A Health Maintenance Organization
Serving: Philadelphia and
seven adjacent counties in
Southeastern Pennsylvania and New
Jersey.
Enrollment in this plan is limited . You must live or work in our
Geographic service area to enroll. see page 8 for requirements
Enrollment Codes for this Plan:
271 Self Only
272 Self and
Family
Serving: Scranton Wilkes-Barre area
Enrollment Codes for
this Plan:
2K1 Self Only
2K2 Self and Family
RI 73-040
Health Net of
Pennsylvania, Inc. http:// www. health. net
2002
For changes
in benefits,
See page 9 1
1
Page 2 3
2002 Health Net of Pennsylvania, Inc. 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………........................................................................
5
Plain
Language……………………………………………………………….......................................................................
5
Inspector General
Advisory……………………………………………………………………………………………. 6
Section
1. Facts about this HMO
plan.........................................................................................................................................
7
How we pay
providers.................................................................................................................................................
7
Who provides my health
care?...................................................................................................................................
7
Your Rights
...................................................................................................................................................................
7
Service Area
..................................................................................................................................................................
8
Section 2. How we change for
2002……………………………………….........................................................................
9
Program-wide
changes................................................................................................................................................
9
Changes to this
Plan.....................................................................................................................................................
9
Section 3. How you get care
………….....................................................................................................................................
10
Identification cards
....................................................................................................................................................
10
Where you get covered care
.....................................................................................................................................
10
Plan providers
......................................................................................................................................................
10
Plan
facilities........................................................................................................................................................
10
What you must do to get covered care
...................................................................................................................
10
Primary care
.........................................................................................................................................................
10
Specialty care
.......................................................................................................................................................
10
Hospital
care.........................................................................................................................................................
11
Circumstances beyond our
control..........................................................................................................................
11
Services requiring our prior
approval.....................................................................................................................
12
Section 4. Your costs for covered
services...............................................................................................................................
13
Copayments
.........................................................................................................................................................
13
Deductible.............................................................................................................................................................
13
Coinsurance
.........................................................................................................................................................
13
Your out-of-pocket
maximum..................................................................................................................................
13
Section 5.
Benefits………………………………………………………….......................................................................
14
Overview......................................................................................................................................................................
14
(a) Medical services and supplies provided by
physicians and other health care professionals ............ 15
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ........ 23
(c)
Services provided by a hospital or other facility, and ambulance services
.......................................... 27 2
2
Page 3 4
2002 Health Net of Pennsylvania, Inc. 3 Table of Contents
(d) Emergency services/ accidents
......................................................................................................................
29
(e) Mental health and substance abuse benefits
..............................................................................................
31
(f) Prescription drug
benefits..............................................................................................................................
34
(g) Special features
...............................................................................................................................................
37
Flexible benefits option
Health Net of Pennsylvania, Inc. HealthLine
Health Newsline and Resource Guide
Being Well Magazine
(h) Dental
benefits.................................................................................................................................................
38
(i) Non-FEHB benefits available to Plan members
........................................................................................
39
Section 6. General exclusions --things we don't
cover.........................................................................................................
40
Section 7. Filing a claim for covered services
..........................................................................................................................
41
Section 8. The disputed claims
process.....................................................................................................................................
42
Section 9. Coordinating benefits with other
coverage
............................................................................................................
44
When you have…
Other health coverage
........................................................................................................................................
44
Original Medicare
...............................................................................................................................................
44
Medicare managed care
plan.............................................................................................................................
47
TRICARE/ Workers' Compensation/ Medicaid
...................................................................................................
48
Other Government agencies
..................................................................................................................................
48
When others are responsible for injuries
.............................................................................................................
48
Section 10. Definitions of terms we use in this
brochure
.......................................................................................................
49
Section 11. FEHB facts
................................................................................................................................................................
51
Coverage
information...............................................................................................................................................
51
No pre-existing condition
limitation...............................................................................................................
51
Where you get information about enrolling in the FEHB
Program.......................................................... 51
Types of coverage available for you and your family
.................................................................................
51
When benefits and premiums start
.................................................................................................................
52
Your medical and claims records are
confidential.......................................................................................
52
When you
retire.................................................................................................................................................
52
When you lose benefits
.........................................................................................................................................
52
When FEHB coverage
ends.............................................................................................................................
52
Spouse equity coverage
...................................................................................................................................
