Serving: Chicago Area
Enrollment in this Plan is limited; see page 5
for requirements.
Enrollment codes for this Plan:
761 Self Only 762 Self and Family
For changes
in benefits
see page 6
2002 Union Health Service 2 Table of Contents
Table of
Contents
Introduction
...................................................................................................................................................................
4
Plain Language
................................................................................................................................................................
4
Inspector General
Advisory.............................................................................................................................................
4
Section 1. Facts about this HMO
plan............................................................................................................................
5
How we pay
providers...................................................................................................................................
5
Your Rights
...................................................................................................................................................
5
Service Area
..................................................................................................................................................
5
Section 2. How we change for 2002
.............................................................................................................................
6
Program-wide changes
..................................................................................................................................
6
Changes to this Plan
......................................................................................................................................
6
Section 3. How you get
care...........................................................................................................................................
7
Identification cards
........................................................................................................................................
7
Where you get covered care
..........................................................................................................................
7
Plan providers
.........................................................................................................................................
7
Plan
facilities...........................................................................................................................................
7
What you must do to get covered care
..........................................................................................................
7
Primary care
............................................................................................................................................
7
Specialty care
..........................................................................................................................................
7
Hospital care
...........................................................................................................................................
8
Circumstances beyond our control
................................................................................................................
9
Services requiring our prior
approval............................................................................................................
9
Section 4. Your costs for covered services
..................................................................................................................
10
Copayments...........................................................................................................................................
10
Deductible
.............................................................................................................................................
10
Coinsurance...........................................................................................................................................
10
Your out-of-pocket
maximum.....................................................................................................................
10
Section 5.
Benefits........................................................................................................................................................
11
Overview
.....................................................................................................................................................
11
(a) Medical services and supplies provided by
physicians and other health care professionals ........... 12
(b) Surgical and anesthesia services provided by physicians and
other health care professionals........ 20
(c)
Services provided by a hospital or other facility, and ambulance
services...................................... 24
(d)
Emergency services/ accidents
..........................................................................................................
27
(e) Mental health and substance abuse
benefits.....................................................................................
29
(f) Prescription drug
benefits.................................................................................................................
31
(g) Special
features.................................................................................................................................
33
(h) Dental
benefits..................................................................................................................................
34
(i) Non-FEHB benefits available to Plan
members...............................................................................
35 2
2 Page 3 4
2002 Union Health Service 3 Table of Contents
Section 6. General exclusions --things we don't cover
..............................................................................................
36
Section 7. Filing a claim for covered services
.............................................................................................................
37
Section 8. The disputed claims
process........................................................................................................................
39
Section 9. Coordinating benefits with other
coverage
.................................................................................................
41
When you have…
Other health coverage
............................................................................................................................
41
Original Medicare
..................................................................................................................................
41
Medicare managed care plan
.................................................................................................................
43
TRICARE/ Workers' Compensation/
Medicaid............................................................................................
44
Other Government agencies
........................................................................................................................
44
When others are responsible for
injuries.....................................................................................................
44
Section 10. Definitions of terms we use in this
brochure.............................................................................................
45
Section 11. FEHB facts
................................................................................................................................................
46
Coverage
information..................................................................................................................................
46
No pre-existing condition
limitation.....................................................................................................
46
Where you get information about enrolling in the
FEHB Program...................................................... 46
Types of coverage available for you and your family
..........................................................................
46
When benefits and premiums
start........................................................................................................
47
Your medical and claims records are
confidential................................................................................
47
When you
retire....................................................................................................................................
47
When you lose benefits
...............................................................................................................................
47
When FEHB coverage
ends..................................................................................................................
47
Spouse equity coverage
.......................................................................................................................
47
Temporary Continuation of Coverage
(TCC)......................................................................................
47
Converting to individual
coverage.......................................................................................................
48
Getting a Certificate of Group Health Plan Coverage
......................................................................... 48
Long term care is coming later in
2002.........................................................................................................................
49
Index
.................................................................................................................................................................
50
Summary of benefits
.....................................................................................................................................................
51
Rates
..................................................................................................................................................
Back Cover 3
3 Page
4 5
2002 Union Health Service 4 Introduction/ Plain Language
Introduction
Union Health Service, 1634 West Polk Street,
Chicago, Illinois 60612
This brochure describes the benefits of Union Health
Service under our contract (CS 1571) with the Office of
Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This brochure
is the
official statement of benefits. No oral statement can modify or
otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1 2002, and
changes are summarized on page 6. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and 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 Union Health Service
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 a comment or suggestion about how to improve the
structure of this brochure, let us know. Visit OPM's "Rate Us" feedback area at
www. opm. gov/ insure or email us at
fehbwebcomments@ opm. gov.
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 312/ 829-4224
ext. 3359 and
explain the situation.
If we do not resolve the issue, call THE HEALTH
CARE FRAUD HOTLINE--202/ 418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud
Hotline, 1900
E Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 4
4 Page 5 6
2002 Union Health
Service 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and
other providers that contract with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We employ individual physicians, own and
operate our medical centers, and contract with hospitals to provide the
benefits in this brochure. These individual physicians are salaried
employees. Other Plan providers accept a
negotiated payment from us. You
will only be responsible for your copayments or coinsurance.
UHS is a Staff Model Group Practice Plan that employs its doctors. All
doctors are either Board certified or eligible
in their specialties and are
affiliated with some of the area's finest hospitals.
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.
Union Health Service is a staff model not-for– profit Health Maintenance
Organization. Union Health Service is a
state certified HMO. We were
established in 1955.
