Serving: Most of Colorado
Enrollment in this Plan is
limited. You must live or work in our Geographic area to enroll. See page 7 for
requirements.
XJ1 Self Only High Option XJ2 Self and Family High Option
XJ4 Self
Only Standard Option XJ5 Self and Family Standard Option
RI 73-027
This Plan has
EXCELLENT ACCREDITATION
from the NCQA, effective
through
April 2003. See the 2002 Guide for
more information on accreditation.
For
changes in
benefits see
page 8
Authorized for distribution by the:
Enrollment codes for this Plan:
1
1 Page 2 3
2002 Rocky Mountain HMO 2
Table of
Contents
Introduction
.................................................................................................................................................................
4
Plain
Language..............................................................................................................................................................
4
Inspector General Advisory
..........................................................................................................................................
5
Section 1. Facts about this HMO
plan..........................................................................................................................
6
How we pay providers
................................................................................................................................
6
Your Rights
.................................................................................................................................................
6
Service
Area................................................................................................................................................
7
Section 2. How we change for 2002
............................................................................................................................
8
Program-wide changes
................................................................................................................................
8
Changes to this
Plan....................................................................................................................................
8
Section 3. How you get care
........................................................................................................................................
9
Identification
cards......................................................................................................................................
9
Where you get covered care
........................................................................................................................
9
Plan providers
.......................................................................................................................................
9
Plan facilities
........................................................................................................................................
9
What you must do to get covered care
........................................................................................................
9
Primary
care..........................................................................................................................................
9
Specialty
care........................................................................................................................................
9
Hospital care
.......................................................................................................................................
Circumstances beyond our control
............................................................................................................
11
Services requiring our prior
approval........................................................................................................
11
Section 4. Your costs for covered
services.................................................................................................................
12
Copayments
........................................................................................................................................
12
Deductible...........................................................................................................................................
12
Coinsurance
........................................................................................................................................
12
Your out-of-pocket
maximum...................................................................................................................
12
Section 5. Benefits
.....................................................................................................................................................
13
Overview...................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals .......... 13
(b) Surgical and anesthesia services
provided by physicians and other health care professionals....... 13
(c)
Services provided by a hospital or other facility, and ambulance
services..................................... 13
(d) Emergency services/
accidents
........................................................................................................
13
(e) Mental health and substance abuse benefits
...................................................................................
13
(f) Prescription drug
benefits...............................................................................................................
13
(g) Dental
benefits................................................................................................................................
13
(h) Non-FEHB benefits available to Plan members
............................................................................. 13
Section 6. General exclusions --things we don't
cover..............................................................................................
42
11 2
2 Page 3 4
2002 Rocky Mountain HMO 3
Section 7. Filing a
claim for covered services
.............................................................................................................
43
Section 8. The disputed claims
process........................................................................................................................
45
Section 9. Coordinating benefits with other
coverage..................................................................................................
47
When you have…
Other health coverage
............................................................................................................................
47
Original
Medicare..................................................................................................................................
48
Medicare managed care plan
.................................................................................................................
51
TRICARE/ Workers'Compensation/ Medicaid
.............................................................................................
52
Other Government agencies
........................................................................................................................
53
When others are responsible for
injuries.....................................................................................................
53
Section 10. Definitions of terms we use in this
brochure.............................................................................................
55
Section 11. FEHB
facts................................................................................................................................................
56
Coverage information
.................................................................................................................................
56
No pre-existing condition limitation
....................................................................................................
56
Where you get information about enrolling in the FEHB Program
..................................................... 56
Types of coverage
available for you and your family
.......................................................................... 56
When benefits and premiums start
.......................................................................................................
57
Your medical and claims records are confidential
...............................................................................
57
When you retire
..................................................................................................................................
57
When you lose benefits
...............................................................................................................................
57
When FEHB coverage
ends..................................................................................................................
57
Spouse equity coverage
.......................................................................................................................
57
Temporary Continuation of Coverage (TCC)
....................................................................................
57
Converting to individual
coverage.......................................................................................................
58
Getting a Certificate of Group Health Plan
Coverage..........................................................................
58
Long term care insurance is coming later in 2002
........................................................................................................
60
Index
.................................................................................................................................................................
62
Summary of benefits
................................................................................................................................................
6
Rates
..................................................................................................................................................
Back cover
3 ..... 3
3 Page
4 5
2002 Rocky Mountain HMO 4
Section 1
Introduction
Rocky Mountain HMO 2775 Crossroads
Boulevard
Grand Junction, CO 81506
This brochure describes the benefits
of Rocky Mountain HMO under our contract (CS 1662) 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 are
summarized on page . 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 Rocky Mountain HMO.
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 meant first.
Our
brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650
8 4
4 Page 5 6
2002 Rocky Mountain HMO 5 Section 1
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 970/ 243-7050 or
1-800-346-
4643 and explain the situation. If we do not resolve the issue
call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the
person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Rocky Mountain
HMO 6 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 co-payments described in this brochure. When you receive emergency services
from non-Plan providers, yoCould not acquire words on page 7 u 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 contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or coinsurance.
Who provides my health care?
Rocky Mountain Health Maintenance
Organization is an individual practice prepayment plan that contracts with
hospitals and health care professionals throughout Colorado.
The first and most important decision each member must make is the selection
of a primary care doctor. The decision is important since it is through this
doctor that all other health services, particularly those of specialists, are
coordinated. It is the responsibility of
your primary care doctor to obtain
any necessary authorization from the Plan before referring you to a specialist
or making arrangements for hospitalization. Services of other providers are
covered only when there has been a referral by the member's primary
care
doctor: with the following exception: a woman may see her Plan gynecologist for
her annual routine examination without a referral.
Your Rights
OPM requires that all FEHB Plans to 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.