52
Temporary Continuation of Coverage
(TCC)..............................................................................................
52
Enrolling in
TCC................................................................................................................................................
53
Converting to individual
coverage..................................................................................................................
53
Getting a Certificate of Group Health Plan
Coverage................................................................................
53 3
3 Page 4 5
2002 Health Net of Pennsylvania, Inc. 4 Table of Contents
Long term care insurance is coming later in
2002……………………………………………………………………. 54
Index
...................................................................................................................................................................................
56
Summary of
benefits......................................................................................................................................................................
57
Rates…………………………………………………………………………………………………………..
Back cover 4
4 Page
5 6
2002 Health Net of Pennsylvania, Inc. 5 Introduction/ Plain
Language/ Advisory
Introduction
Health Net of Pennsylvania,
Inc.
11 Penn Center, 1835 Market St., 10 th Floor
Philadelphia, PA 19103
This brochure describes the benefits of Health Net of Pennsylvania, Inc.
under our contract (CS1743) with the Office
of Personnel Management (OPM),
as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 9. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we" means Health Net of
Pennsylvania, Inc.
We limit acronyms to ones you know, FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel Management. If we use others,
we tell you what they mean first.
Our brochure and other FEHB plans;
brochures have the same format and similar descriptions to help you compare
plans.
If you have comments or suggestions about how to improve the
structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback
area at www. opm. gov/ insure or e-mail -OPM
at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650. 5
5
Page 6 7
2002
Health Net of Pennsylvania, Inc. 6 Introduction/ Plain Language/ Advisory
Inspector General Advisory
Stop health care fraud! Fraud
increases the cost of health care for everyone. If you suspect that a
physician, pharmacy, or hospital has charged you for services you did not
receive, billed you twice for the same service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 1-800-998-2840 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. 6
6 Page 7 8
2002 Health Net of Pennsylvania, Inc. 7 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and
other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We 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 healthcare?
Health Net of Pennsylvania, Inc.
arranges for the provision of services through contracted doctors, nurse
practitioners,
physician assistants, and other skilled medical personnel at
participating medical centers or offices. Your medical
records will be
maintained at the Plan medical office of your choice and your primary health
care will be provided, by
appointment, at that office. Except for
emergencies, all care must be provided by or arranged for you through the
primary care physician that you choose.
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.
The right to receive information about Health Net of Pennsylvania, Inc.,
its Officers, Health Net of Pennsylvania, Inc. Services, healthcare
practitioners and providers, and your rights and responsibilities as a Member.
The right to an Advance Directive, living will, or other directive to your
contracting medical providers with
respect to your future healthcare choices
The right to information regarding how medical treatment decisions are
made by the participating medical providers or Health Net of Pennsylvania, Inc.
as well a payment structure.
Health Net of Pennsylvania, Inc. has been in existence since 1972.
Health Net of Pennsylvania, Inc. is a Health Maintenance Organization. Health
Net of Pennsylvania, Inc. is a wholly owned subsidiary of Health Net Inc., a
for-profit company.
If you want more information about us, call 1-800-998-2840 or write to Health
Net of Pennsylvania, Inc., 11 Penn
Center, 1835 Market St., 10th Floor,
Philadelphia, PA 19103. You may also contact us by fax at (732) 643-7416 or
visit our website at www. health. net. 7
7 Page 8 9
2002 Health Net of Pennsylvania, Inc. 8
Section 1
Service Area
To enroll in this Plan, you must
live or work in our service area. This is where our providers practice. Our
service
area is: The Pennsylvania counties of Bucks, Chester,
Delaware, Lackawanna, Luzerne, Montgomery and
Philadelphia, and the New
Jersey counties of Camden, Burlington and Gloucester.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care benefits. We will not pay for any other health care services out of our
service
area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 8
8 Page
9 10
2002 Health Net of Pennsylvania,
Inc. 9 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 increased speech therapy benefits by removing the requirement that
services must be required to restore functional speech, (Section 5( a)).
Changes to this Plan
Your share of the non-Postal premium for
Code 27 will decrease by -1.3% for Self Only or increase 0.6% for Self
and
Family. Your share of non-Postal premium for Code 2K will increase by 8.8% for
Self Only or increase 8.2%
for Self and Family.
We now provide coverage for up to $100 for one smoking cessation program
per member per lifetime, including all related expenses such as drugs.