If you want more information about us, call our Member Service Department at
312 829-4224 ext. 3377, or write to
Union Health Service, 1634 West Polk
Street, Chicago, IL 60612. You may also contact us by fax at 312/ 423-4380.
Service Area
To enroll with us, you must live or work in our
service area. This is where our providers practice. Our service area is:
The
Chicago Area located in Cook and DuPage counties, Illinois
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 5
5 Page
6 7
2002 Union Health Service 6
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5
Benefits. Also we edited and clarified language
throughout the brochure; any language change not shown here is a
clarification that does not change your benefits.
Program-wide changes
We removed the requirement that services must
be needed to restore functional speech from the speech therapy benefit (Section
5 (a))
Changes to this Plan
Your share of the non-Postal premium will
increase 8.2% for Self Only or 8.2 % for Self and Family.
The copayment for prescription drugs will increase to $10 per prescription
unit or refill from $5 per prescription unit or refill.
We now cover certain intestinal transplants (Section 5 (b)) 6
6 Page 7 8
2002 Union Health Service 7 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it
whenever you receive services from a
Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive
your ID card, use your copy of the
Health Benefits Election Form, SF-2809,
your health benefits enrollment
confirmation (for annuitants), or your
Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call our Member
Service Department at 312 829-4224 ext. 3377
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and deductibles. You will not
have to file claims.
Plan providers Plan providers are physicians and other health care
professionals in our group that we employ to provide covered services to our
members. We
credential Plan providers in accordance with national standards.
We list Plan providers in the provider directory, which we update
periodically.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for
most of your health care. The UHS Physicians
Directory lists all primary
care physicians and specialists. The UHS Member
Service Department
can assist you if you have questions.
Primary care Your primary care physician can be a family
practitioner, internist, pediatrician, or obstetrician/ gynecologist (OB-GYNE).
Your primary
care physician will provide most of your health care, or
give you a
referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must
return to the primary care physician after the
consultation, unless your
primary care physician authorized a certain number
of visits without
additional referrals. The primary care physician must
provide or
authorize all follow-up care. Do not go to the specialist for
return visits
unless your primary care physician gives you a referral.
However, a
woman may see her Plan OB-GYNE without a referral.
Here are other things you should know about specialty care:
If you need to see a participating specialist frequently because of a
chronic, complex, or serious medical condition, your primary care 7
7 Page 8 9
2002 Union Health Service 8 Section 3
physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals.
Your primary care physician will use our criteria when creating your
treatment plan.
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment
from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another
specialist.
You may receive services from your current specialist
until we can make
arrangements for you to see someone else. Contact
us.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB)
Program and
you enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days
after you receive
notice of the change. Contact us, or if we drop out of
the Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the
hospital when your enrollment in our Plan begins, call
our Medical
Management Department immediately at 312 829-4224
ext. 3210. If you are new
to the FEHB Program, we will arrange for you
to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 8
8 Page 9 10
2002 Union Health Service 9 Section 3
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our Your primary care physician has authority to
refer you for internal prior approval services. For external services,
however, your physician must obtain
approval from us. Before giving
approval, we consider if the service is
covered, medically necessary, and
follows generally accepted medical
practice.
Our Medical Director must approve your referral to an outside specialist
before you receive treatment. When you receive a referral from your
primary care physician to an outside specialist, you must return to the
primary care physician after the consultation. Your primary care
physician must provide or authorize all follow-up care. On outside
referrals, your primary care physician will give specific instructions to
the specialist as to what services are authorized. If the specialist
suggests
additional services or visits, you must check with your primary
care
physician for approval and authorization. Do not go to the outside
specialist unless your primary care physician has arranged for and the
Plan has issued an authorization for the referral in advance. 9
9 Page 10 11
2002 Union Health Service 10 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit.
Deductible A deductible is a fixed expense you must incur for certain
covered services and supplies before we start paying benefits for them.
Copayments do not
count toward any deductible. UHS has a deductible for
orthopedic and
prosthetic devices and durable medical equipment, see page
18, otherwise
we do not have a deductible.
NOTE: If you change plans during open season, you do not have to start a
new deductible under you old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the year,
you must begin a new deductible under your new plan.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care. Coinsurance doesn't begin until you meet your
deductible.
In our Plan, you pay 20% of our allowance for orthopedic and prosthetic
devices and for durable medical equipment.
Your out-of-pocket maximum Your out-of-pocket expenses for benefits
covered under this Plan are for deductibles and copayments limited to the
stated copayments and deductibles required for a few
benefits. 10
10 Page 11 12
2002 Union Health Service 11 Section 5
Section 5. Benefits – OVERVIEW
(See page 6 for how our
benefits changed this year and page 51 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 advice, or more information
about our benefits, contact our Member Service
Department at 312 829-4224
ext. 3377.
(a) Medical services and supplies provided by physicians and
other health care professionals……………….. 12-19
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 therapies
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 ....................... 20-23
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services...................................................... 24-26
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/
accidents..........................................................................................................................
27-28
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
....................................................................................................
29-30
(f) Prescription drug benefits
................................................................................................................................
31-32
(g) Special features
......................................................................................................................................................
33
Not for Profit Organization 24 hour emergency line High risk pregnancies
Centers of excellence for transplants/ heart surgery/ etc Translation
Services Urgent Care
Continuity of Care Staff Model
(h) Dental benefits
.......................................................................................................................................................
34
(i) Non-FEHB benefits available to Plan members
....................................................................................................