Rocky Mountain HMO is an
independent, non-profit organization In existence since 1974
In 1975 Rocky
Mountain HMO became the seventh HMO in the nation to be federally qualified
If you want more information about us, call 970-243-7050 or 1-800-346-4643,
or write to 2775 Crossroads Boulevard, Grand Junction, CO 81506. You may also
visit our website at http:// www. rmhmo. org. 6
6
Page 7 8
7 Page 8 9
2002 Rocky Mountain HMO 8 Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5 Benefits. Also, we edited and clarified language throughout the
brochure; any language change not shown here is a
clarification that does
not change benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will
increase by 20. 6% for self only and 18. 5% for Self and Family for High Option
Rocky Mountain HMO will offer two plans for the 2002 benefit year, A High
Option and a Standard Option We clarified the Preventive care, adult benefits by
removing the entry for blood lead level testing for adults
because it is a
test more typically done for children (Section 5 (a) We clarified the Family
planning and Infertility benefits by providing more examples of covered and not
covered
benefits . (Section 5 (a) We increased speech therapy benefits by
removing the requirement that services must be required to restore
functional speech. (Section 5( a) We clarified Surgical procedures to show
that we cover a comprehensive range of services, such as operative
procedures. (Section 5 (b). Your prescription drug benefit will change to
$10 copay for generic $20 copay for preferred brand and $35 copay
for
non-preferred brand name drugs. If you are enrolled in FEDCARE your
prescription drug benefit will change to $10 copay for generic $20 copay
for
preferred brand and $35 copay for non-preferred brand name drugs. Rocky Mountain
HMO now offers a prescription mail order benefit, see section 5f for specific
benefit
information. We no longer limit total blood cholesterol test to
certain age groups. (Section 5 (a)
We now cover certain intestinal
transplants. (Section 5( b) We added a new Section after Section 11 to discuss
the Long Term Care Insurance Program that is coming in
2002 We now cover
routine screening for chlamydial infection. (Section 5( a)
We clarified the
brochure to show why we think you should use generic drugs whenever possible. We
moved other language around within the Prescription drugs section but didn't
change its meaning. (Section 5( f)
We clarified the Medicare Primary Payer
Chart to explain how we coordinate benefits for former spouses. (Section 9)
We clarified other language about coordinating benefits with Medicare.
(Section 9) 8
8 Page
9 10
2002 Rocky Mountain HMO 9
Section 3
Section 3. How you get care
Identification cards We
will send you an identification (ID) card when you enroll. You should carry your
ID card with you at all times. You must show it
whenever you receive
services from a Plan provider, or fill a prescription at a Plan pharmacy. Until
you receive your ID card, use your copy of the
Health Benefits Election
Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or
your Employee Express confirmation
letter.
If you do not receive your ID
card within 30 days after the effective date of your enrollment, or if you need
replacement cards, call us at
970-253-7050.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay co-payments and you will not have to file
claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our
members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically.
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.
Primary care Your primary care physician can be a family practitioner,
internist or pediatrician. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist.
If you want to
change primary care physicians or if your primary care physician leaves the
Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. 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.
. 9
9 Page 10 11
2002 Rocky Mountain HMO 10 Section 3
Here
are other things you should know about specialty care:
If you need to see a
specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician
will develop a treatment plan that
allows you to see your specialist for a certain number of visits without
additional referrals. Your primary
care physician will use our criteria when
creating your treatment plan (the physician may have to get an authorization or
approval
beforehand).
If you are seeing a specialist when you enroll in
our Plan, talk to your primary care physician. Your primary care physician will
decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a
specialist who does. Generally, we will not pay for you to see
a specialist
who does not participate with our Plan.
If you are seeing a specialist and
your specialist leaves the Plan, call your primary care physician, who will
arrange for you to see another
specialist. You may receive services from
your current specialist until we can make arrangements for you to see someone
else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for
other than cause; or
-drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
-reduce our service
area and you enroll in another FEHB Plan,
you may be able to continue seeing
your specialist for up to 90 days after you receive notice of the change.
Contact us or, if we drop out of
the Program, contact your new plan.
If
you are in the second or third trimester of pregnancy and you lose access to
your specialist based on the above circumstances, you can
continue to see
your specialist until the end of your postpartum care, even if it is beyond the
90 days. 10
10 Page
11 12
2002 Rocky Mountain HMO 11
Section 3
Hospital care Your Plan primary care physician or
specialist will make necessary hospital arrangements and supervise your care.
This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 970-243-7050. 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.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most services.
For certain 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. If a service is not approved, we will notify you in
writing.
We call this review and approval process pre-authorization. Your physician
must obtain pre-authorization for the following services:
Hospital admissions Surgery
Home health services Invasive diagnostic
tests
transplants Skilled nursing facility admissions
Mental health
services Alcohol and substance abuse treatment
Some diagnostic procedures
such as MRI's and CT scans Durable medical equipment, orthotic and prosthetic
devices and home
oxygen Hospice services 11
11
Page 12 13
2002
Rocky Mountain HMO Section 4 12
Section 4. Your costs for covered
services
You must share the cost of some services. You are responsible
for:
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit under the high option and $25 under
the standard option and
when you go in the hospital, you pay $200 copay under the high option or $500
copay under the standard option.
Deductible We do not have a deductible.
Coinsurance We do
not have coinsurance.
Your catastrophic protection out-of-pocket maximum
For
copayments
After your co-payments total $750 per person or $1500 per family for the high
option and $1500 per person or $3000 per family for the standard
option in
any calendar year, you do not have to pay any more for covered services.
However, copayments for the following services do not count
toward your
out-of-pocket maximum, and you must continue to pay copayments for these
services.
Prescription drugs
Be sure to keep accurate records of your
copayments since you are responsible for informing us when you reach the
maximum. 12
12 Page
13 14
2002 Rocky Mountain HMO Section
5 (a) 13
Section5. Benefits --OVERVIEW
(See page 8 for
how our benefits changed this year and page 64 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us at 970-243-7050 or
1-800-346-4643 or by e-mail at RMHMO-Member-Service@ rmhmo. org
(a) Medical services and supplies provided by physicians and other health
care professionals…………………. 14-24
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
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 25-29
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue
transplants Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services..................................................... 30-32
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/
accidents.........................................................................................................................
33-34 Medical emergency Ambulance
(e) Mental health and substance abuse
benefits.........................................................................................................
35
(f) Prescription drug benefits
....................................................................................................................................
37
(g) Dental benefits
.....................................................................................................................................................
40
(h) Non-FEHB benefits available to Plan members
..................................................................................................
41
Summary of
benefits...................................................................................................................................................
63 13
13 Page 14
15
2002 Rocky Mountain HMO Section 5 (a) 14
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 no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services for valuable information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
If
you are enrolled in FEDCARE please see page for information on how your benefits
differ from this plan.
I M
P O
R T
A N
T
Benefit Description You pay
High Option
You pay
Standard
Option
Diagnostic and treatment services
Professional services of
physicians
In physician's office
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
Office medical consultations
Second surgical
opinion
$10 per office visit
You pay nothing for professional services
during a hospital or skilled nursing facility
stay.