We cover Chiropractic Services, examinations, manipulations, x-rays and
other therapies such as hot packs and electrical stimulation, up to 30 visits
per member per calendar year subject to a $10 copayment.
We cover
Acupuncture Services up to 20 visits per member per calendar year subject to a
$20 copayment.
We increased the copayment to $50 for Emergency care as an
outpatient or inpatient at hospital, including doctors' services.
We cover Durable Medical Equipment at 50% of the cost of the covered item
to a maximum of $1,500 per member per calendar year.
We now cover
Prescription drugs at a $10 copayment per generic drug, $20 copayment per
preferred brand name drug, and $35 copayment per non-preferred brand name drug.
The cost of prescriptions filled through the Plan's
mail order supplier will
be equal to 2 copayments for a 90 day supply.
We now cover certain
intestinal transplants (small intestine). (Section 5( b)) 9
9 Page 10 11
2002 Health Net of Pennsylvania, Inc. 10
Section 3
Section 3. How you get care
Identification cards
We will send you an identification (ID) card. You should carry your ID card
with you at all times. You must show it whenever you receive
services from a
Plan provider, or fill a prescription at a Plan pharmacy.
Until you receive
your ID card, use your copy of the Health Benefits
Election Form, SF-2809,
your health benefits enrollment confirmation (for
annuitants), or your
Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at
1-800-736-
2096.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments 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. The list is also on our website.
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. The list is also on our
website.
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. A Provider Selection form
is included in your enrollment
package.
Primary care Your primary care physician can be a family
practitioner, general practitioner, or internist. 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. However, you may see your gynecologist for exams
without a referral.
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 10
10 Page 11 12
2002 Health Net of Pennsylvania, Inc. 11
Section 3
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 provider.
If you are in the second or third trimester of pregnancy and you lose access
to your specialist based on the above circumstances, you can continue to
see your specialist until the end of your postpartum care, even if it is
beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise your care. This includes
admission to
a skilled nursing or other type of facility.
If you are in
the hospital when your enrollment in our Plan begins, call our
customer
service department immediately at 1-800-736-2096. 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. 11
11 Page 12 13
2002 Health Net of Pennsylvania, Inc. 12
Section 3
Services requiring our Your primary care physician
has authority to refer you for most services. prior approval 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.
We call this the review and approval process. Your physician must obtain
Prior Authorization for some services, such as:
Non-emergency hospital admissions
MRIs, CT Scans
Any referral
to a non-participating provider or facility
Outpatient services by
physical therapists, speech therapists or
occupational therapists
All
skilled nursing facility admissions or home care
Non-emergency ambulance
transportation
Hospital beds, wheelchairs, prostheses, and insulin pumps
Prescriptions for certain injectable drugs
Home health services
Cardiac nuclear stress test
By following these steps, you'll know you're seeing the right provider for
your medical problem at the right time. Here's all you have to do:
1. Contact your Primary Care Physician (PCP) whenever you think you
need
care from a specialist or a specialized medical procedure.
2. If you PCP
feels you need specialized care, s/ he will refer you to a
participating
specialist for a consultation and possible follow-up visits.
No Prior
authorization by Health Net of Pennsylvania, Inc. is required.
3. Once you
have seen a specialist physician, it may be necessary the
specialist to
request an authorization for certain diagnostic tests or
therapeutic
procedures. We will review the request to be sure the
service is a covered
benefit and that specialized medical procedures are
performed by a
participating, qualified doctor in a qualified facility.
4. In most cases,
Health Net of Pennsylvania, Inc. will notify you of
approval or denial, in
writing, within five days of receiving the request
for authorization. If the
request is approved, make an appointment at
the facility listed on the
referral letter.
Occasionally, you doctor's request may be denied. Health Net of
Pennsylvania, Inc. may require more information from your doctor about
the service requested. Please contact your PCP or Member Services at
1-
800-736-2096 if this happens. If you make an appointment, and the
request was denied, you will be responsible for all charges. 12
12 Page 13 14
2002 Health Net of Pennsylvania, Inc. 13
Section 4
Section 4. Your costs for covered services
You
must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider,
facility,
pharmacy, etc. when you receive services.
Example: When you see your primary care physician or specialist you pay
a
copayment of $10 per office visit.
Deductible A deductible is a fixed expense you must incur for
certain covered services
and supplies before we start paying benefits for
them.
We only have a deductible for external prostheses.
