
Services
provided
by
a
hospital
15%
of
the
Plan
allowance
10%
of
the
Plan
allowance
Emergency
room
–
non-accidental
injury
Outpatient
services
and
supplies
billed
by
a
hospital
for
emergency
room
treatment
Note:
We
pay
Hospital
benefits
if
you
are
admitted.
15%
of
the
Plan
allowance
10%
of
the
Plan
allowance
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
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:
You
must
call
United
Behavioral
Health
at
(877)
564-7505
to
receive
authorization
for
inpatient
and
outpatient
care
from
a
Network
provider.
They
will
authorize
any
covered
treatment
and
tell
you
what
Network
providers
are
available
for
your
treatment.
If
you
do
not
receive
preauthorization
for
care
from
a
Network
provider,
Out-of-
Network
benefits
will
be
paid
for
covered
services.
In-
Network
benefits
-
continued
on
next
page 55
55 Page
56 57
2002
GEHA
56
Section
5( e)
In-Network
benefits
(continued)
Network
deductibles
and
There
is
a
separate
calendar
year
deductible
and
separate
out-of-
pocket
maximum
for
mental
health/
substance
abuse
treatment.
Out-of-
pocket
maximums
The
separate
deductible
is
$300
per
person,
$600
per
family
(High
Option);
or
$450
per
person,
$900
per
family
(Standard
Option).
This
separate
deductible
covers
both
in-network
and
out-of-
network
services
combined
and
applies
to
almost
all
of
the
benefits
in
this
section.
The
separate
out-of-
pocket
maximum
is
$3,000
Self
Only,
$3,500
Self
and
Family
(High
Option);
or
$4,000
Self
Only,
$4,500
Self
and
Family
(Standard
Option).
After
you
meet
this
out-of-
pocket
maximum,
we
pay
100%
of
our
allowable
amount
for
the
remainder
of
the
calendar
year.
The
separate
mental
health/ substance
abuse
deductible
does
not
apply
to
this
out-of-
pocket
maximum. Out-of-pocket
expenses
for
this
mental
health/ substance
abuse
benefit
are:
The
10%
you
pay
for
other
hospital
services
and
supplies,
inpatient
professional
fees,
emergency
room
physician
services
and
diagnostic
services
under
the
High
Option.
The
15%
you
pay
for
hospital
services,
inpatient
professional
fees,
emergency
room
physician
services
and
diagnostic
services
under
the
Standard
Option.
Note:
In
addition,
expenses
which
apply
to
the
in-network
mental
health/ substance
abuse
out-of-
pocket
maximums
are
also
applied
to
the
out-of-
network
mental
health/ substance
abuse
out-of-
pocket
maximum.
Network
deductibles
and
The
following
cannot
be
included
in
the
accumulation
of
mental
health/
substance
abuse
out-of-
pocket
expenses:
Out-
of-
pocket
Maximums
Expenses
in
excess
of
the
Plan
allowance
or
maximum
benefit
limitations.
The
$15
copayment
(High
Option)
and
$25
copayment
(Standard
Option)
for
office
professional
services
and
medication
management. $300 (High Option)
and
$450
(Standard
Option)
calendar
year
mental
health/ substance
abuse
deductible.
Any
amounts
you
pay
because
benefits
have
been
reduced
for
non-compliance
with
our
cost
containment
requirements
(see
pages
12,
13
and
14).
Expenses
for
prescription
drugs
purchased
through
retail
or
Home
Delivery
Pharmacy
service.
Network
limitation
If
you
do
not
obtain
an
approved
treatment
plan,
we
will
provide
only
Out-of-
Network
benefits.
How
to
submit
network
claims
You
or
your
provider
should
submit
claims
to:
United
Behavioral
Health
P. O.
Box
8570
Emeryville,
CA
94662-8570
If
you
need
help
in
filing
your
claim,
get
in
touch
with
us
at
(816)
257-5500,
toll-free
(800)
821-6136,
TDD
(800)
821-4833
or
contact
United
Behavioral
Health
at
(877)
564-7505. 56
56 Page
57 58
2002
GEHA
57
Section
5( e)
Out-of-
Network
Benefit
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. See pages
53-56
for
In-Network
benefits.
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.
Benefit
Description
You
Pay
Out-of-
Network
mental
health
and
substance
abuse
benefits
Standard
Option
High
Option
Inpatient
Hospital/
Facility
for
treatment
of
mental
health
100
day
limit
per
calendar
year
Precertification
required
Inpatient
Hospital/
Facility
treatment
of
alcoholism
and
drug
abuse
30
day
maximum
per
lifetime
Precertification
required
Outpatient
Hospital/ Intensive
Day
Treatment
Program
for
mental
health
/substance
abuse
60
day
limit
per
calendar
year
50%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount;
$500
inpatient
hospital
and
outpatient
hospital
/intensive
day
treatment
deductible
applies
per
person,
per
year
50%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount;
$500
inpatient
hospital
and
outpatient
hospital
/intensive
day
treatment
deductible
applies
per
person,
per
year
Out-
of-
Network
Benefit
-
continued
on
next
page 57
57 Page
58 59
2002
GEHA
58
Section
5( e)
You
Pay
Out-of-
Network
Benefit
(continued)
Standard
Option
High
Option
Inpatient
Visits
for
Psychotherapy
100
inpatient
visits
limit
per
calendar
year
Outpatient
Visits
for
Psychotherapy
and
group
sessions
30
session
limit
per
calendar
year
for
treatment
of
mental
health
and
substance
abuse
50%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount,
$450
mental
health
calendar
year
deductible
applies Both Network
and
Out-of-
Network
expenses
will
apply
to
the
mental
health
deductible.
50%
of
the
Plan
allowance
and
any
difference
between
our
allowance
and
the
billed
amount,
$300
mental
health
calendar
year
deductible
applies Both Network
and
Out-of-
Network
expenses
will
apply
to
the
mental
health
deductible.
Not
covered
out-
of-network:
Services
by
pastoral,
marital,
drug/ alcohol
and
other
counselors
including
therapy
for
sexual
problems.
Treatment
for
learning
disabilities
and
mental
retardation
Services
rendered
or
billed
by
schools,
residential
treatment
centers
or
halfway
houses
or
members
of
their
staffs
All
charges
All
charges
Lifetime
Maximum
Out-of-
Network
inpatient
care
for
the
treatment
of
alcoholism
and
drug
abuse
is
limited
to
a
30
day
maximum
per
lifetime.
Precertification
The
medical
necessity
of
your
admission
to
a
hospital
or
other
covered
facility
for
a
mental
health
or
substance
abuse
must
be
precertified
to
receive
Out-of-
Network
benefits.
Emergency
admissions
must
be
reported
within
two
business
days
following
admission
even
if
you
have
been
discharged.
Otherwise,
the
benefits
payable
will
be
reduced
by
$500.
See
Section
3
for
details.
Call
United
Behavioral
Health
at
(877)
564-7505
to
precertify.
Out-
of-
Network
benefits
-
continued
on
next
page 58
58 Page
59 60
2002
GEHA
59
Section
5( e)
Out-of-
Network
Benefit
(continued)
Out-of-
Network
Deductible
The
calendar
year
mental
health/
substance
abuse
deductible
is
$300
per
person
($
600
per
family)
under
the
High
Option
calendar
year
maximums
&
and
$450
per
person
($
900
per
family)
under
the
Standard
Option.
out-of-
pocket
maximums
The
calendar
year
deductible
applies
to
all
mental
health/
substance
abuse
benefits
in
this
Section
except
inpatient
and
outpatient
hospital
facility
charges.
There
is
a
separate
$500
hospital
inpatient
and
outpatient
hospital/
intensive
day
treatment
mental
health/
substance
abuse
deductible,
per
person,
per
calendar
year.
Inpatient
hospital
care
for
mental
health
is
limited
to
100
days
per
calendar
year.
Intensive
Day
Treatment
is
limited
to
60
visits
per
calendar
year.
Inpatient
care
for
the
treatment
of
alcoholism
and
drug
abuse
is
available
up
to
a
30
day
maximum
per
lifetime.
Inpatient
visits
for
psychotherapy
sessions
are
limited
to
100
visits
per
calendar
year.
Home
and
office
visits
for
psychotherapy
and
group
sessions
for
mental
health/
substance
abuse
are
limited
to
30
sessions
per
calendar
year.
When
the
deductibles
and
coinsurance
for
all
covered
family
members
(or
an
individual
under
Self
Only)
exceeds
$8,000
for
the
treatment
of
mental
health
(inpatient
or
outpatient)
and
outpatient
substance
abuse
in
any
one
calendar
year,
we
will
pay
in
full
all
remaining
allowable
charges
incurred
during
the
remainder
of
that
same
year .