$25 per office visit
You pay nothing for professional services
during a hospital or skilled nursing facility
stay.
At home Nothing Nothing
51
$10 per office visit $25 per office visit 14
14 Page 15 16
2002 Rocky Mountain HMO Section 5( a) 15
Lab and other diagnostic tests You pay
High Option
You pay
Standard Option
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
20% of charges for Lab services 30% of charges for Lab services
X-ray
X-rays Non-routine Mammograms
Cat Scans/ MRI Ultrasound
Electrocardiogram and EEG
$25 copay $50 copay
Preventive care, adult
Routine screenings, such as
Total Blood Cholesterol – once every three years
Eye exams to determine
the need for vision correction
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years
starting at age 50.
Prostate Specific Antigen (PSA) – one annually
For men age 40 and older
Nothing Nothing
Routine pap test
Note: The office visit is covered if pap test is
received on the same day; see Diagnosis and
Treatment, above.
Nothing Nothing 15
15 Page
16 17
2002 Rocky Mountain HMO Section
5( a) 16
Preventive care, adult (Continued) You pay
High Option
You Pay
Standard Option
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 Nothing
Not covered: Physical exams required for obtaining or continuing
employment or
insurance, attending schools or camp, or travel, unless it is
the only physical examination
obtained during the calendar year.
All charges. 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
Nothing Nothing
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing Nothing
Examinations, such as:
Eye exams to determine the need for vision
correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)
$10 per office visit $25 per office visit
Well-child care charges for routine examinations, immunizations and care
(through age 22)
Nothing Nothing 16
16
Page 17 18
2002
Rocky Mountain HMO Section 5( a) 17
Maternity care You pay
High
Option
You pay
Standard Option
Complete maternity (obstetrical)
care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here
are some things to keep in mind:
You do not need to precertify your normal
delivery.
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.
No referral is required to a
plan provider.
$10 for the initial visit only, $200 for the
inpatient admission
$25
for the initial visit only, $500 for
inpatient admission
Not covered: Routine sonogram or amniocentesis to determine fetal age,
size or sex All charges All charges
Family planning
A broad
range of voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives (such as
Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine
devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the
prescription drug benefit.
$10 per office visit $25 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges. All charges 17
17
Page 18 19
2002
Rocky Mountain HMO Section 5( a) 18
Infertility services You pay
High Option
You pay
Standard Option
Diagnosis and treatment
of infertility, such as:
Artificial insemination, up to four attempts per
pregnancy:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover
injectable fertility drugs under medical benefits and oral fertility drugs under
the
prescription drug benefit when pre-authorized.
$10 per office visit $25 per office visit.
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote
ZIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
All charges. All charges
Allergy care
Testing and treatment
Allergy injection
$10
per office visit $25 per office visit
Allergy serum Nothing Nothing
Not covered: provocative food testing
and sublingual allergy desensitization All charges. All charges 18
18 Page 19 20
2002 Rocky Mountain HMO Section 5( a) 19
Treatment therapies You pay
High Option
You pay
Standard
Option
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
28.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
diaCould not acquire words on page 20 lysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Your physician will contact us for pre-authorization. We will send you a
letter if pre-authorization
is denied.
$10 per office visit $25 per office visit 19
19
Page 20 21
20 Page 21 22
2002 Rocky Mountain HMO Section 5( a) 21
Vision services (testing, treatment, and supplies) You pay
High
Option
You pay
Standard Option
One pair of eyeglasses or contact
lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery (such as for cataracts)
Diagnosis and treatment of diseases of the eye.
No referral required to
plan provider.
$10 per office visit $25 per office visit
Annual eye refractions may be obtained from any licensed optometrist or
ophthalmologist
with the plan's service area.
No referral required to plan provider.
$10 per office visit $25 per office visit
Not covered:
Eyeglasses or contact lenses
Eye
exercises and orthoptics
Radial keratotomy and other refractive
surgery
All charges. 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 office visit $25 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and
similar routine treatment of conditions of the foot, except as stated
above
Treatment of weak, strained or flat feet or bunions or spurs; and of any
instability,
imbalance or subluxation of the foot (unless the treatment is
by open cutting surgery)
All charges. All charges 21
21 Page 22 23
2002 Rocky
Mountain HMO Section 5( a) 22
Orthopedic and prosthetic devices You
pay
High Option
You pay
Standard Option
Artificial arms and legs, externally worn breast
prostheses and surgical
bras, including necessary
replacements, following a mastectomy.
Artificial eyes and orthotic devices such as
braces, splints and collars,
orthopedic shoes
and custom foot orthoses with pre authorization.
Internal prosthetic devices, such as artificial
joints, pacemakers and
surgically implanted
breast implant following mastectomy. Note:
See 5(
b) for coverage of the surgery to insert
the device.
20% of all charges
50% of all charges
Nothing
20% of all charges
50% of all charges
Nothing
Not covered:
arch supports
heel pads and heel cups
lumbosacral
supports
corsets, trusses and other supportive devices
prosthetic
replacements provided less than 3
years after the last one we covered
cochlear implants
All charges. All charges
22
22 Page 23
24
2002 Rocky Mountain HMO Section 5( a) 23
Durable medical equipment (DME) You pay
High Option
You pay
Standard Option
Rental or purchase, at our option, including repair
and adjustment, of durable medical equipment
prescribed by your Plan physician, such as oxygen and dialysis equipment.
Under this
benefit, we also cover:
hospital beds;
Non motorized
wheelchairs
crutches
walkers
blood glucose monitors
insulin
pumps.
Durable medical equipment, such as wheelchair and hospital beds, on loan from
the plan.
Durable medical equipment must be pre-authorized by the plan and provided by
a participating vendor.
20% of all charges 30% of all charges
Not covered: Motorized wheel chairs All charges. All charges
Home health services
Home health care ordered by a Plan
physician and provided by a registered nurse (R. N.),
licensed practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or
home health
aide.
Services include oxygen therapy, intravenous therapy
and medications.
Nothing Nothing
Not covered: nursing care requested by, or for the
convenience
of, the patient or the patient's family;
Services primarily for hygiene, feeding, exercising, moving the patient,
homemaking,
companionship or giving oral medication.
All charges. All charges 23
23 Page 24 25
2002 Rocky
Mountain HMO Section 5( a) 24
Chiropractic You pay
High Option
You pay
Standard Option
Not covered All charges All charges
Alternative treatments
Not covered:
Acupuncture naturopathic services
hypnotherapy
biofeedback
All charges. All charges
Educational classes and programs
Coverage is limited to:
Diabetic Education Services, provided by a plan approved diabetic educator
or education
program.