Note: If you change
plans during open season, you do not have to start a
new deductible under
your old plan between January 1 and the effective
date of your new plan. If
you change plans at another time during the year,
you must begin a new
deductible under your new plan.
And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your
old option to the deductible of your new option.
Coinsurance Coinsurance is the percentage of our negotiated fee
that you must pay for
your care. Coinsurance doesn't begin until you meet
your deductible.
Example: In our Plan, you pay 50% of our allowance for infertility
services.
Your catastrophic protection
out-of-pocket maximum for After your
copayments total $500 per person in any calendar year, you do copayments,
deductibles and not have to pay any more for covered services. However,
copayments for
coinsurance 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. 13
13 Page 14 15
2002 Health Net of Pennsylvania, Inc. 14 Section 5
Section 5. Benefits --OVERVIEW
(See page 9 for how our
benefits changed this year and page 57 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us
at 1-800-736-2096
or at our website at www. health. net.
(a) Medical services and supplies provided by physicians and other health
care professionals .......................................... 15-22
Diagnostic and treatment services
Lab, X-ray, and other diagnostic
tests Preventive
care, adult
Preventive care, children
Maternity
care Family
planning
Infertility services
Allergy care Treatment
therapies
Physical and occupational therapies
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and
supplies)
Foot care
Orthopedic
and prosthetic devices
Durable medical equipment (DME)
Home
health services
Chiropractic
Alternative treatments
Educational
classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals .......................... 23-26
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/
tissue transplants Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
............................................................ 27-28
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care
facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents
.......................................................................................................................................
29-30
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits................................................................................................................
31-33
(f) Prescription drug benefits
...............................................................................................................................................
34-36
(g) Special
features.......................................................................................................................................................................
37
Flexible benefits option
Health Net of Pennsylvania, Inc.
HealthLine
Health Newsline and Resource Guide
Being Well Magazine
(h) Dental benefits
........................................................................................................................................................................
38
(i) Non-FEHB benefits available to Plan members
...............................................................................................................
39
Summary of
benefits......................................................................................................................................................................
57 14
14 Page 15
16
2002 Health Net of Pennsylvania, Inc. 15
Section 5( a)
Section 5 (a) Medical services and supplies provided
by physicians and other health care professionals
I M
P O
R T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
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 calendar year deductible is:
$100 per person. The calendar year deductible applies to external prostheses
only.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office $10 per
office visit
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical
consultations
Second surgical opinion
$10 per office visit
nothing
nothing
$10 per office visit
$10
per office visit
At home nothing
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these
services during your office visit;
otherwise, $10 per office visit 15
15 Page 16 17
2002 Health Net
of Pennsylvania, Inc. 16 Section 5( a)
Preventive care, adult
You Pay
Routine screenings, such as:
Total Blood Cholesterol –
once every three years
Colorectal Cancer Screening, including
Fecal
occult blood test
$10 per office visit
Sigmoidoscopy, screening – every five years starting at age 50
Prostate
Specific Antigen (PSA test) – one annually for men age 40 and older $10 per
office visit
Routine pap test
Note: The office visit is covered if pap
test is received on the same day;
see Diagnostic and Treatment,
above.
$10 per office visit
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Preventive care, children
Childhood immunizations recommended by
the American Academy
of Pediatrics
$10 per office visit
Well-child care charges for routine examinations, immunizations and care (
under age 22)
Examinations, such as:
Eye exams through age 17 to
determine the need for vision correction.
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( under age 22)
$10 per office visit 16
16 Page 17 18
2002 Health Net
of Pennsylvania, Inc. 17 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in
mind:
You do not need to precertify your normal delivery; see page 12 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular
delivery
and 96 hours after a cesarean delivery. We will extend
your inpatient stay
if medically necessary.
We cover routine nursery care of the newborn child during the
covered
portion of the mother's maternity stay. We will cover other
care of an
infant who requires non-routine treatment only if we
cover the infant under
a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$10 for initial prenatal office visit
only/ you pay nothing thereafter
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
$100 copay
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
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges. 17
17 Page 18 19
2002 Health Net
of Pennsylvania, Inc. 18 Section 5( a)
Infertility services
You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
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.