Out-of-
pocket
expenses
for
this
mental
health/
substance
abuse
benefit
are:
The
$500
deductible
for
Inpatient
and
Outpatient
Hospital/
Intensive
Day
Treatment
of
mental
health/
substance
abuse
The
50%
you
pay
for
inpatient
and
outpatient
hospital
and
intensive
day
treatment
expenses;
The
50%
you
pay
for
inpatient
visits;
The
50%
you
pay
for
outpatient
care.
In
addition,
expenses
which
apply
to
the
in-network
mental
health/
substance
abuse
out-of-
pocket
maximums
are
also
applied
to
the
out-of-
network
mental
health/
substance
abuse
out-of-
pocket
maximum.
The
following
cannot
be
included
in
the
accumulation
of
out-of-
pocket
expenses:
Expenses
in
excess
of
the
Plan
allowance
or
maximum
benefit
limitations.
Expenses
for
outpatient
psychotherapy
sessions
in
excess
of
30
sessions
per
year.
Expenses
for
inpatient
care
in
excess
of
100
days
per
year.
$300
calendar
year
deductible
for
High
Option.
$450
calendar
year
deductible
for
Standard
Option.
Out-
of-
Network
benefits
-
continued
on
next
page 59
59 Page
60 61
2002
GEHA
60
Section
5( e)
Out-of-
Network
Benefit
(continued)
Expenses
for
intensive
day
treatment
in
excess
of
60
days
per
year.
Any
amounts
you
pay
because
benefits
have
been
reduced
for
non-compliance
with
our
cost
containment
requirements
(see
pages
12,
13
and
14).
Expenses
for
prescription
drugs
purchased
through
retail
or
Home
Delivery
Pharmacy
service.
Expenses
in
excess
of
the
50%
of
our
allowable
amount
for
inpatient
substance
abuse
charges.
How
to
submit
You
or
your
provider
should
submit
claims
to:
out-of-
network
claims
United
Behavioral
Health
P.
O.
Box
8570
Emeryville,
CA
94662-8570
(877)
564-7505
If
you
need
help
in
filing
your
claim,
get
in
touch
with
us
at
(816)
257-5500,
toll-free
(800)
821-6136
or
TDD
(800)
821-4833. 60
60 Page 61 62
2002
GEHA
61
Section
5( f)
Section
5
(f).
Prescription
drug
benefits
I M P O R T A N T
Here
are
some
important
things
to
keep
in
mind
about
these
benefits:
We
cover
prescribed
drugs
and
medications,
as
described
in
the
chart
beginning
on
page
64.
All
benefits
are
subject
to
the
definitions,
limitations
and
exclusions
in
this
brochure
and
are
payable
only
when
we
determine
they
are
medically
necessary.
There
is
no
calendar
year
deductible
for
prescription
drugs.
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.
Under
the
High
Option
plan,
if
Medicare
is
your
primary
insurance
and
you
have
both
Medicare
Part
A
&
B
coverage,
you
pay
less
for
your
prescriptions
(see
page
65).
I M P O R T A N T
There
are
important
features
you
should
be
aware
of.
These
include:
Who
can
write
your
prescription.
A
licensed
physician
or
a
licensed
dentist
must
write
the
prescription.
For
Home
Delivery
Pharmacy
service
prescriptions,
the
physician
must
be
licensed
in
the
United
States.
In
addition,
your
mailing
address
must
be
within
the
United
States
or
include
an
APO
address. Where you
can
obtain
them.
You
may
fill
the
prescription
at
a
PAID
network
pharmacy,
a
non-network
pharmacy,
or
by
home
delivery.
We
pay
a
higher
level
of
benefits
when
you
use
a
network
pharmacy.
For
medications
you
may
take
on
a
regular,
long-term
basis,
we
pay
a
higher
level
of
benefits
through
the
Merck-Medco
Home
Delivery
Pharmacy
service.
Preferred
Prescriptions
voluntary
formulary
Your
prescription
drug
program
includes
a
voluntary
"formulary"
feature.
The
Preferred
Prescriptions
Drug
Formulary
is
a
list
of
selected
FDA
approved
prescription
medications
reviewed
by
an
independent
group
of
distinguished
health
care
professionals.
Prescription
drugs
are
subjected
to
rigorous
clinical
analysis
from
the
standpoint
of
efficacy,
safety,
side
effects,
drug-to-
drug
interactions,
dosage
and
cost-benefit
in
determining
whether
they
are
included
on
or
excluded
from
the
formulary.
A
formulary
is
a
list
of
commonly
prescribed
medications
from
which
your
physician
may
choose
to
prescribe.
The
formulary
is
designed
to
inform
you
and
your
physician
about
quality
medications
that,
when
prescribed
in
place
of
other
non-formulary
medications,
can
help
contain
the
increasing
cost
of
prescription
drug
coverage
without
sacrificing
quality.
In
many
therapeutic
categories,
there
are
several
drugs
of
similar
effectiveness.
Many
doctors
are
often
unaware
of
the
significant
variations
in
price
among
these
similar
drugs
and,
as
a
result,
their
prescribing
decisions
often
do
not
consider
cost.
However,
when
the
cost
difference
is
brought
to
their
attention,
doctors
will
frequently
prescribe
the
less
costly
medications.
Your
physicians
will
be
contacted
to
discuss
their
prescribing
decision.
No
change
in
the
medication
prescribed
will
be
made
without
your
physicians'
approval.
Compliance
with
this
formulary
list
is
voluntary
and
there
is
no
financial
penalty
for
obtaining
drugs
not
on
the
formulary
list.
Prescription
drug
benefits
-
continued
on
next
2002
GEHA
62
Section
5( f)
Prescription
drug
benefits
(continued)
These
are
the
dispensing
limitations:
Using
the
PAID
Retail
Network
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.
Each
purchase
is
limited
to
a
30-day
supply.
Refills
cannot
be
obtained
until
75%
of
the
drug
has
been
used.
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.
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.
Some
medications
may
require
prior
approval
by
Merck-Medco
or
GEHA.
You
may
fill
your
prescription
at
any
pharmacy
participating
in
the
PAID
TelePAID
system.
For
the
names
of
participating
pharmacies,
call
(800)
551-7675.
Using
the
Home
Delivery
Pharmacy
service
Through
this
service,
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
RX
even
though
the
prescription
is
for
90
days.
Even
though
insulin,
syringes,
diabetic
supplies
and
ostomy
supplies
do
not
require
a
physician's
prescription,
to
obtain
through
the
Home
Delivery
Pharmacy
service,
you
should
obtain
a
prescription
from
your
physician
for
a
90-day
supply.
Some
medications
may
require
approval
by
Merck-
Medco
or
GEHA.
Not
all
drugs
are
available
through
the
Home
Delivery
Pharmacy
service.
In
order
to
use
the
Home
Delivery
Pharmacy
service,
your
prescriptions
must
be
written
by
a
physician
licensed
in
the
United
States.
In
addition,
your
mailing
address
must
be
within
the
United
States
or
include
an
APO
address.
Each
enrollee
will
receive
an
installment
kit
that
includes
a
brochure
describing
the
Home
Delivery
Pharmacy
service,
an
order
form,
a
questionnaire,
and
a
return
envelope.
To
order
new
prescriptions,
ask
your
doctor
to
prescribe
needed
medication
for
up
to
a
90-day
supply,
plus
refills,
if
appropriate.
Complete
the
Health,
Allergy,
&
Medication
Questionnaire
the
first
time
you
order
through
this
service.
Complete
the
information
on
the
Ordering
Medication
Form,
enclose
your
prescription
and
the
correct
copayment.
Mail
to:
Merck-Medco
RX
Services
P.
O.
Box
98830
Las
Vegas,
NV
89195-0249
You
should
receive
your
medication
within
14
days
from
the
date
you
mail
your
prescription.
You
will
also
receive
reorder
instructions.
If
you
have
any
questions
about
your
prescription,
you
may
call
the
Home
Delivery
Pharmacy
service
toll-free
at
(800)
551-7675
available
24
hours
a
day,
7
days
a
week.
Emergency
consultation
with
a
registered
pharmacist
is
available
seven
days
a
week,
24
hours
per
day.
Forms
necessary
for
refills
will
be
provided
each
time
you
receive
a
supply
of
medication
from
the
service.
Refilling
your
medication:
to
be
sure
you
never
run
short
of
your
prescription
medication,
you
should
re-order
on
or
after
the
refill
date
indicated
on
the
refill
slip
or
when
you
have
approximately
14
days
of
medication
left.