35
Summary of benefits
.....................................................................................................................................................
51 11
11 Page 12
13
2002 Union Health Service 12 Section 5(
a)
Section 5 (a) Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have deductibles
for prosthetic and orthopedic devices and durable medical equipment
Be sure
to read Section 4, Your costs for covered service, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other
coverage, including Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
After the calendar year deductible…
Diagnostic and treatment services
Professional services of
physicians
In physician's office
In an urgent care center
Office
medical consultations
Second surgical opinion
$10 per visit
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
Nothing
At home $10 per visit
Diagnostic and treatment services --Continued on
next page 12
12 Page
13 14
2002 Union Health Service 13
Section 5( a)
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – once every three years, ages 19 through 64
Colorectal
Cancer Screening, including
-Fecal occult blood test
Nothing
-Sigmoidoscopy, screening – every five years starting at age 50 $10 per visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
$10 per visit
Routine pap test
Note: The office visit is covered if pap
test is received on the same day;
see Diagnosis and Treatment, above.
$10 per visit
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
Nothing.
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
Charges
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per visit 13
13 Page
14 15
2002 Union Health Service 14
Section 5( a)
Preventive care, children You pay
Childhood
immunizations recommended by the American Academy of Pediatrics $10 per visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
-Eye exams through age 17 to determine
the need for vision
correction.
-Ear exams through age 17 to determine the need for hearing
correction
-Examinations done on the day of immunizations (up to age 22)
$10 per visit
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things
to keep in mind:
You do not need prior approval for your normal delivery; see page 26 for
other circumstances, such as extended stays for you or your
baby.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care
of the newborn child during the covered portion of the mother's maternity stay.
We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$10 per visit
Not covered: Routine sonograms to determine fetal age, size or sex All
charges 14
14 Page
15 16
2002 Union Health Service 15
Section 5( a)
Family planning You pay
A broad range of
voluntary family planning services, such as;
Voluntary sterilization
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral
contraceptives under the prescription drug
benefit
$10 per visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges.
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
-intravaginal insemination (IVI)
-intracervical insemination (ICI)
-intrauterine insemination (IUI)
Fertility drugs are covered as mandated by the State of Illinois.
Other
assisted reproductive technology (ART) procedures that enable a woman with
otherwise untreatable infertility to become pregnant
through artificial conception procedures such as in vitro fertilization
and embryo transfers including medical examinations in accordance
with
the limitations specified in the State of Illinois mandated benefits.
Note: The State of Illinois has limitations on the number of ART
procedures.
$10 per visit
Not covered:
Cost of donor sperm
Assisted
reproductive technology (ART) procedures, such as:
-in vitro fertilization
-embryo transfer and GIFT
Services and supplies related to excluded ART
procedures
All charges.
Allergy care
Testing and treatment $10 per visit 15
15 Page 16 17
2002 Union Health Service 16 Section 5( a)
Allergy serum
Allergy injection
Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges.
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 22.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when the treatment is authorized by
the
Medical Director. We will ask your primary care physician to
submit
information that establishes that the GHT is medically
necessary.
Authorization must be given before you begin GHT
treatment; otherwise, we
will only cover GHT services from the date of
approval. 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.
Growth Hormone therapy is covered under the plan's medical benefits.
$10 per visit
Physical and Occupational therapies
60 treatments per condition
for the services of each of the following:
-licensed physical therapists;
-occupational therapists.
Note: We
only cover short-term therapy to restore bodily function
when there has been
a total or partial loss of bodily function due to
illness or injury.
Occupational therapy is limited to services that
assist the member to
achieve and maintain self-care and improved
functioning in other activities
of daily living.
Cardiac rehabilitation following a heart transplant, bypass
surgery or a
myocardial infarction, is provided for up to 30
sessions.
$10 per visit
Not covered:
long-term rehabilitative therapy
exercise programs
All charges. 16
16 Page 17 18
2002 Union
Health Service 17 Section 5( a)
Speech therapy You Pay
60 treatments per condition upon approval of the Plan's Medical
Director. $10 per visit
Not covered:
therapy that will not result in improvement to
your condition within 60 visits
All charges
Hearing services (testing, treatment, and supplies) You Pay
Hearing testing only when necessitated by accidental injury
Hearing
testing for children through age 17 (see Preventive care, children)
$10 per visit
Not covered:
all other hearing testing hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
In addition to
the medical and surgical benefits provided for diagnosis
and treatment of
diseases of the eye, you may obtain one annual eye
refraction (which
includes the written lens prescription).
$10 per visit
Eye exam to determine the need for vision correction for children through age
17 (see preventive care)
Annual eye refractions
$10 per visit
Not covered:
Eyeglasses or contact lenses.
Eye
exercises and orthoptics
Radial keratotomy and other refractive
surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained, flat feet,
bunions or spurs; and of any instability, imbalance or subluxation of the foot
(unless the
treatment is by open cutting surgery)
All charges. 17
17 Page 18 19
2002 Union
Health Service 18 Section 5( a)
Orthopedic and prosthetic
devices You pay
Artificial limbs and eyes; stump hose
Externally
worn breast prostheses and surgical bras, including necessary replacements,
following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant following
mastectomy.
Note: See 5( b) for coverage of the surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
20% of charges after you pay the
calendar year deductible.
$100 deductible per member per
calendar year (maximum $300
family
deductible).
Not covered:
Orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
All charges.