No charge for Initial evaluation
Up to 50% of cost after initial
evaluation
Not covered:
Reversal of voluntary, surgically-induced
sterility
Assisted reproductive technology (ART) procedures, such
as:
in vitro fertilization
embryo transfer, gamete GIFT
and zygote ZIFT
---Zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 18
18 Page 19 20
2002 Health Net of Pennsylvania, Inc. 19
Section 5( a)
Treatment therapies You pay
Chemotherapy
and radiation therapy
Note: High dose chemotherapy in association with
autologous bone
marrow transplants are limited to those transplants listed
under
Organ/ Tissue Transplants on page 25.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment.
Call 1-800-50-REFER for preauthorization. We
will ask you to submit
information that establishes that the GHT is
medically necessary. Ask
us to authorize GHT before you begin treatment;
otherwise, we will
only cover GHT services from the date you submit the
information. If
you do not ask or if we determine GHT is not medically
necessary, we
will not cover the GHT or related services and supplies. See
Services
requiring our prior approval in Section 3.
$10 per office visit
Physical and occupational therapies
60 visits per condition for
the services of each of the following:
qualified physical therapists and
occupational therapists.
Note: We only cover therapy to restore bodily
function when there
has been a total or partial loss of bodily function due
to illness or
injury.
Cardiac rehabilitation following a heart transplant, bypass
surgery or
a myocardial infarction, is provided for up to 20
sessions
$10 per office visit
Nothing per visit during covered
inpatient
admission.
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
Two (2) consecutive months per condition with
approval from the Medical Director $10 per office visit 19
19 Page 20 21
2002 Health Net of Pennsylvania, Inc. 20
Section 5( a)
Hearing services (testing, treatment, and supplies)
You Pay
First hearing aid and testing only when necessitated by
accidental
injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered:
all other hearing testing
hearing
aids, testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
$10 per office visit
Annual eye exam to determine the need for vision correction for children
through age 17 (see preventive care)
Bi-annual eye exam to determine the
need for vision correction for
adults over age 17 (see preventive care)
Annual eye refractions
$10 per office visit
Not covered:
Eyeglasses or contact lenses and, after age 17,
examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per 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. 20
20 Page 21 22
2002 Health Net
of Pennsylvania, Inc. 21 Section 5( a)
Orthopedic and
prosthetic devices You pay
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following
mastectomy. Note: See 5( b) for coverage of the surgery
to insert the
device.
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following
mastectomy. Note: We pay internal prosthetic devices as
hospital benefits;
see Section 5 (c) for payment information. See
5( b) for coverage of the
surgery to insert the device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
$10 per office visit
$100 deductible per calendar year
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel
cups
lumbosacral supports
corsets, trusses, elastic
stockings, support hose, and other supportive
devices
prosthetic replacements provided less than 3 years after the last one we
covered
All charges.
Durable medical equipment (DME)
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;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
$10 per office visit
50% of the cost of the covered item to
a maximum
of $1,500 per member per
calendar year
Not covered:
Motorized wheel chairs All charges. 21
21 Page 22 23
2002 Health Net of Pennsylvania, Inc. 22
Section 5( a)
Home health services You Pay
Home health
care ordered by a Plan physician and provided by a
registered nurse (R. N.),
licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.),
or home health aide.
Services include oxygen therapy, intravenous therapy and
medications.
You pay nothing.
Not covered:
nursing care requested by, or for the
convenience of, the patient or the patient's family;
home health care primarily for personal assistance that does not
include a medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges.
Chiropractic
When approved in advance, Chiropractic care on an
outpatient basis for
up to 30 visits per member per calendar year.
Manipulation of the spine and extremities
Adjunctive procedures such
as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold
pack application.
$10 per office visit
Alternative treatments
Acupuncture services are covered when
approved in advance up to 20
visits per member per calendar year
$20
per office visit.
Not covered:
Naturopathic services
Hypnotherapy
biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses
such as drugs.
$10 per office visit. 22
22 Page 23 24
2002 Health Net
of Pennsylvania, Inc. 23 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.
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
changes associated with the facility (i. e. hospital, surgical
center,
etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION 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.
I M
P O
R T
A N
T
Benefit Description You pay
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
procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual
weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must
be age 18 or over
Insertion of internal prostethic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
$10 per office visit
Nothing in a hospital.
Surgical procedures continued on next page. 23
23 Page 24 25
2002 Health Net of Pennsylvania, Inc. 24
Section 5( b)
Surgical procedures (Continued) You
pay
Voluntary sterilization $100 copay
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
Nothing in a hospital
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$10 per office visit
Nothing in a hospital.