Nothing Nothing 24
24 Page
25 26
2002 Rocky Mountain HMO 25
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 have no calendar
year deductible
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the
facility (i. e. hospital, surgical center, etc.)
YOU MUST GET
PREAUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the
precertification information shown in Section 3 to be sure which
services require precertification and identify which surgeries require
precertification.
If you are enrolled in FEDCARE please see page for
information on how your benefits differ from this plan.
I M
P O
R T
A N
T
Benefit Description You pay
High Option
You pay
Standard
Option
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting Normal
pre-and post-operative care by the
surgeon Correction of amblyopia and strabismus
Endoscopy procedure Biopsy
procedure
Removal of tumors and cysts Correction of congenital anomalies
(see
reconstructive surgery) Surgical treatment of morbid obesity --a
condition in which an individual weighs 100 pounds or 100% over his or her
normal
weight according to current underwriting standards; eligible members
must be age 18
or over. Insertion of internal prosthetic devices. See
5
(a) – Orthopedic and prosthetic devices for device coverage information.
$10 per office visit or
$200 per inpatient admission
$25 per office
visit or
$500 per inpatient admission
Surgical procedures continued on next page.
51 25
25 Page
26 27
2002 Rocky Mountain HMO 26
Section 5( b)
Surgical procedures (Continued) You
pay
High Option
You pay Standard Option
Voluntary sterilization Treatment of burns
Note: Generally, we pay for
internal prostheses (devices) according to where the
procedure is done. For
example, we pay Hospital benefits for a pacemaker and Surgery
benefits for
insertion of the pacemaker.
$10 per office visit or $200 per inpatient
admission
$25 per office
visit or $500 per inpatient
admission
Not covered: Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
All charges. All charges
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the condition produced a major effect on the member's appearance and
-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation
from the common form or norm. Examples of congenital
anomalies are: protruding ear
deformities; cleft lip; cleft palate; birth
marks; webbed fingers; and webbed toes.
$10 per office visit or
$200 per inpatient admission
$25 per office
visit or
$500 per inpatient admission 26
26
Page 27 28
2002
Rocky Mountain HMO 27 Section 5( b)
Reconstructive surgery
(Continued) You pay
High Option
You pay
Standard
Option
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 office visit or $200 per inpatient
admission
$25 per office
visit or $500 per inpatient
admission
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 All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: Reduction of fractures of the jaws or facial
bones; Surgical correction of cleft lip, cleft palate or
severe
functional malocclusion; Removal of stones from salivary ducts;
Excision of
leukoplakia or malignancies; Excision of cysts and incision of abscesses
when done as independent procedures; and Other surgical procedures that do
not involve
the teeth or their supporting structures.
$10 per office visit or $200 per inpatient
admission.
$25 per office
visit or $500 per inpatient
admission
Not covered: Oral implants and transplants
Procedures
that involve the teeth or their supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
Dental care involved in
treatment of temporomandibular joint dysfunction syndrome,
(TMJ) pain.
All charges. All charges 27
27 Page 28 29
2002 Rocky
Mountain HMO 28 Section 5( b)
Organ/ tissue transplants You
pay
High Option
You pay
Standard Option
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
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
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine
with multiple organs such as the liver, stomach,
and pancreas
Allogeneic (donor) marrow transplants
Note: We cover related medical and
hospital expenses of the donor when we cover the recipient on this plan
$10 per office visit or $200 per inpatient
admission
$25 per office
visit or $500 per inpatient
admission
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 All charges
28
28 Page 29
30
2002 Rocky Mountain HMO 29 Section 5( b)
Anesthesia You Pay High Option You Pay Standard Option
Professional services provided in –
Hospital (inpatient)
Nothing Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
Nothing Nothing 29
29 Page
30 31
2002 Rocky Mountain HMO 30
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.
There is no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
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 PREAUTHORIZATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services
require pre-authorization.
If you are enrolled in FEDCARE please see page for information on how your
benefits differ from this plan.
I M
P O
R T
A N
T
Benefit Description You pay
High Option
You pay
Standard
Option
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.
$200 per inpatient admission $500 per inpatient admission
Inpatient hospital continued on next page.
51 30
30 Page
31 32
2002 Rocky Mountain HMO 31
Section 5( c)
Inpatient hospital (Continued) You pay
High Option
You pay
Standard Option
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 Dressings,
splints, casts, and sterile tray
services Medical supplies and equipment,
including
oxygen Anesthetics, including nurse anesthetist
services
Take-home items
Medical supplies, appliances, medical equipment, and any
covered items billed
by a hospital for use at home
$200 per inpatient admission $500 per inpatient admission
Not covered: Blood or blood plasma, if not donated or
replaced
Custodial care
Non-covered facilities, such as nursing homes.,
schools
Personal comfort items, such as telephone, television, barber
services, guest meals and
beds Private nursing care
All charges. All charges
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.
$100 for outpatient surgery and invasive
diagnostic tests
$200 for
outpatient surgery and invasive
diagnostic tests
Not covered: blood and blood derivatives not replaced by the member All
charges All charges 31
31 Page 32 33
2002 Rocky
Mountain HMO 32 Section 5( c)
Extended carebenefits/
skillednursing care facility benefits You pay
High Option
You pay
Standard Option
Extended care or skilled nursing facility: up to 100 days per calendar year.
$10 copay per day $25 copay per day
Not covered: custodial care All charges All charges
Hospice
care
Supportive and palliative care for a terminally ill member is
covered in the home or hospice
facility. A maximum of ten (10) days of respite care are provided. 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 Nothing
Not covered: Independent nursing, homemaker services All charges All
charges
Ambulance
Local professional ambulance service when
medically appropriate
Air ambulance
$75 copay $100 copay 32
32
Page 33 34
2002
Rocky Mountain HMO 33 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.
We have no calendar year deductible.
Be sure to read Section 4, Your
costs for covered services for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more serious; examples include deep cuts and broken
bones. Others are emergencies because they are
potentially life-threatening,
such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for quick
action. If you use the emergency room for something that is not a true
emergency, you may have to pay for the service yourself.
What to do in case of emergency:
Emergencies within our service area:
Contact your primary care doctor or in extreme emergency call the local
emergency system (e. g., the 911) or go to the nearest hospital emergency room.