Durable medical equipment (DME)
Purchase or rental (up to the
purchase price), at our option, including
repair and adjustment, of durable
medical equipment prescribed by your
Plan physician as medically necessary,
such as oxygen and dialysis
equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs
crutches
walkers;
blood glucose
monitors; and
insulin pumps.
Note: Call our Medical Management Department at 312 829-4224 ext.
3210 as
soon as your Plan physician prescribes this equipment. We will
arrange with
a health care provider to rent or sell you durable medical
equipment at
discounted rates and will tell you more about this service
when you call.
20% of charges after you pay the
calendar year deductible.
$100 deductible per member per
calendar year (maximum $300
family
deductible.
Not covered:
Motorized wheel chairs Equipment that is
not medically necessary All charges. 18
18
Page 19 20
2002
Union Health Service 19 Section 5( a)
Home health services You
Pay
Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), or home
health aide.
Services include oxygen therapy, intravenous therapy and
medications.
Home health care is provided for homebound members at their home when
prescribed by a Plan physician.
Note: Our Medical Management Department will
monitor all home
health care.
$10 per visit
Not covered:
Nursing care requested by, or for the convenience
of, the patient or the patient's family;
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges.
Alternative treatments
No benefit for services such as:
Acupuncture Naturopathic services
Hypnotherapy Biofeedback
All charges.
Chiropractic
Your UHS Orthopedic physician may refer you for a
chiropractic
consultation or chiropractic care.
Note: You must receive prior approval from the Plan's Medical Director to
receive chiropractic services. The Plan's medical director will review your
chiropractor's treatment plan after your receive your consultation. (See
section 3 for services requiring prior approval)
$10 per visit 19
19 Page
20 21
2002 Union Health Service 20
Section 5( b)
Section 5 (b). Surgical and anesthesia services
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We only have
deductibles for prosthetic and orthopedic devices and durable medical equipment
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
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
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information and services requiring our prior
approval shown in Section 3 to be sure which services require
precertification or prior approval.
I M
P O
R T
A N
T
Benefit Description You pay
After the calendar year deductible…
Surgical procedures
A comprehensive range of services and
operative procedures, such as:
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy
procedures Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery) Surgical treatment of morbid obesity --a condition
in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members
must be age 18 or over. Surgery for morbid obesity
should be performed only
as a last resort, when the member's
health is endangered and more
conservative medical measures,
including prescription drugs such as appetite
suppressants, have
not been successful.
Insertion of internal prosthetic devices such as pacemakers and artificial
joints. See 5( a) – Orthopedic and prosthetic devices for
device coverage information.
$10 per visit; nothing for hospital
visits
Surgical procedures continued on next page. 20
20 Page 21 22
2002 Union Health Service 21 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization Treatment of burns $10 per visit
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care. All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the
condition produced a major effect on the member's
appearance and
-the condition can reasonably be expected to be corrected by such
surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; or webbed toes.
$10 per visit; nothing for hospital
visits
All stages of breast reconstruction surgery following a mastectomy, such as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast
prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
$10 per visit; nothing for hospital
visits
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges 21
21 Page 22 23
2002 Union
Health Service 22 Section 5( b)
Oral and maxillofacial surgery
You Pay
Oral surgical procedures, limited to:
Reduction of fractures
of the jaws or facial bones; Surgical correction of cleft lip, cleft palate;
Removal of stones from salivary ducts; Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abcesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
$10 per visit; nothing for hospital
visits
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
Shortening of the mandible or maxillae for cosmetic purposes,
correction of malocclusion, and any other dental care involved in
treatment of temporomandibular joint (TMJ) pain dysfunction
syndrome.
All charges.
Organ/ tissue transplants
Limited to:
Cornea
Heart
Kidney
Liver
Allogeneic (donor) bone marrow transplants;
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors (autologous bone marrow
transplants limited to non-random
clinical trials)
Intestinal transplants (small intestine) and small intestine with the liver
or small intestine with multiple organs such as the liver,
stomach, and pancreas
Limited Benefits -Treatment for breast cancer,
multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or
NIH-approved
clinical trial at a Plan-designated center of excellence and if
approved
by the Plan's Medical Director in accordance with the Plan's
protocols.
Note: Transplants must be approved by the Medical Director. We will
refer
you to a specific treatment location. We cover related medical and
hospital
expenses of the donor when we cover the recipient.
$10 per visit; nothing for hospital
visits.
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges 22
22 Page 23 24
2002 Union
Health Service 23 Section 5( b)
Anesthesia You pay
Professional services provided in –
Hospital (inpatient) Hospital outpatient department
Skilled nursing
facility Ambulatory surgical center
Office
Nothing 23
23 Page
24 25
2002 Union Health Service 24
Section 5( c)
Section 5 (c). Services provided by a hospital or
other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in
Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 (services requiring our approval) to be sure
which services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
Ward, semiprivate, or intensive care accommodations; General nursing
care; and
Meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 24
24 Page 25 26
2002 Union Health Service 25 Section 5( c)
Inpatient hospital (Continued) You pay
Other
hospital services and supplies, such as:
Operating, recovery, maternity, and
other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Medical
supplies, appliances, medical equipment, and any covered items billed by a
hospital for use at home (Note: calendar year
deductible applies to durable
medical equipment and prosthetic
and orthopedic devices.)
Nothing
Not covered:
Custodial care, rest cures, domiciliary or
convalescent care Non-covered facilities
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Pre-surgical testing Dressings,
casts, and sterile tray services
Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do
not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges 25
25 Page
26 27
2002 Union Health Service 26
Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You pay
We provide a comprehensive range of benefits
for up to 60 days per
calendar year when full time nursing care is necessary
and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan.