To
order
by
phone:
call
Member
Services
at
(800)
551-7675.
Have
your
refill
slip
with
the
prescription
information
ready.
To
order
by
mail:
Simply
mail
your
refill
slip
and
copayment
in
the
return
envelope.
To
order
online:
Go
to
www.
geha.
com/
prescriptions/
index.
html
then
click
on
the
link
to
Merck-Medco,
or
go
to
www.
merck-medco.
com
Prescription
drug
benefit
-
continued
on
next
page 62
62 Page
63 64
2002
GEHA
63
Section
5( f)
Prescription
drug
benefits
(continued)
Coordinating
with
other
drug
coverage
If
you
also
have
drug
coverage
through
another
group
health
insurance
plan
and
we
are
your
secondary
insurance,
follow
these
procedures:
At
participating
pharmacies,
do
not
present
your
GEHA
drug
card.
Purchase
your
drug
and
submit
the
bill
to
your
primary
insurance.
When
they
have
made
payment,
file
the
claim
and
the
Explanation
of
Benefits
(EOB)
with
GEHA
(see
page
74).
If
you
use
GEHA's
prescription
drug
card
when
another
insurance
is
primary,
you
will
be
responsible
for
reimbursing
us
any
amount
in
excess
of
our
secondary
benefit.
Drugs
purchased
at
non-participating
pharmacies
should
be
submitted
to
our
claims
office
(see
page
74)
along
with
the
primary
insurance
EOB.
We
will
accept
either
the
drug
receipts
or
a
PAID
Prescriptions,
Inc.
drug
claim
form.
Submit
these
claims
to
GEHA,
P.
O.
4665,
Independence,
MO
64051-
4665,
when
we
are
your
secondary
insurance.
If
another
insurance
is
primary,
you
should
use
their
drug
benefit.
If
you
elect
to
use
the
Home
Delivery
Pharmacy
service,
Merck-Medco
RX
services
will
bill
you
directly.
Pay
Merck-Medco
RX
the
amount
billed
and
submit
the
bill
to
your
primary
insurance.
When
your
primary
insurance
makes
payment,
file
the
claim
and
their
EOB
to
us
(see
page
74).
In
some
cases,
Medicare
covers
prescription
drugs
and
supplies.
If
Medicare
is
your
primary
insurance
and
you
use
prescription
drugs
or
supplies
covered
by
Medicare,
we
will
attempt
to
recover
the
cost
of
the
drug
or
supply
from
Medicare.
You
must
cooperate
with
us
in
obtaining
this
reimbursement.
If
we
are
unsuccessful
in
recovering
our
payment
from
Medicare,
we
reserve
the
right
to
require
you
to
purchase
the
medication
and
then
file
a
claim
with
Medicare.
After
Medicare
makes
payment,
you
may
file
a
claim
with
us
for
the
out-of-
pocket
cost,
in
excess
of
your
GEHA
copayment. Three-tier
drug
benefit
Under
the
High
Option,
we
divide
prescription
drugs
into
three
categories
or
tiers:
generic,
single-source
brand
name,
and
multi-source
brand
name.
When
an
approved
generic
equivalent
is
available,
that
is
the
drug
you
will
receive,
unless
you
or
your
physician
specify
that
the
prescription
must
be
filled
as
written.
When
an
approved
generic
equivalent
is
not
available,
you
will
pay
the
brand
name
single-source
copayment.
If
an
approved
generic
equivalent
is
available,
but
you
or
your
physician
specify
that
the
prescription
must
be
filled
as
written,
you
will
pay
the
brand
name
multi-source
copayment.
Generic
drugs:
are
chemically
and
therapeutically
equivalent
to
the
corresponding
brand
drug,
but
are
available
at
a
lower
price.
Equivalent
generic
products
for
brand
name
medications
become
available
after
a
patent
and
other
exclusivity
rights
for
the
brand
expire.
The
Food
and
Drug
Administration
must
approve
all
generic
versions
of
a
drug
and
assure
that
they
meet
strict
standards
for
quality,
strength
and
purity.
The
FDA
requires
that
generic
equivalent
medications
contain
the
same
active
ingredients
and
be
equivalent
in
strength
and
dosage
to
brand
name
drugs.
The
main
difference
between
a
generic
and
its
brand
name
drug
is
the
cost
of
the
product.
Single-
source
brand
name
drugs
are
available
from
only
one
manufacturer
and
are
patent-protected.
No
generic
equivalent
is
available.
Multi-
source
brand
name
drugs
are
available
from
more
than
one
manufacturer
and
have
a
least
one
generic
equivalent
alternative
available.
Any
rebates
or
savings
received
by
the
Plan
on
the
cost
of
drugs
purchased
under
this
plan
from
drug
manufacturers
are
credited
to
the
health
plan
and
are
used
to
reduce
health
care
costs .
Prescription
drug
benefit
-
continued
on
next
page 63
63 Page
64 65
2002
GEHA
64
Section
5( f)
Benefit
Description
You
Pay
Covered
medications
and
supplies
Standard
Option
High
Option
Each
new
enrollee
will
receive
a
description
of
our
prescription
drug
program,
a
combined
prescription
drug/ Plan
identification
card,
an
order
form,
a
questionnaire,
and
a
reply
envelope. You may
purchase
the
following
medications
and
supplies
prescribed
by
a
physician
from
either
a
pharmacy
or
by
mail:
Drugs
and
medicines
(including
those
administered
during
a
non-covered
admission
or
in
a
non-covered
facility)
that
by
Federal
law
of
the
United
States
require
a
physician's
prescription
for
their
purchase,
except
those
listed
as
Not
Covered. Insulin Needles and
syringes
for
the
administration
of
covered
medications
Contraceptive
drugs
Ostomy
supplies
Note:
A
generic
equivalent
will
be
dispensed
if
it
is
available
unless
you
or
your
physician
specifies
that
the
prescription
be
dispensed
as
written,
when
a
Federally
approved
generic
drug
is
available.
GEHA
Primary: Network Retail
Pharmacy
(initial
amount
prescribed,
for
up
to
a
30-day
supply):
$5
generic/ 50%
brand
name
for
up
to
30-day
supply
Non-
Network
Retail
you
pay:
$5
generic/ 50%
brand
name
and
any
difference
between
our
allowance
and
the
cost
of
the
drug (You
must
submit
your
claim
to
PAID
Prescriptions,
L.
L.
C.)
Home
Delivery
Pharmacy
Service
for
up
to
a
90-day
supply,
you
pay:
$15
generic/ 50%
brand
name
GEHA
Primary: Network Retail
Pharmacy
(initial
fill
not
to
exceed
a
30-
day
supply,
and
the
first
refill):
$5
generic/$
15
single-
source
brand
name/$
30
multi-source
brand
name
All
subsequent
refills,
you
pay
the
greater
of
50%
or
the
copayments
described
above
Non-
Network
Retail
(initial
fill
not
to
exceed
a
30-
day
supply,
and
the
first
refill):
$5
generic/$
15
single-
source
brand
name/$
30
multi-source
brand
name
and
any
difference
between
our
allowance
and
the
cost
of
the
drug
All
subsequent
refills,
you
pay
the
greater
of
50%
or
the
copayments
described
above
and
any
difference
between
our
allowance
and
the
cost
of
the
drug (You
must
submit
your
claim
to
PAID
Prescriptions,
L.
L.
C.)
Home
Delivery
Pharmacy
Service
for
up
to
a
90-day
supply,
you
pay:
$10
generic/$
35
single-source
brand
name/$
50
multi-source
brand
name
Prescription
drug
benefits
-
continued
on
next
page 64
64 Page
65 66
2002
GEHA
65
Section
5( f)
Prescription
drug
benefits
You
Pay
Covered
medications
and
supplies
Standard
Option
High
Option
Here
are
some
things
to
keep
in
mind
about
our
prescription
drug
program:
Note:
If
there
is
no
generic
equivalent
available,
you
pay
the
brand
name
copayment.
Note:
If
a
participating
pharmacy
is
not
available
where
you
reside
or
you
do
not
use
your
identification
card,
you
must
submit
your
claim
to:
PAID
Prescriptions,
L.
L.
C.
P.
O.
2187
Lee's
Summit,
MO
64063-2187
Your
claim
will
be
calculated
on
the
50%
coinsurance
or
the
appropriate
copayments.
Reimbursement
will
be
based
on
GEHA's
costs
had
you
used
a
participating
pharmacy.
You
must
submit
original
drug
receipts.