Be sure to
tell the emergency room personnel that you are a Rocky Mountain
HMO plan member so they can notify the plan.
Emergencies outside our service area: Go to the nearest emergent or
urgent care center for treatment. If you need to be hospitalized, the plan must
be notified at 1-800-346-4643. 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. Follow-up care recommended by
non-plan providers must be
approved by the plan or provided by plan
providers. You pay 50% of charges for follow-up care up to a maximum plan
payment of $250. 33
33 Page
34 35
2002 Rocky Mountain HMO 34
Section 5( d)
Benefit Description You pay
High Option
You
pay
Standard Option
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$10 per office visit
$35 per visit
$75 per visit
$25 per office visit
$50 per visit
$100 per visit
Not covered: Elective care or non-emergency care All charges. 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
Reasonable charges for emergency care
services to the
extent the services would
have been covered if received from plan
providers.
Reasonable charges for emergency care
services to the extent fhe services
would
have been covered if received from plan
providers.
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. All charges
Ambulance
Professional ambulance service and air ambulance when
medically appropriate.
See 5( c) for non-emergency service.
$75 copay $100 copay 34
34 Page 35 36
2002 Rocky Mountain HMO 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
Parity
When you get our approval for services and follow a
treatment plan we approve, cost-sharing and limitations for Plan mental health
and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some
important things to keep in mind about these benefits:
All benefits are
subject to the definitions, limitations, and exclusions in this brochure.
Be
sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
If you are enrolled in FEDCARE please see page for information on how yoCould
not acquire words on page 37 ur benefits differ from this plan.
I M
P O
R T
A N
T
Benefit Description You pay
High Option You pay Standard Option
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. You must complete the entire treatment
program for services to be covered.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Your cost sharing responsibilities are no
greater than
for other illness or conditions.
Professional services, including individual or
group therapy by providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per office visit if the program is completed.
All charges if the
program is not
completed.
$25 per office visit if the program is
completed. All charges if the
program
is not completed.
Mental health and substance abuse benefits -Continued on next page
51 35
35 Page
36 37
2002 Rocky Mountain HMO 36
Section 5( e)
Mental health and substance abuse benefits
(Continued) You pay
High Option
You pay
Standard
Option
Diagnostic tests Nothing in addition to
the office visit copay Nothing in
addition to the office visit copay.
Services provided by a hospital or other facility
Services in approved
alternative care settings
such as partial hospitalization, half-way house,
residential treatment, full-day hospitalization,
facility based intensive outpatient treatment
$200 per inpatient admission. You pay
all charges if program is not
completed
$500 per inpatient admission. You pay
all charges if program
is not completed.
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's
clinical appropriateness. OPM will generally not order us to pay or
provide one clinically
appropriate treatment plan in favor of another.
All charges. All charges
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
Your physician is responsible for getting our approval before you receive
any of the listed services. Before giving approval, we consider if the service
is medically necessary, and if it follows generally accepted medical
practice. It is important that you use plan providers for all services. You can
get a
directory by calling 800-346-4643. If we do not approve a service for
you we will notify you in writing.
Limitation We may limit your benefits if you do not follow your
treatment plan. 36
36 Page 37 38
37 Page 38 39
2002 Rocky Mountain HMO 38 Section 5( f)
Benefit Description You pay
High Option You pay Standard Option
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan physician and obtained from
a Plan pharmacy.
Drugs and medicines that by Federal law of the United States require a
physician's prescription
for their purchase, except as excluded below.
Insulin
Disposable needles and syringes for the administration of covered
medications
Drugs for sexual dysfunction Contraceptive drugs and devices
$10 copay for generic drugs
$20 for preferred brand drugs
$35 for
non-preferred brand drugs
Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay.
If you
choose the brand name when a generic is
available, you will pay the brand
name copay and the
difference in cost between the generic and the brand
name
$10 copay for generic drugs
$20 for preferred brand drugs
$35 for
non-preferred brand drugs
Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay.
If you
choose the brand name when a generic is
available, you will pay the brand
name copay and the
difference in cost between the generic and the brand
name
Viagra (limited to 5 pills per month) $35 $35 38
38 Page 39
40
2002 Rocky Mountain HMO 39 Section 5( f)
Covered medications and supplies (continued) You pay
High Option
You pay
Standard Option
Here are some things to keep in mind about our prescription drug program:
We have a closed formulary. If your physician believes a name brand product
is
necessary or there is no generic available, your physician may prescribe
a name brand
drug from a formulary list. This list of name brand drugs is a
preferred list of drugs that
we selected to meet patient needs at a lower
cost.
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers
them
Nonprescription medicines -excluding insulin
Drugs not included on the plan formulary
Weight loss drugs
All Charges All Charges 39
39 Page 40 41
2002 Rocky
Mountain HMO 40 Section 5( g)
Section 5 (g). 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.
We have no calendar year deductible.
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 with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
High Option
You pay
Standard Option
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 not from
biting or chewing. Treatment must be completed
within 24 months from the date of the injury.
Note: A tooth is not considered sound and natural if it has more than one
surface restoration,
a crown or root canal, and/ or the tooth is a partial,
a denture or implant.
$10 per office visit $25 per office visit
Plan provides preventive dental services to children under age 12. This
benefit is limited to
two visits per child per calendar year. The following
dental services are covered.
Oral Exams
Prophylaxis (Cleaning)
Topical application of fluoride (if
drinking water is not fluoridated
Sealants
$10 per office visit $25 per office visit 40
40
Page 41 42
41 Page 42 43
2002 Rocky Mountain HMO Section 6 42
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 that were authorized by another plan before you
enrolled in this plan;
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.
Examinations that are not necessary for medical
reasons, such as those required for obtaining or continuing employment or
insurance, attending school or camp, or travel unless such examination is
the only physical examination obtained during the calendar year.
Surgery
primarily for cosmetic purposes
Hearing aids
Chiropractic services
Homemaker services
Blood and blood derivative not replaced by the member
or,
Transplants not specified as covered. 42
42
Page 43 44
2002
Rocky Mountain HMO 43 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. Rocky
Mountain HMO will
bill you for any co-payments due.
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 970-243-7050 or 1-800-346-4643.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a claim form 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: Rocky Mountain HMO,
2775 Crossroads
Blvd.
Grand Junction, CO 81506
Prescription drugs Drugs and supplies must be obtained by a plan
pharmacy, except for
medical emergencies.