Bed, board and general nursing
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility (SNF)
when prescribed by a Plan doctor and managed by our Medical
Management
Department.
Nothing
Not covered: custodial care All charges
Hospice care
We cover
supportive and palliative care for a terminally ill member in
the home or
hospice facility. Services include inpatient and outpatient
care, and family
counseling; these services are provided under the
direction of a Plan doctor
who certifies that the patient is in the terminal
stages of illness, with a
life expectancy of approximately six months or
less
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when approved by
the Plan and medically appropriate Nothing 26
26
Page 27 28
2002
Union Health Service 27 Section 5( d)
Section 5 (d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe
endangers your life or could result in serious
injury or disability, and requires immediate medical or
surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more
serious; examples include deep cuts and broken bones. Others are
emergencies because they are
potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability
to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency: Emergencies within our service area:
If you are in an emergency situation, please call the Plan
24-hour
emergency number at once at 312/ 829-4224. The Plan has doctors on call around
the clock,
seven days a week. In extreme emergencies, if you are unable to
contact your doctor, contact the local
emergency system (e. g., the 911
telephone system) or go to the nearest hospital emergency room. Be sure
to
tell the emergency room personnel that you are a Plan member so they can notify
the Plan. You or a
family member must notify the Plan within 48 hours unless
it was not reasonably possible to do so. It is
your responsibility to ensure
that the Plan has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 48 hours or on the
first working day following your
admission, unless it was not reasonably possible to notify the Plan within
that time, If you are hospitalized in non-Plan facilities and Plan doctors
believe care can be better
provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges
covered in
full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a
Plan provider would result in death,
disability or significant jeopardy to your condition.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness
If you need to be hospitalized, the Plan must
be notified within 48 hours or on the first working day
following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If a
Plan doctor believes care can be better provided in a Plan
hospital, you will be transferred when medically
feasible with any ambulance
charges covered in full. 27
27 Page 28 29
2002 Union
Health Service 28 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at a Plan urgent care
center
$10 per visit
Emergency care at a non-Plan urgent care center
Emergency care as an
outpatient at a hospital, including doctors' services
$25 per visit
We waive the copay if you are admitted to the hospital.
Not covered:
Elective care or non-emergency care All charges.
Emergency outside
our service area
Emergency care at a doctor's office Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$25 per visit
We waive the copay if you are admitted to the hospital.
Not covered:
Elective care or non-emergency care
Emergency care
provided outside the service area if the need for care could have been foreseen
before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
Air ambulance when approved by the Plan and medically
appropriate
See 5( c) for non-emergency service.
Nothing 28
28 Page
29 30
2002 Union Health Service 29
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than for
similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in
this brochure.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including Medicare.
YOUR PHYSICIAN MUST GET PREAUTHORIZATION
OF THESE SERVICES. See the instructions after the benefits section below.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year
deductible…
Mental health and substance abuse benefits
All diagnostic and
treatment services recommended by a Plan provider
and contained in a
treatment plan that we approve. The treatment plan
may include services,
drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing
responsibilities are no
greater than for other
illness
or conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$10 per visit
Mental health and substance abuse benefits -Continued on next page 29
29 Page 30 31
2002 Union Health Service 30 Section 5( e)
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests when ordered by a Plan doctor Nothing
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, residential
treatment, full-day hospitalization, facility
based intensive outpatient
treatment
Nothing.
Not covered:
Services we have not approved. Psychiatric
evaluation or therapy on court order or as a condition of
parole or probation, unless determined by a Plan doctor to be
necessary and appropriate
Services rendered or billed by a school or a member of its staff
Psychotherapy or psychoanalysis credited toward furthering
education, training, or earning a degree
Intelligence, IQ,
aptitude, ability, or interest testing not necessary to determine the
appropriate treatment of a psychiatric condition.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not
order
us to pay or provide one clinically appropriate treatment plan in
favor of
another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
YOU MUST GET PRECERTIFICATION OF SOME PROCEDURES. Please refer
to
Section 3 for information on which services require precertification or prior
approval.
The Plan emergency number, (312) 829-4224, can be accessed 24-hours a
day
7 days a week.
Referrals will be written by the Plan Primary Care Physicians to network
mental health and substance abuse providers
Upon initial consultation
an authorized treatment plan will be determined
and structured .
Inpatient services will be precertified through the Plan's case managers
Review and discharge planning are all through the Plan case managers
Limitation We may limit your benefits if you do not obtain a treatment
plan 30
30 Page 31
32
2002 Union Health Service 31 Section 5(
f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with
other coverage, including Medicare.
I
M
P
O R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist
must write the prescription.
Where you can obtain them. You must fill
the prescription at a plan pharmacy. The Plan pharmacy can fill some maintenance
medications by mail.
These are the dispensing limitations. Prescription drugs will be
dispensed for up to a 30-day supply or 100 unit supply, whichever is less; 240
milliliters of liquid (8oz.); 60 grams of ointment,
creams or topical
preparation; or one commercially prepared unit (i. e., one inhaler, one vial
ophthalmic medication or insulin).
Certain maintenance prescriptions can be mail ordered according to Food and
Drug Administration
Guidelines and you can obtain these by mail from the
plan pharmacy. Contact the plan pharmacy at
312 829-4224 ext. 3260 to make
arrangements.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires
a name brand. If you receive a name brand
drug when a Federally-approved generic drug is
available, and your physician
has not specified Dispense as Written for the name brand drug, you
have to
pay the difference in cost between the name brand drug and the generic.