Note:
A
generic
equivalent
will
be
dispensed
if
it
is
available
unless
you
or
your
physician
specifies
that
the
prescription
be
dispensed
as
written,
when
a
Federally
approved
generic
drug
is
available.
Medicare
A
&
B
Primary:
Network
Retail
Pharmacy
(initial
amount
prescribed,
for
up
to
a
30-day
supply):
$5
generic/ 50%
brand
name
Non-
Network
Retail
you
pay:
$5
generic/ 50%
brand
name
and
any
difference
between
our
allowance
and
the
cost
of
the
drug (You must
submit
your
claim
to
PAID
Prescriptions,
L.
L.
C.)
Home
Delivery
Pharmacy
Service
for
up
to
a
90-day
supply,
you
pay:
$15
generic/ 50%
brand
name
Medicare
A
&
B
Primary:
Network
Retail
Pharmacy
(initial
fill
not
to
exceed
a
30-
day
supply,
and
the
first
refill):
$3
generic/$
10
single-
source
brand
name/$
25
multi-source
brand
name
All
subsequent
refills,
you
pay
the
greater
of
50%
or
the
copayments
described
above
Non-
Network
Retail
you
pay:
(initial
fill
not
to
exceed
a
30-
day
supply,
and
the
first
refill):
$3
generic/$
10
single-
source
brand
name/$
25
multi-source
brand
name
and
any
difference
between
our
allowance
and
the
cost
of
the
drug
All
subsequent
refills,
you
pay
the
greater
of
50%
or
the
copayments
described
above
and
any
difference
between
our
allowance
and
the
cost
of
the
drug (You
must
submit
your
claim
to
PAID
Prescriptions,
L.
L.
C.)
Home
Delivery
Pharmacy
Service
for
up
to
a
90-day
supply,
you
pay:
$5
generic/$
17
single-
source
brand
name/$
30
multi-source
brand
name
Prescription
drug
benefit
-
continued
on
next
page 65
65 Page
66 67
2002
GEHA
66
Section
5( f)
Prescription
drug
benefits
(continued)
You
Pay
Covered
medications
and
supplies
Standard
Option
High
Option
Not
covered: Drugs and
supplies
for
cosmetic
purposes
Vitamins,
nutrients
and
food
supplements
even
if
a
physician
prescribes
or
administers
them
including
enteral
formula
available
without
a
prescription
Nonprescription
medicines
Drugs
to
aid
in
smoking
cessation
except
those
limited
to
the
$100
lifetime
maximum
as
part
of
the
smoking
cessation
benefit
(see
page
33).
You
may
not
obtain
smoking
cessation
drugs
with
your
PAID
Prescription
card
or
through
the
Home
Delivery
Pharmacy
service.
You
must
purchase
these
drugs
and
file
the
claim
with
us.
Medical
supplies
such
as
dressings
and
antiseptics
Drugs
which
are
investigational
Drugs
prescribed
for
weight
loss
Drugs
to
treat
infertility
Drugs
to
treat
impotency
All
charges
All
charges 66
66 Page 67 68
2002
GEHA
67
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.
Services
for
deaf
and
hearing
impaired
TDD
service
is
available
at
(800)
821-4833
for
members
who
are
hearing
impaired.
High
risk
pregnancies
To
participate
in
our
enhanced
maternity
program,
call
(800)
747-GEHA
at
any
time
as
soon
as
you
think
you
or
your
covered
dependent
may
be
pregnant.
Early
participation
in
the
program
guarantees
you
ongoing
communication
with
a
registered
nurse
throughout
the
pregnancy.
Complimentary
educational
materials
include
the
book
"From
Here
to
Maternity". 67
67 Page
68 69
2002
GEHA
68
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.
There
is
no
calendar
year
deductible
for
dental
benefits.
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
We
cover
restorative
services
and
supplies
necessary
to
promptly
repair
sound
natural
teeth.
The
need
for
these
services
must
result
from
an
accidental
injury.
The
repair
of
accidental
injury
to
sound
natural
teeth
includes
but
is
not
limited
to,
expenses
for
xrays,
drugs,
crowns,
bridgework,
inlays,
and
dentures.
Masticating
(biting
or
chewing)
incidents
are
not
considered
to
be
accidental
injuries.
Accidental
dental
injury
is
covered
at
100%
for
charges
incurred
within
72
hours
of
an
accident.
Services
incurred
after
72
hours
are
paid
at
regular
Plan
benefits.
Dental
benefits
Service
Standard
Option
Scheduled
Allowance
High
Option
Scheduled
Allowance
We
pay
You
pay
We
pay
You
pay
Diagnostic
and
preventive
services,
limited
to
two
visits
per
year
including
examination,
prophylaxis
(cleaning),
X-rays
of
all
types
and
fluoride
treatment.
Benefits
are
payable
per
visit
not
per
service
50%
up
to
the
plan
allowance
for
diagnostic
and
preventive
services
(maximum
two
visits
per
year)
50%
up
to
the
plan
allowance
and
all
charges
in
excess
of
the
plan
allowance
for
diagnostic
and
preventive
services
$22
per
visit
(maximum
two
visits
per
year)
All
charges
in
excess
of
the
scheduled amount listed to
the
left
Dental
benefits
-
continued
on
next
page 68
68 Page
69 70
2002
GEHA
69
Section
5( h)
Dental
benefits
(continued) Service
Standard
Option
Scheduled
Allowance
High
Option
Scheduled
Allowance
We
pay
You
pay
We
pay
You
pay
Amalgam
restorations Resin-Based Composite
Restorations
Gold
Foil
Restorations Inlay/ Onlay Restorations
$21
One
Surface
$28
Two
or
More
Surfaces
All
charges
in
excess
of
the
scheduled amounts listed to
the
left
$21
One
Surface
$28
Two
or
More
Surfaces
All
charges
in
excess
of
the
scheduled amounts listed to
the
left
Simple
Extractions
$21
Simple Extraction
All
charges
in
excess
of
the
scheduled amount listed to
the
left
$21
Simple Extraction
All
charges
in
excess
of
the
scheduled amount listed to
the
2002 GEHA 70 Section 5( i)
Section 5 (i). Non-FEHB
benefits available to Plan members
The benefits on pages 70 and 71 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.
Non-Covered
Prescription Drugs (800) 417-1893
Certain prescription drugs not covered
by GEHA's Prescription Drug Program are available to GEHA health plan members at
a discount. If your physician writes a prescription for a non-covered drug to
treat impotency or hair
loss, you may purchase it through the Home Delivery Pharmacy service, paying
100% of the discounted amount. To order, complete the form called Ordering
Medications from the Home Delivery Pharmacy Service. Mail this form
along
with your prescription and check or credit card number to: Merck-Medco Rx
Services
P. O. Box 98830 Las Vegas, NV 89195-0249
If paying by a check,
please call first to obtain the cost of the medication. Full payment must be
included with your order.
Online Shopping
GEHA health
plan members have access to special features offered on the Merck-Medco web
site, www. merck-medco. com. On this web site, you can refill mail
order prescriptions and manage your mail order account. A new
feature is online shopping for thousands of non-prescription drugstore
products available from CVS, America's leading retail pharmacy chain. Items
available include nonprescription medications, vitamins, herbal remedies and
personal care products.
CONNECTION Hearing (877) 674-3594 www. miracle-ear. com
Free to all
GEHA health plan members, CONNECTION Hearing offers cost savings at 1,155
Miracle Ear locations nationwide. The program provides a free hearing
evaluation, up to a 20 percent discount off the retail price of
hearing aids, a 30-day satisfaction refund guarantee, free unlimited
follow-up visits, and free annual checkups for hearing aids. Program benefits
are available to GEHA health plan members and their families, including parents
and
grandparents. Call to locate providers in your area.
CONNECTION
Long-Term Care (888) 469-GEHA
Available for an additional premium,
CONNECTION Long-Term Care offers GEHA health plan members and their families
(including spouses, parents, grandparents, in-laws and grandparents-in-law) a 10
percent premium discount
on long-term care insurance, with an additional discount when a spouse also
enrolls. The program is available through CNA. Long-term care policies from CNA
provide coverage for home health care, adult day care, assisted
living,
nursing home and hospice care.
CONNECTION Vision (800) 800-EYES
Free to all GEHA health plan members, CONNECTION Vision offers cost
savings at more than 11,000 eye care locations nationwide. GEHA health plan
members get discounts off the retail price of lenses, frames and specialty
items such as tints, lightweight plastics and scratch-resistant coatings.