Submit your claims to:
Rocky Mountain HMO
2775 Crossroads Blvd.
Grand Junction, CO 81506 43
43 Page 44 45
2002 Rocky Mountain HMO 44 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 within 30 days when we ask
for additional information. We may delay processing or deny your claim if you do
not respond. 44
44 Page
45 46
2002 Rocky Mountain HMO 45
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 pre-authorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must: (a) Write to us within 6 months from the date of our
decision; and
(b) Send your request to us at: 2775 Crossroads Blvd, Grand
Junction CO, 81506
(c) Include a statement about why you believe our initial
decision was wrong, based on specific
benefit provisions in this brochure;
and
(d) Include copies of documents that support your claim, such as
physicians' letters, operative reports, bills, medical records, and explanation
of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim if applicable or 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 medical provider for more information. If we ask your provider,
we will send you
a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us --if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 2, 1900 E Street, NW, Washington, DC 20415-3620
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. 45
45 Page 46 47
2002 Rocky
Mountain HMO 46 Section 8
Note: You are the only person who has a
right to file a disputed claim with OPM. Parties acting as your representative,
such as medical providers, must include a copy of your specific written consent
with the
review request.
Note: The above deadlines may be extended if
you show that you were unable to meet the deadline because of reasons beyond
your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies or from the year in which your 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 pre-authorization then call us at 970-243-7050 or 1-800-346-4643 and we will
expedite our review; or We denied your initial request for care or
pre-authorization/
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 2 at 202/ 606-3818
between 8 a. m. and 5 p. m. eastern time. 46
46
Page 47 48
2002
Rocky Mountain HMO 47 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health
care
expenses without regard to fault. This is called "double coverage."
When you
have double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the
secondary payer. We,
like other insurers, determine which coverage is primary according to the
National Association of Insurance
Commissioners' guidelines.
When we are
the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
Diligent Pursuit of Coverage Whenever this Plan is determined to be
the secondary policy, you must diligently pursue obtaining coverage from the
primary policy before
receiving any benefits from this Plan as the secondary
policy. You must comply with all conditions and requirements for coverage under
the
primary policy, including, but not limited to, filing claims, providing
notice and information and obtaining treatment by an approved provider,
panel or facility as may be required by the primary policy. Your failure to
comply with this provision will result in non-coverage by this Plan of
any
services or benefits subject to coverage by the primary policy
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
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free Part A insurance.
(Someone who was a Federal employee on January 1 1983 or since
automatically
qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or
your
retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various health
plan
choices available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits with Medicare, depending on the
type of
Medicare managed care plan you have. 47
47
Page 48 49
2002
Rocky Mountain HMO 48 Section 9
The Original Medicare Plan
The Original Medicare Plan 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. You may go to any doctor,
specialist, or hospital that accepts Medicare. The Original
Medicare Plan
pays its share and you pay your share. Some things are not covered under
Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care.
See
page 45 for a list of differences between the benefits of this plan and the
Medicare plan.
(Primary payer chart begins on next page.) 48
48 Page 49 50
2002 Rocky Mountain HMO 49 Section 9
The following chart illustrates whether the Original Medicare Plan or
this Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you tell us
if you or
a covered family member has Medicare coverage so we can administer
these requirements correctly.
Primary Payer Chart
Then the primary
payer is… A. When either you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if
your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have
Medicare based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD
coordination period and are still eligible for Medicare due to ESRD,
3)
Become eligible for Medicare due to ESRD after Medicare became primary for you
under another provision,
C. When you or a covered family member have
FEHB and…
1) Are eligible for Medicare based on disability, and
a)
Are an annuitant, or
b) Are an active employee or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee 49
49 Page
50 51
2002 Rocky Mountain HMO 50
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 Medicare.
When we are the primary payer, we process the
claim first.
When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something about
filing your claims, call us at 970-243-7050 or 1-800-346-4643. 50
50 Page 51 52
2002 Rocky Mountain HMO 51 Section 9
Medicare managed care plan If you are eligible for Medicare, you
may choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan--a
Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. If you enroll in a
Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan (FEDCARE) and also remain enrolled
in our FEHB
plan. In this case, we do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
The table below explains how FEDCARE is different from the Rocky Mountain
HMO Health Plan Brochure for Federal Employees. For
additional information,
please refer to the Summary of Benefits on page 63.
You Pay Inpatient Care
FedCare Plan 1 FedCare Plan 2
Inpatient Hospital Nothing $300 copay per admission
Mental Conditions
Nothing $300 copay per admission
Substance Abuse Nothing $300 copay per
admission
Organ Transplants Nothing $300 copay per admission
Medicare Enrollment Information
Most Federal annuitants have
Medicare Part A. Those without Medicare Part A may join the FEDCARE
prepaid plan but will have to pay for
hospital coverage in addition to the
Part B premium. Before you join the plan, ask whether the plan covers
hospital benefits and, if so, what you
will have to pay. Contact your
retirement system for information on dropping your FEHB enrollment and changing
to a Medicare prepaid
plan.
If you are Medicare eligible and are
interested in enrolling in FEDCARE sponsored by this Plan without dropping your
enrollment in this Plan's
FEHB program, call 1-800-346-4643 for information
on the benefits available under the FEHB Medicare HMO Plan. 51
51 Page 52 53
2002 Rocky Mountain HMO 52 Section 9
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
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.
TRICARE TRICARE is the health care program for eligible dependents of
military persons. TRICARE includes the CHAMPUS program. If both
TRICARE and
this Plan cover you, we pay first. See your TRICARE Health Benefits Advisor if
you have questions about TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related disease or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a
similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its
maximum benefits for your treatment, we will cover your benefits. You must use
our providers
Medicaid When you have this Plan and Medicaid, we pay first. 52
52 Page 53 54
2002 Rocky Mountain HMO 53 Section 9
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 injuries medical or
hospital care for injuries or illness caused by another person, you must
reimburse us for any expenses we paid. However, we will cover the cost of
treatment that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation.
In the event this Plan pays or incurs costs or expenses for
benefits provided to you for injuries, illness or conditions for which you have
a
legal claim against a third party for damages or for which you have a
right to receive payment from a third party's insurer, with or without
regard to fault, then this Plan shall succeed to and become the owner of all
rights, claims, remedies and security existing on your behalf against
the
third party to the extent of cost or expenses paid or incurred, or that in the
future may be paid or incurred, by this Plan on your behalf, with full
power
and authority to enforce such claim in the name of this Plan. "Third party"
shall mean any person or entity, including, but not limited
to, a member
other than the member to whom this Plan is subrogated. In the event this Plan
seeks to enforce recovery from the third party or
obtain information about
your claims against the third party, you must cooperate with this Plan in the
(1) securing and the giving of evidence as
shall be reasonable or necessary
in connection with recovery efforts, including attending depositions, hearing
and trials, (2) furnishing of
information and documents to this Plan when
requested, and (3) assisting in the securing of other witnesses in the conduct
of
administrative or legal proceedings. Recovery by this Plan pursuant to
its right of subrogation shall not affect your obligation to pay premiums,
co-payments or other sums due the Plan.