Sexual dysfunction drugs have dispensing limitations. Contact the Plan
pharmacy for details.
Why use generic drugs. Generic drugs are lower-priced drugs in which
the therapeutic ingredient is chemically equivalent to more expensive brand-name
drugs. They must contain the same active
ingredients and must be equivalent in strength and dosage to the original
brand-name product.
Generics cost less than the equivalent brand-name
product. The U. S. Food and Drug
Administration sets quality standards for
generic drugs to ensure that these drugs meet the same
standards of quality
and strength as brand-name drugs.
When you have to file a claim. You will not have to file a claim
unless you receive covered prescription drugs during an out of area emergency.
See Section 7 for information on how to file
your claim 31
31 Page
32 33
2002 Union Health Service 32
Section 5( f)
Benefit Description You pay After the calendar year
deductible…
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan
physician and obtained from a
Plan pharmacy or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those listed as Not
covered.
Insulin Disposable needles and syringes for the administration
of covered
medications
Drugs for sexual dysfunction when medically necessary
Contraceptive drugs and devices
Intravenous fluids and medication for home use, implantable drugs, and some
injectable drugs are covered under Medical and Surgical
benefits
Fertility drugs are covered under infertility benefits, see page 15
$10 per prescription unit or refill
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins and nutritional substances that can be purchased without a
prescription
Drugs available without a prescription or for which there is a
nonprescription equivalent available
Drugs obtained at a non-Plan pharmacy except for out of area emergencies
Drugs to enhance athletic performance
Medical supplies
such as dressings and antiseptics
All Charges 32
32 Page 33 34
2002 Union
Health Service 33 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Not for Profit Organization UHS is a
not-for-profit organization managed by a Board composed of members representing
Unions, physicians, and community leaders.
24 hour emergency line Emergencies -24 hours a day, 7 days a week, you
may call 1-312-829-4224.
High risk pregnancies Affiliated with Major Medical Centers
Centers of excellence for transplants/ heart
surgery/ etc
Affiliated with Major Medial Centers and guided by National
Transplant
Program
Translation Services Extensive translation skills among staff and
physicians
Urgent Care UHS offers urgent care/ extended clinic hours
at our main facility on weekends.
Continuity of Care Union Health Service has low physician and employee
turnover
Staff Model Because of our staff model status, most physicians are
employees who work for UHS at our locations. For example: podiatry,
ophthalmology, optometry, cardiology, allergy, gastroenterology, and
dentists are all some of the many specialties that work at our main
medical facility. 33
33 Page 34 35
2002 Union
Health Service 34 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization
for dental procedures only when a non-dental physical impairment exists which
makes hospitalization necessary to safeguard the health of the
patient; we do not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other
coverage, including Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.
$10 per visit
Dental benefits
We have no other FEHB dental benefits. (Please
refer to Non-FEHB benefits available to Plan members) 34
34 Page 35 36
2002 Union Health Service 35 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed
claim about them. Fees you pay
for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Vision care One annual refraction (which includes the written lens
prescription) may be obtained from a UHS optometrist. The services are available
by appointment at the UHS Eye Care Center
312 829-4224 ext. 3320 located at the UHS Main Facility, 1634 West Polk
Street, Chicago, IL
60612
UHS Plan members receive special package prices and discounts on eyeglasses,
frames, lenses, contact lenses and optical accessories at all For Eyes Optical
store locations.
For further information about our Vision Benefits please contact our Member
Service Department at 312 829-4224 ext. 3377
Dental Care Dental Services are available to UHS Plan members. The
services are available by appointment at UHS Dental Office 312 829-4224 ext.
3308 located at the UHS Main Facility, 1634 West Polk
Street, Chicago, IL
60612
Annual Office……………………………………………………………… No Charge Annual Oral
Examination and diagnosis………………………………….. No Charge
Annual Fluoride Treatment………………………………………………... No Charge (dependent under age
19)
Other dental services are available at reduced cost with an additional
20% discount. Payment is required at the time of service.
The benefits are
available only at the UHS Dental Office
For further information about our
Dental Benefits, please contact our Marketing Department at 312 829-4224 ext.
3222
Benefits on this page are not part of the FEHB contract 35
35 Page 36 37
2002 Union Health Service 36 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we
will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 36
36 Page 37 38
2002 Union
Health Service 37 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at
Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 312 829-4224 ext. 3304.
When you must file a claim --such as for out-of-area care – submit the
hospital bill or the claim on the HCFA-1500 that includes the
information shown below. Bills and receipts should be itemized and
show:
Covered member's name and ID number;
Name and address of the physician or facility that provided the service or
supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your services.
Submit your claims to:
Union Health Service Insurance Department 1634 West Polk Street
Chicago,
Illinois 60612
Prescription drugs Submit out-of-area and emergency prescription drug
reimbursement claims to:
Submit your claims to: Union Health Service
Pharmacy
1634 West Polk Street
Chicago, IL 60612
Other supplies or services All other claims for supplies or services
should be sent to the following department for review and processing
Submit your claims to: Union Health Service Insurance Department
1634 West Polk Street
Chicago, Illinois 60612 37
37 Page 38 39
2002 Union Health Service 38 Section 7
Deadline for filing your claim Send us all of the documents for
your claim as soon as possible. You must submit the claim by December 31 of the
year after the year you
received the service, unless timely filing was
prevented by administrative
operations of Government or legal incapacity,
provided the claim was
submitted as soon as reasonably possible.