Discounts are available for surgical procedures (including LASIK, RK, PRK and
ALK) not covered under the GEHA health plan. For discounts on mail-order
contact lenses and non-prescription sunglasses, call (800) 878-3901. This
program is offered through Coast to Coast Vision. Call to locate providers in
your area. When you purchase the dental plan, but not GEHA health
insurance,
you also have free access to the CONNECTION Vision program. 70
70 Page 71 72
2002 GEHA 71 Section 5( i)
CONNECTION Dental (800) 296-0776
Free to all GEHA health plan
members, CONNECTION Dental offers cost savings at 22,000 providers nationwide.
Participating dentists agree to limit their charges to a fee schedule for GEHA
members. When you choose a
participating dentist, you pay only up to the maximum charge on the
CONNECTION Dental fee schedule. If your dentist has not yet joined, ask your
dentist to call GEHA for a CONNECTION Dental information packet. Call for a
list of providers in your area.
CONNECTION Dental Plus
(800) 793-9335
Available for an additional premium,
CONNECTION Dental Plus is a supplemental dental plan that pays benefits
for a wide variety of procedures, from cleanings and X-rays to crowns, dentures
and orthodontia for children. This
optional dental insurance is provided
directly by GEHA. Certain waiting periods and limitations apply.
Enrollment
is now open to all federal employees, retirees and annuitants, including those
who are not members of the GEHA health plan. When you also join the GEHA health
plan, you pay a lower premium for CONNECTION
Dental Plus. When you
purchase the dental plan, but not GEHA health insurance, you also have free
access to the CONNECTION Vision program.
Benefit Percentages Covered Services Calendar Year
Deductible Per
Person
Provider Participation
1 st Year 2 nd Year 3 rd Year
In-Network 100% 100% 100% Class A
Specified Diagnostic and
Preventative
$0
Out-of-Network 60% 80% 80%
In-Network 70% 75% 80% Class B
Other Diagnostic,
Preventative,
Restorative &
Specified Oral Surgery
$50
Out-of-Network 50% 55% 60%
In-Network 40% 50% Class C
Endodontics, Periodontics,
Prosthodontics & Crowns,
Inlays, Onlays
$100
Out-of-Network
0% 12 Month
Waiting Period 30% 40%
In-Network 50% Class D
Orthodontics-Comprehensive
Case (ages
6-18)
$0
Out-of-Network
0% 24 Month
Waiting Period
0% 24 Month
Waiting Period 25%
Benefits described on page 70 and 71 are neither offered nor guaranteed
under contract with the FEHB Program. The cost of CONNECTION programs is not
included in the health plan premium you pay. Charges for these
services do
not count toward your GEHA deductible or out-of-pocket maximum. The GEHA PPO
copayment does not apply. CONNECTION benefits are not subject to the FEHB
disputed claims procedure. GEHA does not
guarantee that providers are
available in all areas or that prices at a participating provider are lower than
prices that may be available from a non-participating provider. 71
71 Page 72 73
2002 GEHA 72 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 were not enrolled in this Plan;
Services, drugs, or
supplies that are not medically necessary;
Services, drugs, or supplies not
required according to accepted standards of medical, dental, or psychiatric
practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term, or when the
pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations; sexual
dysfunction or sexual inadequacy;
Services, drugs, or supplies you receive
from a provider or facility barred from the FEHB Program;
Services or
supplies for which no charge would be made if the covered individual had no
health insurance coverage;
Services or supplies furnished without charge (except as described on page
17) 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 or supplies furnished by immediate relatives or household
members, such as spouse, parents, children, brothers or sisters by blood,
marriage or adoption;
Services or 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 or supplies
for cosmetic purposes;
Surgery to correct congenital anomalies for
individuals age 18 and older unless there is a functional deficit;
Services
or supplies not specifically listed as covered;
Services or supplies not
reasonably necessary for the diagnosis or treatment of an illness or injury,
except for routine physical examinations and immunizations;
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 the enrollee or Plan has no legal obligation to pay, such as
excess charges for an annuitant age 65 or older who is not covered by Medicare
Parts A and/ or B (see page 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 19), or State premium taxes
however applied;
Charges in excess of the "Plan allowance" as defined on page 86;
Biofeedback, educational, recreational or milieu therapy, either in or out
of a hospital;
Inpatient private duty nursing;
Stand-by physicians and
surgeons;
Clinical ecology and environmental medicine; 72
72 Page 73 74
2002 GEHA 73 Section 6
Chelation
therapy except for acute arsenic, gold, or lead poisoning;
Treatment for
impotency, even if there is an organic cause for impotency. (Exclusion applies
to medical/ surgical treatment as well as prescription drugs.);
Treatment other than surgery of temporomandibular joint dysfunction and
disorders (TMJ);
Computer devices to assist with communications; or
Computer programs of any type, including but not limited to those to assist
with vision therapy or speech therapy. 73
73
Page 74 75
2002 GEHA 74 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) 821-6136, or at our web site at www. geha.
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.
Mail to: GEHA P. O. Box 4665
Independence,
MO 64051-4665
For claims questions and assistance, call us at (800)
821-6136.
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 and address of person or firm providing the service or
supply;
Dates that services or supplies were furnished;
Diagnosis;
Type of each service or supply; and
The charge for each service or
supply.
Note: Canceled checks, cash register receipts, or balance due
statements are not acceptable substitutes for itemized bills.
In addition:
You must send a copy of the explanation of benefits (EOB)
from any primary payer (such as the Medicare Summary Notice (MSN)) with your
claim.
Bills for home nursing care must show that the nurse is a
registered or licensed practical nurse and should include nursing notes.
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. 74
74
Page 75 76
2002
GEHA 75 Section 7
Claims for prescription drugs and supplies that
are not purchased through the Prescription Drug Program must include receipts
that
include the prescription number, name of drug or supply, prescribing
physician's name, date, and charge.
To control administrative costs, we will not issue benefit checks that do not
exceed $1.
Records Keep a separate record of the medical expenses of each covered
family member as deductibles and maximum allowances apply separately to
each
person. Save copies of all medical bills, including those you accumulate to
satisfy a deductible. In most instances they will serve as
evidence of your
claim. We will not provide duplicate or year-end statements.
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
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 itemized bills that include an English translation. Charges
should be converted to U. S. dollars using the exchange rate applicable at the
time the expense was incurred. If possible, include a receipt showing the
exchange rate on the date the claimed services were performed.
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. 75
75 Page
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2002 GEHA 76 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: GEHA, P. O. Box 4665,
Independence, MO 64051-4665; and
(c) Include a statement about why you
believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we
will send you a copy of our
request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us --if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 2, 1900 E Street, NW, Washington, D. C. 20415-3620.
76
76 Page 77 78
2002 GEHA 77 Section 8
Section 8.
The disputed claims process (continued)
Send OPM the
following information:
A statement about why you believe our decision was
wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
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) 821-6136 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. 77
77
Page 78 79
2002
GEHA 78 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 or auto insurance 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 1-800-MEDICARE for more
information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your
monthly Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in
how you get your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits
with
Medicare, depending on the type of Medicare + Choice plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available (Part A or Part B) 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. 78
78 Page 79 80
2002 GEHA 79 Section 9
Claims process when you have the
Original Medicare Plan – You probably will never have to file a claim form
when you have both our
Plan and the Original Medicare Plan.
When we are
the primary payer, we process the claim first.
When Original Medicare is the
primary payer, Medicare processes your claim first. In most cases, your claims
will be coordinated
automatically and we will pay the balance of covered charges. You will not
need to do anything. To find out if you need to do
something about filing your claims, call us at (800) 821-6136 or
visit our web site at www. geha. com.
We waive some costs when you have the Original Medicare Plan – When
Original Medicare is the primary payer, we will waive some out-of-
pocket
costs, as follows:
Inpatient Hospital Benefits: If you are enrolled
in Medicare Part A, we waive the deductible and coinsurance
Medical and Surgery Benefits and Mental Health/ Substance Abuse care:
If you are enrolled in Medicare Part B, we waive the
deductible and
coinsurance.
Office Visits PPO Providers: If you are enrolled in
Medicare Part B, we waive the copayments for PPO office visits.
Prescription Drugs: If you have Medicare Parts A and B, you will pay a
copayment for drugs through the Home Delivery Pharmacy
service and at retail
pharmacies as shown on page 65.
Chiropractic Benefits: There is no
change in benefit limits or maximums for chiropractic care when Medicare is
primary. See
page 32 for benefits.