Any money or property paid to or
recovery by you from a third party or third party insurer, including an insurer
providing
uninsured/ underinsured automobile insurance, in payment of any
claim or judgement, illness or condition caused by the third party, shall be
deemed to be held in trust by you for the benefit of this Plan to the extent
of costs or expenses paid or incurred, or that in the future may be paid or
incurred, by this Plan for benefits related to the injury, illness or
condition. You must promptly pay to this Plan all of the monies,
proceeds or
property received from the third party or insurer to the extent of this Plan's
costs or expenses paid or incurred, or that in the future may
be paid or
incurred, in connection with you injury, illness or condition. You agree that
such monies, proceeds or property shall be paid over this
Plan regardless of
whether the money, property or proceeds are specifically designated or allocated
for a particular type or injury or
claim, regardless of whether you were or
were not fully compensated for all losses or damages suffered in connection with
such injury, illness or
condition.
You shall not, without prior written
consent of this Plan, grant any type of release to or enter into any settlement
with any third party of any claim
for damages resulting from injuries,
illness or condition for which this Plan paid or incurred, or in the future may
pay or incur, costs or expenses
for benefits provide to you and for which
you have legal claim against such third party. If you grant such a release or
enter into such settlement
without this Plan's prior written consent, this
Plan may, at its option, 53
53 Page 54 55
2002 Rocky
Mountain HMO 54 Section 9
refuse to provide benefits related to
such injury, illness or condition. In addition, this Plan may recover from you
any amounts paid to you for
such claims to the extent of all amounts paid or
incurred, or that in the future may be paid or incurred, by this Plan for
benefits related to such
injury, illness or condition. All amounts received
or to be received by you for or on account of medical, hospital or other health
services you
may need in the future for such injury, illness or condition
shall be placed in trust at a financial institution designated by this Plan for
payment of
such services. 54
54 Page 55 56
2002 Rocky
Mountain HMO 55 Section 10
Section 10. Definitions of terms we
use in this brochure
Calendar year January 1 through December 31 of the
same year. For new enrollees, the calendar year begins on the effective date of
their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Care which is furnished mainly to assist a
person in the activities of daily living, and for which professional skill or
training is not required.
Experimental or investigational services The plan will determine the
experimental/ investigational nature of a
service, supply or drug through
its Medical Department and Medical Director. The plan, in its discretion, may
review material from, or seek
input from, the following groups: The Food and
Drug Administration, The National Institutes of Health and the American Medical
Association.
The Plan may also consider any local community standard with
respect to each service in question, and inquire as to the coverage of such
service
by group health insurance companies an other health maintenance
organizations in the Plan's service area.
Medical necessity Services that are necessary to preserve a member's
health according to the standards of medical practice in the community. Services
provided
only as a convenience are not considered necessary. The fact that a
plan provider prescribes, recommends or orders a service or supply does not
make it medically necessary.
Us/ We Us and we refer to Rocky Mountain HMO
You You refers
to the enrollee and each covered family member. 55
55
Page 56 57
2002
Rocky Mountain HMO 56 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. 56
56 Page
57 58
2002 Rocky Mountain HMO 57
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.
Temporary continuation of coverage (TCC) If you leave Federal service,
or if you lose coverage because you no
longer qualify as a family member,
you may be eligible for Temporary Continuation of Coverage (TCC). For example,
you can receive TCC if
you are not able to continue your FEHB enrollment
after you retire, if you lose your job, if you are a covered dependent child and
you turn 22
or marry, etc. 57
57 Page 58 59
2002 Rocky
Mountain HMO 58 Section 11
You may not elect TCC if you are fired
from your Federal job due to gross misconduct.
Enrolling in TCC. Get
the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal
Employees Health Benefits Plans for
Temporary Continuation of Coverage and
Former Spouse Enrollees, from your employing or retirement office or from
www. opm. gov/ insure.
It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
Your coverage under TCC or the spouse equity law ends. If you canceled your
coverage or did not pay your premium, you cannot
convert;
You decided
not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who is
losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability an
Accountability ACT of 1996 Group Health Plan Coverage (HIPAA) is a
Federal law that offers limited Federal protections for
health coverage
availability and continuity to people who lose employer group coverage. If you
leave the FEHB Program, we will give you a
Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You can use
this certificate when getting
health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods, limitations,
or exclusions for health
related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have
been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web
site (www. opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently
asked question. These highlight HIPAA rules, such
as the requirement that
Federal employees must exhaust any TCC eligibility as one condition for
guaranteed access to individual health
coverage under HIPAA, and information
about Federal and State agencies you can contact for more information 58
58 Page 59 60
2002 Rocky Mountain HMO 59 Section 11
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. 59
59 Page 60 61
2002 Rocky
Mountain HMO 60 Section 11
Long Term Care Insurance Is Coming
Later in 2002!
The Office of Personnel Management (OPM) will
sponsor a high-quality long term care insurance program effective in October
2002. As part of its educational effort, OPM asks you to consider these
questions:
What is long term care (LTC) insurance? It's
insurance to help pay for long term care services you may need if you can't take
care of yourself because of
an extended illness or injury, or an age-related
disease such as Alzheimer's. LTC insurance can provide broad, flexible benefits
for care in a nursing home, in an assisted living facility, in
your home,
adult day care, hospice care, and more. LTC insurance can supplement care
provided by family members, reducing the burden you place on them.
I'm healthy. I won't need long term care. Or, will I? 76% of Americans
believe they will never need long term care, but the facts are that about half
of them will.
And it's not just the old folks. About 40% of people needing
long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
We hope you will
never need long term care, but you should have a plan just in case. LTC
insurance may be vital to your financial and retirement planning.
Is long term care expensive? Yes. A year in a nursing home can exceed
$50,000 and only three 8-hour shifts a week can exceed $20,000 a
year,
that's before inflation! LTC can easily exhaust your savings but LTC insurance
can protect it.