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. 38
38 Page
39 40
2002 Union Health Service 39
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:
Step Description
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: UHS Medical Director, 1634 West Polk Street, Chicago, IL
60612; 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.
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.
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.
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 3,
1900 E Street, NW, Washington, D. C.
20415-3630. 39
39 Page
40 41
2002 Union Health Service 40
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.
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.
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
312 829-4224 ext. 3359 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 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 40
40
Page 41 42
2002
Union Health Service 41 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays heatlh 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. If we are
the secondary payer, we may be entitled to
receive payment from your primary
plan.
We will always provide you with the benefits described in this brochure.
Remember:
even if you do not file a claim with your other plan, you must
still tell us that you have
double coverage.
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
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 managed care plan you have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere in the United States. It is the way everyone
used to get Medicare benefits and is the way most people
get their Medicare
Part A and Part B benefits now. You may go to any doctor, specialist,
or
hospital that accepts Medicare. The Original Medicare Plan pays its share and
you pay
your share. Some things are not covered under Original Medicare,
like prescription
drugs.
When you are enrolled in this Plan and Original Medicare, you still need to
follow the
rules in this brochure for us to cover your care. Your care must
continue to be authorized
by your Plan PCP, or precertified as required
We will not waive any of our copayments, coinsurance, or deductibles.
(Primary payer chart begins on next page.) 41
41 Page 42 43
2002 Union Health Service 42 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
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 42
42 Page
43 44
2002 Union Health Service 43
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 312 829-4224
ext. 3304.
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:
Deductible for inpatient hospitalization The balance of what Medicare does
not pay for physician services
In the following cases, we do not waive any out-of-pocket costs:
Medical
services and supplies provided by physicians and other health care professionals
who do not follow all of our rules, and
guidelines;
Care received from out-of-plan providers.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from a Medicare managed care
plan. These are health care choices (like HMOs)
in some areas of the
country. In most Medicare managed care plans, you can only go to
doctors,
specialists, or hospitals that are part of the plan. Medicare managed care plans
provide all the benefits the 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. We
do not have a Medicare Managed Care Plan; however, we do
have a Medicare Health
Care Prepayment Plan (HCPP). For more information on
our Medicare HCPP, call us at
312/ 829/ 4224 ext. 3377. 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 (if you use our Plan
providers), 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+ Choice service area.
Enrollment in Note: If you choose not to enroll in Medicare Part B,
you can still be Medicare Part B covered under the FEHB Program. We
cannot require you to enroll in Medicare. 43
43
Page 44 45
2002
Union Health Service 44 Section 9
TRICARE TRICARE is the
health care program for eligible dependents of military person, 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.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will
cover your eligible care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for for injuries injuries or illness caused
by another person, you must reimburse us for any expenses we
paid. However,
we will cover the cost of treatment that exceeds the amount you received
in
the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If
you need more information, contact us for our subrogation
procedures. 44
44 Page
45 46
2002 Union Health Service 45
Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 10.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 10
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Treatment
or services that are designed mainly to help the patient with daily living
activities
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services. See page 10.
Experimental or If a medical treatment, procedure, drug, device, or
biological product is investigational services FDA approved, the Plan
will use this as a basis for providing coverage.
If it lacks FDA's approval,
the Plan will make a policy decision based on specific statements from specialty
societies or medical organizations such
as the American Cancer Society, the
American College of Surgeons, and the American Medical Society
Group health coverage Health care coverage that a member is eligible
for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies.
Medically necessary A Medically Necessary service is a service that is
(1) consistent with the Enrollee's condition, disease, ailment or injury, (2)
appropriate with
regard to standards of good medical practice, (3) not
solely for the
convenience of the Enrollee or provider, and (4) the most
appropriate
supply or level of service which can be safely rendered to the
Enrollee.
When specifically applied to an inpatient, it further means that
the
Enrollee's medical symptoms or condition require that the diagnosis or
treatment cannot be effectively, safely and economically provided to the
Enrollee in an outpatient setting.
Your Primary Care Physician, in accordance with the above standards
adopted by Union Health Service, will determine when a service is
medically necessary.
Us/ We Us and we refer to Union Health Service
You You
refers to the enrollee and each covered family member. 45
45 Page 46 47
2002 Union Health Service 46 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. 46
46 Page
47 48
2002 Union Health Service 47
Section 11
When benefits and The benefits in this brochure are
effective on January 1. If you joined premiums start this Plan during
Open Season, your coverage begins on the first day of your first
pay period
that starts on or after January 1. Annuitants' coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing
office will tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for
other forms of coverage, such as temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary
Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
TCC If you leave Federal service, or if you lose coverage because you
no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you
are not able to continue your FEHB enrollment after you retire, if
you lose
your job, if you are a covered dependent child and you turn 22
or marry,
etc.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5,
the Guide to Federal Employees Health Benefits Plans for 47
47 Page 48 49
2002 Union Health Service 48 Section 11
Temporary Continuation of Coverage and Former Spouse Enrollees,
from
your employing or retirement office or from www. opm. gov/ insure.
Both
explain what you have to do to enroll in TCC.
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 You may be entitled to continued coverage
through the Health Insurance Group Health Plan Coverage Portability and
Accountability Act of 1996 (HIPPA). This Federal law
offers limited Federal
protections for health care 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.
OPM pamphlet RI79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program highlights HIPPA rules.