Physical, Speech and Occupational Therapy
Benefits: There is no change in benefit limits or maximums for therapy when
Medicare is primary. 79
79 Page 80 81
2002 GEHA
80 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 80
80 Page
81 82
2002 GEHA 81 Section 9
Medicare managed care plan If
you are eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from another type of Medicare+ Choice plan --a
Medicare managed
care plan. These are health care choices (like HMOs) in some areas of the
country. In most Medicare managed care
plans, you can only go to doctors,
specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits that
Original Medicare covers. Some cover extras,
like prescription drugs. To learn more about enrolling in a Medicare managed
care plan,
contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare managed care
plan: You may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed
care plan's
network and/ or service area, but we will not waive any of our copayments,
coinsurance, or deductibles. If you enroll in a
Medicare managed care plan,
tell us. We will need to know whether you are in the Original Medicare Plan or
in a Medicare managed care
plan so we can correctly coordinate 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 If you do not have one or both Parts of
Medicare, you can still be Medicare Part A or Part B 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
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. 81
81 Page
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2002 GEHA 82 Section 9
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care.
Medicaid When you have this Plan
and Medicaid, we pay first.
When other Government agencies We do not
cover services and supplies when a local, State, are responsible for your
care or Federal Government agency directly or indirectly pays for them.
When others are responsible If you or a dependent suffer injuries in
an accident or become ill for injuries because of another person's act or
omission, and you later receive
compensation from that person and/ or your
own or other insurance, you are required to refund GEHA. We will make
conditional payments,
subject to our contractual benefits. Included in
GEHA's lien are any services and supplies to diagnose or treat the injuries or
illness. You
are required to reimburse GEHA for the benefit payments even if
the total compensation received is not sufficient to compensate you or your
dependent for the damages sustained. In other words, unless we agree
otherwise in writing, you are bound to reimburse the Plan in full even if
you are not "made whole" for all of the damages by the compensation. GEHA's
lien is not subject to reduction for attorney's fees or costs
under the
"common fund" doctrine without GEHA's written consent.
GEHA enforces our
right of reimbursement by asserting a lien against any and all compensation that
you or your dependent receive, whether
by court order or out-of-court
settlement, and regardless of how that compensation is characterized, such as
"pain and suffering". GEHA's
lien includes payments from any source,
including Medpay, Personal Injury Protection, no-fault coverage, third-party,
and uninsured and
underinsured motorists coverage. You must cooperate with
GEHA by promptly notifying our subrogation unit when you or a dependent file a
claim against some other person( s) for compensation. You must supply GEHA
with all relevant information relating to the claim, and sign any
releases
GEHA requires to obtain information about that claim from other sources. You
must promptly disclose to GEHA all information
relating to any settlement or
recovery received. In addition, you must: accept GEHA's lien for the full amount
of the benefits paid; assign any
proceeds from third-parties, your own, or
other insurance to GEHA when asked to do so; and sign a Reimbursement Agreement
if asked by
GEHA to do so. However, a Reimbursement Agreement is not
necessary to enforce the lien. The lien extends to all related expenses
incurred prior to the settlement or judgment date, whether or not those
expenses were submitted in a timely manner to GEHA. Related
expenses
incurred after all settlements are not included in the lien. In short, GEHA is
entitled to be reimbursed for all benefits paid for
medical care resulting
from the injury or illness through the date of settlement of your claim, unless
we agree in writing to accept less than
100% of the lien. The lien remains
the member's obligation until it is satisfied in full. Failure to reimburse GEHA
or cooperate with our
reimbursement efforts may result in an overpayment
that can be collected from you or any dependent.
Please contact GEHA's Subrogation unit at (800) 821-4742, Ext. 5503, or Ext.
5735, to report your claim or discuss this process. 82
82 Page 83 84
2002 GEHA 83 Section 10
Section
10. Definitions of terms we use in this brochure
Accidental injury An
injury caused by an external force or element such as a blow or fall that
requires immediate medical attention. Also included are animal
bites,
poisonings, and dental care required to repair injuries to sound natural teeth
as a result of an accidental injury, not from biting or
chewing.
Admission The period from entry (admission) into a hospital or other
covered facility until discharge. In counting days of inpatient care, the date
of
entry and the date of discharge are counted as the same day.
Assignment An authorization by an enrollee or spouse for the Plan to
issue payment of benefits directly to the provider. The Plan reserves the right
to pay
the member directly for all covered services.
Calendar year January 1 through December 31 of the same year. For new
enrollees, the calendar year begins on the effective date of their enrollment
and
ends on December 31 of the same year.
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 15-16.
Congenital anomaly A condition existing at or from birth which is a
significant deviation from the common form or norm. For purposes of this Plan,
congenital
anomalies include cleft lips, cleft palates, birthmarks, webbed
fingers or toes and other conditions that the Plan may determine to be
congenital anomalies. Surgical correction of congenital anomalies is limited
to children under the age of 18 unless there is a functional
deficit. In no
event will the term congenital anomaly include conditions relating to teeth or
intra-oral structures supporting the teeth.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 15.
Cosmetic Any procedure or any
portion of a procedure performed primarily to improve physical appearance and/
or treat a mental condition through
change in bodily form.
Covered services Services we provide benefits for, as described in
this brochure.
Custodial care Treatment or services, 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: (1) personal care such as help in: walking; getting in and out
of bed;
bathing; eating by spoon, tube or gastrostomy; exercise; dressing;
(2) homemaking, such as preparing meals or special diets;
(3) moving the
patient; (4) acting as companion or sitter;
(5) supervising medication that
can usually be self administered; or 83
83 Page 84 85
2002 GEHA
84 Section 10
(6) 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.
The Carrier determines 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 15.
Durable medical equipment Equipment and supplies that:
(1) are
prescribed by your attending doctor; (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.
Effective date The date the benefits described in this brochure are
effective:
(1) January 1 for continuing enrollments and for all annuitant
enrollments;
(2) the first day of the first full pay period of the new year
for enrollees who change plans or options or elect FEHB coverage
during the
open season for the first time; or (3) for new enrollees during the calendar
year, but not during the open
season, the effective date of enrollment as
determined by the employing office or retirement system.
Elective surgery Any non-emergency surgical procedure that may be
scheduled at the patient's convenience without jeopardizing the patient's life
or causing
serious impairment to the patient's bodily functions.
Expense An expense is "incurred" on the date the service or supply is
rendered.
Experimental or A drug, device, or biological product is experimental
or investigational investigational services 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.
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.
84
84 Page 85 86
2002 GEHA 85 Section 10
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 of appropriate government publications such as those of the
National Institute of Health, National Cancer Institute, Agency for Health
Care Policy and Research, Food and Drug Administration, and
National Library
of Medicine. Independent evaluation and opinion by Board Certified Physicians
who are professors, associate professors, or
assistant professors of
medicine at recognized United States Medical Schools may be obtained for their
expertise in subspecialty areas.
Group health coverage Health care coverage that a member or covered
dependent is eligible for because of employment by, membership in, or connection
with, a
particular organization or group that provides payment for hospital,
medical, dental or other health care services or supplies, including
extension of any of these benefits through COBRA.
Infertility The inability to conceive after a year of unprotected
intercourse or the inability to carry a pregnancy to term.
Intensive day treatment Outpatient treatment of mental condition or
substance abuse rendered at and billed by a facility that meets the definition
of a hospital.
Treatment program must be established which consists of
individual or group psychotherapy and/ or psychological testing.
Medical necessity Services, drugs, supplies or equipment provided by a
hospital or covered provider of the health care services that the Plan
determines:
(1) are appropriate to diagnose or treat the patient's
condition, illness or injury;
(2) are consistent with standards of good
medical practice in the United States;
(3) are not primarily for the
personal comfort or convenience of the patient, the family, or the provider,
(4) are not a part of or associated with the scholastic education or
vocational training of the patient; and
(5) 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. 85
85 Page
86 87
2002 GEHA 86 Section 10
Mental health/ Conditions and diseases listed in the most recent
edition of the Substance abuse International Classification of Diseases
(ICD) as psychoses, neurotic
disorders, or personality disorders; other
nonpsychotic mental disorders listed in the ICD, to be determined by the Plan;
or disorders listed in
the ICD requiring treatment for abuse or dependence
upon substances such as alcohol, narcotics, or hallucinogens.
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 Plan
allowance as follows:
We consult standard industry guides, such as national databases of prevailing
health care charges from Ingenix. We use the 70 th percentile.
This means
that out of every 100 reports, 30 charges billed may be more, but 70 charges
will be the allowed amount or less. Charges
determined in this way include,
but are not limited to, surgery, doctor's services, physical therapy, speech
therapy, occupational therapy, lab
testing and X-ray expenses; and under the
Standard Option diagnostic and preventive dental services. Some Plan allowances
are stated in this
brochure. These include limited benefits such as
chiropractic care and routine dental care.