But won't my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look under "Not covered" in sections 5( a) and 5( c) of
your FEHB brochure. Custodial care, assisted
living, or continuing home
health care for activities of daily living are not covered. Limited stays in
skilled nursing facilities can be covered in some circumstances.
Medicare
only covers skilled nursing home care after a hospitalization with a 100 day
limit. Medicaid covers LTC for those who meet their state's guidelines, but
restricts covered services and where they
can be received. LTC insurance can
provide choices of care and preserve your independence.
When will I get
more information? Employees will get more information from their agencies
during the late summer/ early fall of 2002.
Retirees will receive
information at home.
How can I find out more about the program NOW? A
toll-free telephone number will begin in mid-2002. You can learn more about the
program now at
www. opm. gov/ insure/ ltc
Many FEHB enrollees think their health plan and/ or Medicare covers long-term
care. Unfortunately, they are WRONG! How are YOU planni ng to pay for the
future custodial or chronic care you may need? Consider buying long term care
insurance. 60
60 Page
61 62
2002 Rocky Mountain HMO 61
Section 11
TCC eligibility See Section 11, FEHB Facts; it
explains temporary continuation of coverage (TCC). Under this DoD/ FEHB
Demonstration Project the only individual eligible
for TCC is one who
ceases to be eligible as a "member of family" under your self and family
enrollment. This occurs when a child turns 22, for example, or if you
divorce and your spouse does not qualify to enroll as an unremarried former
spouse under title 10, United States Code. For these individuals, TCC begins the
day after their enrollment in the DoD/ FEHB Demonstration Project ends. TCC
enrollment terminates after 36 months or the end of the Demonstration Project,
whichever occurs first. You, your child, or another person must notify the
IPC when a family member loses eligibility for coverage under the DoD/ FEHB
Demonstration Project.
TCC is not available if you move out of a DoD/
FEHB Demonstration Project area, you cancel your coverage, or your coverage is
terminated for any reason. TCC is
not available when the demonstration
project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project. 61
61 Page 62 63
2002 Rocky Mountain HMO 62 Index
Index Do not rely on this page; it is for your convenience and
may not show your benefit coverage.
Accidental injury 31 Allergy
tests 17
Alternative treatment 23 Ambulance 32
Anesthesia 27 Autologous
bone marrow
transplant 27 Biopsies 24
Blood and blood plasma 29
Breast cancer screening 15
Changes for 2001 7 Chemotherapy 18
Cholesterol tests 14 Claims 43
Colorectal cancer screening 14
Contraceptive devices and drugs 16
Coordination of benefits 47 Covered
providers 5
Crutches 22 Definitions 57
Dental care 38 Diagnostic
services 13
Disputed claims review 45 Donor expenses (transplants) 27
Durable medical equipment (DME) 22
Educational classes and
programs 23 Effective date of enrollment 54
Emergency 31 Experimental or
investigational 52
Eyeglasses 20 Family planning 16
Fecal occult blood test 14 General Exclusions 42
Hearing
services 19 Home health services 22
Hospice care 30 Home nursing care 22
Hospital 28 Immunizations 15
Infertility 17 Inhospital physician
care 13
Insulin 36 Laboratory and pathological
services 14
Machine diagnostic tests 14
Magnetic Resonance Imagings (MRIs) 14
Mammograms 15 Maternity Benefits 16
Medically necessary 52 Medicare 47
Mental Conditions/ Substance Abuse Benefits 33
Newborn care 16 Non-FEHB
Benefits 39
Nursery charges 16 Obstetrical care 16
Occupational
therapy 19 Office visits 13
Oral and maxillofacial surgery 26 Orthopedic
devices 21
Out-of-pocket expenses 11 Outpatient facility care 29
Pap test 14 Physical examination 13
Physical therapy 19
Precertification 10
Preventive care, adult 14 Preventive care, children 15
Prescription drugs 35 Prostate cancer screening 14
Prosthetic devices 21
Radiation therapy 18
Rehabilitation therapies 19 Renal dialysis 18
Room and board 28 Skilled nursing facility care 13
Speech therapy 19
Subrogation 51
Substance abuse 33 Surgery 24
Anesthesia 27 Oral 26
Reconstructive 25 Temporary continuation of
coverage 54
Transplants 27
Treatment therapies 18 Vision services 20
Well
child care 15 Wheelchairs 22
Workers' compensation 50 X-rays 14
62
62 Page 63 64
2002 Rocky Mountain HMO 63 Section 11
Summary of benefits for the Rocky Mountain HMO – 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
High Option
You Pay
Standard Option
Page
Medical services provided by physicians:
Diagnostic and treatment
services provided in the
office
..............................................................................
Office visit copay: $10 primary care; $10
specialist
Office visit copay: $25 primary care; $25
specialist
14
Services provided by a hospital:
Inpatient
...........................................................................
Outpatient
........................................................................
$200 per admission
$100 for outpatient surgery
$500 per admission
$200 for outpatient surgery
25
Emergency benefits:
In-area..............................................................................
Out-of-area
......................................................................
$10 per office visit
$35 urgent care visit
$75 Emergency room visit
Reasonable charges for emergency care
services to the extent the services
would
have been covered if received from plan
providers
$25 per office visit
$50 urgent care visit
$100 Emergency room visit
Reasonable charges for emergency care
services to the extent the services
would
have been covered if received from plan
providers
33
Mental health and substance abuse treatment...................... Regular
benefits Regular benefits 35
Prescription drugs
................................................................. $10 generic
$20 preferred
$35 name brand
$10 generic
$20 preferred
$35 name brand
37
Protection against catastrophic costs (your out-of-pocket
maximum)............................................. Nothing after $750 Self
Only or $1500 for
Family enrollment per year
Some costs do not count toward this
protection
Nothing after $1500 Self Only or $3000 for
Family enrollment per year
Some costs do not count toward this
protection
12 63
63 Page
64
2002 Rocky Mountain HMO 64 Section 11
2002 Rate Information for Rocky Mountain HMO Benefit Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and
special FEHB guides are published for
Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
High Option
Self Only XJ1 $97.86 $60.57 $212.03 $131.24 $115. 52
$42.91
High Option
Self and Family XJ2 $223.41 $147.13 $484.06 $318.78 $263.
75 $106.79
Standard Option
Self Only XJ4 $97.86 $44.73 $212.03 $96.92 $115. 52
$27.07
Standard Option
Self and Family XJ5 $223.41 $110.08 $484.06 $238.50
$263. 75 $69.74 64