For example, the
requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health coverage
under
HIPPA. The pamphlet has information about Federal and State agencies
you can contact for more information. 48
48 Page 49 50
2002 Union
Health Service 49 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:
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 nursing home care, care in an assisted living facility,
care in your home, adult day
care, hospice care, and more.
Welcome to the club! 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 everyone should have a plan
just in case.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And
that's before inflation!
Long term care can easily exhaust your savings.
Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c)
of your FEHB brochure. Health plans don't cover custodial
care or a stay in
an assisted living facility or a continuing need for a
home health aide to
help you get in and out of bed and with other
activities of daily living.
Limited stays in skilled nursing facilities
can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It also has a 100 day limit.
Medicaid covers
long term care for those who meet their state's poverty guidelines, but has
restrictions on covered services and
where they can be received. Long term care insurance can provide
choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in
mid-2002. In the meantime, you can learn more about the program on our web site
at
www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are
YOU planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 49
49 Page 50 51
2002 Union Health Service 50 Index
Index
Do not rely on this page; it is for your convenience and does not
explain your benefit coverage.
Accidental injury 21, 34, 50 Allergy
tests 15, 16
Alternative treatment 19 Ambulance 26, 28
Anesthesia 23, 25
Autologous bone marrow
transplant 22 Biopsies 20
Blood and blood
plasma 25 Breast cancer screening 13,
Casts 25 Catastrophic
protection 10
Changes for 2002 6 Chemotherapy 16
Childbirth 14
Cholesterol tests 13
Claims 37, 38, 39, 40 Coinsurance 10, 45
Colorectal
cancer screening 13 Congenital anomalies 20, 21
Contraceptive devices and
drugs 32 Coordination of benefits 41, 42,
43, 44 Covered services 45
Covered providers 7, 8
Crutches 18 Deductible 10
Definitions 45 Dental care 22, 34, 35
Diagnostic services 12 Disputed
claims review 39, 40
Donor expenses (transplants) 22 Dressings 25, 32
Durable medical equipment (DME) 10, 18
Effective date of
enrollment 47 Emergency 27, 28
Experimental or investigational 45 Eyeglasses
17, 35
Family planning 15 Fecal occult blood test 13
General Exclusions 36 Hearing services 17
Home health
services 19 Hospice care 26
Home nursing care 19 Hospital 8, 24, 25, 37
Immunizations 13, 14 Infertility 15
Inhospital physician care 24
Inpatient Hospital Benefits 24
Insulin 31, 32 Laboratory and
pathological
services 13 Magnetic Resonance Imagings
(MRIs) 13
Mail Order Prescription Drugs 32
Mammograms 13 Maternity Benefits 14
Medicaid 44 Medically necessary 45
Medicare 41, 42, 43 Mental
Conditions/ Substance
Abuse Benefits 29 ,30 Newborn care 14
Non-FEHB Benefits 35 Nursery charges 14
Obstetrical care 14
Occupational therapy 16
Office visits 12 Oral and maxillofacial surgery 22
Orthopedic devices 18 Out-of-pocket expenses 10
Outpatient facility care
25 Oxygen 25
Pap test 13 Physical examination 13
Physical therapy
16 Physician 7, 8, 9
Precertification/ Prior-approval 9, 20, 24, 30
Preventive care, adult 13
Preventive care, children 14 Prescription drugs 32, 33,
38 Preventive
services 13,14
Prior approval 9 Prostate cancer screening 13
Prosthetic
devices 18, 20, 21
Psychologist 29, 30 Psychotherapy 30
Radiation
therapy 16 Rehabilitation therapies 16
Renal dialysis 16 Room and board
24
Second surgical opinion 12 Skilled nursing facility care 26
Smoking cessation 33 Speech therapy 6, 17
Splints 25 Sterilization
procedures
15, 21 Subrogation 44
Substance abuse 29, 30 Surgery 20, 21,
22, 23
Anesthesia 23, 25 Oral 23
Outpatient 25 Reconstructive 21
Syringes 32 Temporary continuation of
coverage 48 Transplants 22
Treatment therapies 15
Vision services 17, 36 Well child
care 14
Wheelchairs 18 Workers' compensation 44
X-rays 13, 25 50
50 Page 51 52
2002 Union Health Service 51
Summary of
benefits for the Union Health Service -2002
Do
not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the
definitions, limitations, and exclusions in
this brochure. On this page we summarize specific expenses we cover;
for
more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $10 primary care; $10 specialist 12
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient..........................................................................................
"Nothing"
"Nothing"
24
25
Emergency benefits:
In-area
..............................................................................................
Out-of-area
.......................................................................................
$25 per….
$25 per…
28
28
Mental health and substance abuse
treatment...................................... Regular cost sharing 29
Prescription
drugs..................................................................................
$10 per prescription unit or refill 32
Dental
Care........................................................................................
Accidental injury benefit 34
Vision
Care........................................................................................
Medical, surgical for diagonosis
and treatment of diseases, one
annual
eye refraction
17
Special features…………………………………………………… Not for Profit Organization, 24
hour
emergency line, High risk pregnancies, Centers for excellence for transplants/
heart surgery/ etc.,
Translation services, Urgent care, Continuity of Care,
Staff Model
33 51
51 Page
52
2002 Union Health Service Back Cover
2002 Rate
Information for
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
Self Only 761 $72.81 $24.27 $157.76 $52.58 $86.16 $10.92
Self and
Family 762 $180.59 $60.19 $391.27 $130.42 $213.69 $27.09 52