Some Plan allowances may be submitted to medical consultants who recommend
allowances based on special industry guidelines. We may
also conduct
independent surveys to determine the usual cost of a service or supply in a
geographic area.
If we negotiate a reduced fee amount on an individual claim for services or
supplies which is lower than the Plan allowance, covered
benefits will be
limited to the negotiated amount. Your coinsurance will be based on the reduced
fee amount. If you choose to use a
provider other than the one we negotiated
a reduction with, you will be responsible for the difference in these amounts.
Our PPO allowances are negotiated with each provider who participates in the
network. PPO allowances may be based on a standard reduction
or on a
negotiated fee schedule. For these allowances, the PPO provider has agreed to
accept the negotiated reduction and you are not
responsible for this
discounted amount. In these instances, the benefit paid plus your coinsurance
equals payment in full.
For more information, see Differences between our allowance and the bill
in Section 4.
Primary care physician For purposes of the office visit copayment for
the Standard Option benefits, primary care physicians are individual doctors (M.
D. or D. O.)
whose medical practice is limited to Family/ General Practice,
Internal Medicine, Pediatrics/ Adolescent Medicine or Obstetrics/ Gynecology
(OB/ Gyn). Doctors listed in provider directories or advertisements under
any other medical specialty or sub-specialty area (such as
Internal Medicine
doctors also listed under Cardiology or Geriatrics, or Pediatric sub-specialties
such as Pediatric Allergy) are considered
specialists, not primary care
physicians. Chiropractors, eye doctors, dentists, and mental health/ substance
abuse providers are not
considered primary care physicians. 86
86 Page 87 88
2002 GEHA 87 Section 10
Sound
natural tooth Sound and Natural Tooth is a whole or properly restored tooth
that has no condition that would weaken the tooth, or predispose it to injury,
prior to the accident, such as decay, periodontal disease, or other
impairments. For purposes of the Plan, damage to a restoration, such as
a
prosthetic crown or prosthetic dental appliances (i. e. bridgework), would not
be covered as there is no injury to the natural tooth structure.
Us/ We Us and we refer to Government Employees Hospital Association,
Inc.
You You refers to the enrollee and each covered family member.
87
87 Page 88 89
2002 GEHA 88 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing
or retirement office about enrolling in the can answer your questions and
give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self
Only coverage is for you alone. Self and Family coverage is for for you and
your family you, your spouse, and your unmarried dependent children under
age 22,
including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you
may also continue coverage for a disabled child 22 years of age or older who is
incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period
in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please
tell us immediately when you add or remove family members from your coverage for
any reason, including divorce, or when your child
under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by another
FEHB plan. 88
88 Page
89 90
2002 GEHA 89 Section 11
When benefits and The benefits in this brochure are effective on
January 1. If you joined this premiums start 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 We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as
other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage
ends You will receive an additional 31 days of coverage, for no additional
premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB
coverage under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact
your ex-spouse's employing or retirement
office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans
for Temporary
Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage choices.
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no of Coverage (TCC) 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. 89
89 Page
90 91
2002 GEHA 90 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 You may convert to a non-FEHB
individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled your
coverage or did not pay your premium, you cannot
convert);
You decided
not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days
after you receive
this notice. However, if you are a family member who is losing coverage, the
employing or retirement office will not notify
you. You must apply in
writing to us within 31 days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health and we
will
not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 Group Health Plan Coverage (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 web site (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.
2002 GEHA 91 Long Term Care Insurance
Long Term Care
Insurance Is Coming Later in 2002!
The Office of Personnel Management
(OPM) will sponsor a high-quality long term care insurance program effective in
October 2002. As part of its educational effort, OPM asks you to consider these
questions:
What is long term care (LTC) insurance?
It's insurance
to help pay for long term care services you may need if you can't take care of
yourself because of an extended illness or injury, or an age-related disease
such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for care in a nursing
home, in an assisted living facility, in your home, adult day care, hospice
care, and more. Long term care insurance can supplement care provided by
family
members, reducing the burden you place on them.
I'm
healthy. I won't need long term care. Or, will I?
76% of Americans
believe they will never need long term care, but the facts are that about half
of them will. And it's not just the 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 multiple sclerosis, etc. We
hope you will never need long term care, but you should have a plan just in
case. LTC insurance may be vital to
your financial and retirement
planning.
Is long term care expensive?
Yes. A year in a
nursing home can exceed $50,000 and only three 8-hour shifts a week can exceed
$20,000 a year, that's before inflation!
LTC can easily exhaust your savings but LTC insurance can protect it.
But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look at "Not covered" in sections 5( a) and 5( c) of
your FEHB brochure. Custodial care, assisted living, or continuing home health
care for activities of daily living are not covered. Limited stays in skilled
nursing facilities can
be covered in some circumstances. Medicare only
covers skilled nursing home care after a hospitalization with a 100 day limit.
Medicaid covers LTC for those who meet their state's guidelines, but
restricts covered services and where they can be received. LTC insurance can
provide choices of care and preserve your independence.
When will I get more information?
Employees will get more
information from their agencies during the late summer/ early fall of 2002.
Retirees will receive information at home.
How can I find out more about the program NOW?
A toll-free
telephone number will begin in mid-2002. You can learn more about the program
now at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare covers
long-term care. Unfortunately, they are WRONG!
How are YOU planning
to pay for the future custodial or chronic care you may need? Consider buying
long term care insurance. 91
91 Page 92 93
2002 GEHA 92 Department of Defense
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 Commonwealth of Puerto Rico Fort
Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt
County, CA area New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair
County, IA area Coffee County, GA area
When you can join You may
enroll under the FEHB/ DoD Demonstration Project during the 2001 open season,
November 12, 2001, through December 10, 2001. Your coverage
will begin
January 1, 2002. DoD has set-up an Information Processing Center (IPC) in Iowa
to provide you with information about how to enroll. IPC staff
will verify
your eligibility and provide you with FEHB Program information, plan brochures,
enrollment instructions and forms. The toll-free phone number
for the IPC is
1-877/ DOD-FEHB (1-877/ 363-3342).
You may select coverage for yourself
(Self Only) or for you and your family (Self and Family) during open season.
Your coverage will begin
January 1, 2002. If you become eligible for the
DoD/ FEHB Demonstration Project outside of open season, contact the IPC to find
out how to enroll and
when your coverage will begin.
DoD has a web site
devoted to the Demonstration Project. You can view information such as their
Marketing/ Beneficiary Education Plan, Frequently
Asked Questions, demonstration area
locations and zip code lists at www. tricare. osd. mil/ fehbp. You can also
view information about the
demonstration project, including "The 2002
Guide to Federal Employees Health 92
92 Page 93 94
2002 GEHA 93 Department of Defense
Benefits Plans Participating in the DoD/ FEHB Demonstration
Project," on the OPM web site at www. opm. gov.
Temporary
Continuation See Section 11, FEHB Facts; it explains Temporary Continuation
of Coverage 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. 93
93 Page 94 95
2002 GEHA 94 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 38, 50, 83 Abortion 24, 72
Allergy tests 26 Allogeneic (donor) bone marrow
transplant 39
Alternative treatment 33
Ambulance 49, 51, 52 Ambulatory surgical center 47
Anesthesia 42 Artificial insemination 25
Assignment 83 Assisted
reproductive technology 25
Autologous bone marrow transplant 39
Biopsies 35 Blood and blood plasma 44, 45, 47
Breast cancer
screening 23 Breast Prosthesis 30
Calendar year deductible 15, 56, 59
Casts 44, 47 Catastrophic
protection 16, 17, 56, 59 Changes for 2002 8, 9
Chemotherapy 26, 41, 42
Childbirth 24, 45, 46, 47, 88
Chiropractic 32 Cholesterol tests 23
Claims 74, 75 Coinsurance 15, 83
Colorectal cancer screening 23
Congenital anomalies 35, 37, 83
Contact lenses 29 Contraceptive devices and
drugs 25, 64 Conversion 89, 90
Coordination of benefits 78-82 Cosmetic
surgery 37, 83
Cost containment 12, 13, 14 Covered charges 83
Covered
facility 10,11 Covered providers 10
Crutches 30 Custodial care 32, 83
Days certified 12, 13, 14 Deductible 15, 56, 59, 84
Definitions
83-87 Dental care 68, 69
Department of Defense (DoD) Demonstration Project
92, 93
Diabetic supplies 62, 64 Diagnostic services 21, 54
Disputed
claims review 76, 77
Donor expenses (transplants) 40, 42 Dressings 44, 45, 47
Durable medical
equipment 30, 31, 84
Educational classes and programs 33 Effective date of enrollment 84
Emergency 22, 50, 51, 52 Environmental medicine 26, 33
Experimental or
investigational 84 Eye exams 23, 29
Eyeglasses 29
Family limit 15
Family planning 25
Fecal occult blood test 23 Flexible benefits option 67
Foot care 29
Freestanding ambulatory
facilities 47
Gamete intrafallopian
transfer (GIFT) 25
General Exclusions 72, 73
Hearing services 28 Home health services
31, 32
Home uterine devices 24 Hospice care 11, 48
Home delivery pharmacy
service 61 -66
Home nursing care 31, 32 Hospital 11, 12, 43-47
Immunizations 23 Impacted teeth 38
Incidental procedures 36
Infertility 25, 85
Inhospital physician care 22, 54, 58 Inpatient Hospital
Benefits 44-46
Insulin 62, 64 Intensive day treatment 57, 85
Laboratory and pathological services 22
Lifetime maximums 29, 31,
57, 59 Long Term Care 70, 91
Magnetic Resonance Imagings (MRIs) 22
Mammograms 23 Maternity
Benefits 24, 45, 46, 47
Medicaid 82 Medical necessity 85
Medically
underserved areas 10 Medicare 18, 19, 78, 79, 80, 81
Members 4, 87 Mental Health/ Substance Abuse
Benefits 53-60, 86
Newborn care 23, 24 No-Fault 78, 82
Non-FEHB Benefits 70, 71
Nurse
Licensed Practical Nurse 31 Nurse Anesthetist 10
Nurse Midwife 10
Nurse Practitioner 10
Registered Nurse 31 Nursery charges 24, 45
Nursing
School Administered Clinic 10
Obstetrical care 24 Occupational therapy 27
Ocular injury 29
Office visits 21
Oral and maxillofacial surgery 38 Oral contraceptives 62,
64
Organ/ tissue transplant 39, 40, 41, 42
Orthopedic devices 30 Ostomy
and catheter supplies 62,
64 Out-of-pocket expenses 15, 16,
17, 56, 59
Outpatient facility care 47
Overseas claims 75 Oxygen 44, 45, 47
Pap test 22, 23 Physical examination 21
Physical therapy 27
Physician 10, 86
Plan allowance 16, 86 Pre-admission testing 47
Precertification 12, 13, 14, 53, 57 Preferred Provider Organization
(PPO) 6, 16, 17 Prescription drugs 61-66
Preventive care, adult 23
Preventive care, children 23
Prior approval 14 Private room 44
Prostate
cancer screening 23 Prosthetic devices 30, 37
Psychologist 54 Psychotherapy
54, 58 94
94 Page
95 96
2002 GEHA 95 Index
Radiation therapy 26 Renal dialysis 26
Room and board 44, 45,
46, 48 Routine services 23
Second surgical opinion 21, 41 Sigmoidoscopy 23
Skilled nursing
facility care 27, 47 Smoking cessation 33
Social Worker 54 Speech therapy 28
Splints 44 Sterilization procedures 25, 36
Subrogation 82 Substance
abuse 53-60, 86
Surgery 34 Anesthesia 42
Assistant surgeon 35 Multiple
procedures 36
Oral 38 Reconstructive 35, 37
Syringes 62, 64
Temporary continuation of coverage 89, 90
Temporomandibular
Joints 38, 73 Transplants 39-42
Treatment therapies 26
Vision
services 23, 29, 31, 70 Vitamins 70
Well child care 23 Wheelchairs 30
Workers' compensation 81
X-rays 22, 68 95
95 Page 96 97
2002 GEHA
96 Summary
Summary of benefits for GEHA – Standard Option 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 $450 calendar year deductible.
And, after we pay, you generally pay any difference between our allowance and
the billed amount if you use a Non-PPO physician or
other health care
professional.
Benefits You Pay Pages
Medical services provided by
physicians: Diagnostic and treatment services
provided in the office ……………..
PPO: $10 copay primary care physician; $25
copay specialist for covered office visits and 15%* of other covered
professional services including X-ray and lab
Non-PPO: 35%* of covered
professional services
21-42
Services provided by a hospital: Inpatient …………………………..
Outpatient
………………………….
PPO: 15%* of covered hospital charges
Non PPO: 35%* of
covered hospital charges
43-49
Emergency benefits: Accidental injury
Medical emergency
other
professional services …………
Nothing up to plan allowance of covered charges incurred within 72 hours of
an accident
Regular benefits*
50-52
Mental health and substance abuse treatment …………………………….. In-Network: Regular
cost sharing Out-of-Network: Benefits are limited 53-60
Prescription drugs
…………………… Network pharmacy: Member pays $5 for generic drugs/ 50% brand name for
up to 30 day supply.
Non-network pharmacy: Member pays $5 for generic drugs/ 50% brand name and
any difference between our
allowance and the cost of the drug.
By mail:
Member pays $15 for generic drugs/ 50% brand name for 90-day supply
61-66
Dental Care ………………………….. 50% up to plan allowance for diagnostic and
preventive services and charges in excess of the scheduled amounts for
restorations and extractions
68-69
Special features: Flexible benefits option, services for deaf and hearing
impaired, high-risk pregnancies 67
Protection against catastrophic costs
(your out-of-pocket maximum) ……… Nothing after $4000/ Self Only or $4,500/
Family enrollment per year for PPO providers;
Nothing after $5,000/ Self Only or $5,500/ Family enrollment per year for
Non-PPO providers.
Some costs do not count toward this protection
16-17 96
96 Page
97 98
2002 GEHA 97 Summary
Summary of benefits for GEHA – High Option 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 $300 calendar year
deductible. And, after we pay, you
generally pay any difference between our
allowance and the billed amount if you use a Non-PPO physician or other health
care professional.
Benefits You Pay Pages
Medical services provided by physicians:
Diagnostic and treatment services
provided in the office …………….
PPO: $15 copay per covered office visit and
10%* of other covered professional services including x-ray and lab
Non-PPO: 25%* of covered professional services
21-42
Services provided by a hospital: Inpatient ………………………….
Outpatient*
………………………
PPO: Nothing for room and board, 10% of other hospital charges
Non-PPO: Nothing for room and board, 25% of other hospital charges
43-49
Emergency benefits: Accidental injury …………………
Medical emergency
other
professional services ……….
Nothing up to plan allowance of covered charges incurred within 72 hours of
an accident
Regular benefits*
50-52
Mental health and substance abuse treatment …………………………….. In-Network: Regular
cost sharing Out-of-Network: Benefits are limited 53-60
Prescription drugs
…………………… Network pharmacy: Member pays $5 for generic drugs/$ 15 single-source
brand name/$ 30 multi-source brand name for
up to 30 day supply for the
initial fill and first refill. Subsequent fills are the greater of 50% or the
copays listed
above.
Non-network pharmacy: Member pays $5 for generic
drugs/$ 15 single-source brand name/$ 30 multi-source brand
name for up to a 30 day supply for the initial fill and first refill and any
difference between our allowance and the cost
of the drug. Subsequent fills
are the greater of 50% or the copays listed above and any difference between our
allowance and the cost of the drugs.
By mail: Member pays $10 for
generic drugs/ $35 single-source brand name/$ 50 multi-source brand name for
90-day
supply.
61-66
Dental Care ………………………….. Charges in excess of the scheduled amounts for
diagnostic and preventive services, restorations, and extractions 68-69
Special features: Flexible benefits option, services for deaf and hearing
impaired, high-risk pregnancies 67
Protection against catastrophic costs
(your out-of-pocket maximum) ……… Nothing after $3,000/ Self Only or $3,500/
Family enrollment per year for PPO providers;
Nothing after $4,000/ Self Only or $4,500/ Family enrollment per year for Non
PPO providers.
Some costs do not count toward this protection
16-17 97
97 Page
98
2002 Rate Information for Government Employees Hospital
Association, Inc. (GEHA)
Benefit Plan
Non-Postal rates apply to most
non-Postal enrollees. If you are in a special enrollment category, refer to the
FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply
and special FEHB guides are published for
Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
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
High Option
Self Only 311 $97.86 $59.70 $212.03 $129.35 $115. 52
$42.04
High Option
Self and Family 312 $223.41 $119.50 $484.06 $258.91 $263.
75 $79.16
Standard Option
Self Only 314 $82.50 $27.50 $178.75 $59.58 $97.63
$12.37
Standard Option
Self and Family 315 $187.50 $62.50 $406.25 $135.42
$221.88 $28.12 98