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.
See above.
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 24
24 Page 25 26
2002 Health Net
of Pennsylvania, Inc. 25 Section 5( b)
Oral and maxillofacial
surgery You Pay
Oral surgical procedures, limited to:
Reduction of
fractures of the jaws or facial bones;
Surgical correction of cleft lip,
cleft palate 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.
TMJ surgery and other non-dental treatment.
$10 per office visit
Nothing in a hospital.
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
All charges.
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung:
Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and
peripheral
stem cell support) for the following conditions: acute
lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced
non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants
(small intestine) and the small intestine with
the liver or small intestine
with multiple organs such as the liver,
stomach, and pancreas
National
Transplant Program (NTP)
Limited Benefits -Treatment for breast cancer,
multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or
NIH-approved
clinical trial at a Plan-designated center of excellence and if
approved
by the Plan's medical director in accordance with the Plan's
protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
Organ/ tissue transplants continued on next page 25
25 Page 26 27
2002 Health Net of Pennsylvania, Inc. 26
Section 5( b)
Organ/ tissue transplants (continued)
You pay
Not covered:
Donor screening tests and
donor search expenses, except those performed for the actual donor
Implants of artificial organs
Transplants not listed as
covered
All charges
Anesthesia
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
$10 per office visit 26
26 Page 27 28
2002 Health Net
of Pennsylvania, Inc. 27 Section 5( c)
Section 5 (c). Services
provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and
exclusions in this brochure and are payable only when we determine they
are
medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized
in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including 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 PRECERTIFICATION OF HOSPITAL
STAYS.
Please refer to Section 3 to be sure which services require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations;
general
nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies
and equipment, including oxygen
Anesthetics, including nurse anesthetist
services
Take-home items
Medical supplies, appliances, medical
equipment, and any covered items billed by a hospital for use at home (Note:
calendar year
deductible applies.)
Nothing
Inpatient hospital continued on next page. 27
27 Page 28 29
2002 Health Net of Pennsylvania, Inc. 28
Section 5( c)
Inpatient hospital (Continued) You pay
Not covered:
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.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration
of blood, blood plasma, and other biologicals
Blood and blood plasma, if
not donated or replaced
Pre-surgical testing
Dressings, casts, and
sterile tray services
Medical supplies, including oxygen
Anesthetics
and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do
not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
Skilled nursing facility (SNF): 120 days limitation/ year
Nothing
Not covered: custodial care All charges
Hospice care
Supportive and palliative care for terminally ill members in home or
hospice facility, including:
Inpatient and outpatient care
Family counseling
Note: These
services are provided under the direction of a Plan doctor
who certifies
that the patient is in terminal stages of illness, with a life
expectancy of
approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when
medically appropriate Nothing 28
28 Page 29 30
2002 Health Net
of Pennsylvania, Inc. 29 Section 5( d)
Section 5 (d).
Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including 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.
What to do in case of emergency:
Emergencies within our service area: If you are in a non-threatening
emergency situation, please call your primary care doctor. In life-threatening
emergencies, if you are unable to contact your doctor, contact the
local
emergency system (e. g., the 911-telephone system) or go to the nearest hospital
emergency room. Be sure to
tell the emergency room personnel that you are a
Plan member so they can notify the Plan. You or a Family
member should
notify the Plan within 48 hours. It is your responsibility to ensure that the
plan has been timely
notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following
your admission, unless it was not
reasonably possible to notify the Plan within that time. If you are hospitalized
in
non-Plan facilities and Plan doctors believe care can be better provided
in a Plan hospital, you may be transferred
when medically stable with any
ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan
provider would result in death,
disability or significant jeopardy to your condition. To be covered by this
Plan,
any follow-up care recommended by non-Plan providers must be approved
by the Plan or provided by Plan
providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following
your admission, unless it was not
reasonably possible to notify the Plan within that time. If a Plan doctor
believes
care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any
ambulance charges covered in
full. To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided by Plan providers 29
29 Page 30 31
2002 Health Net of Pennsylvania, Inc. 30
Section 5( d)
Benefit Description You pay
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
$25 per office visit/
waived if admitted to
hospital
$50 per visit/ waived if
admitted to hospital
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
$10 per office visit
$25 per office visit
$50 per visit/ waived if
admitted to hospital
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
No charge
Not covered: air ambulance All charges. 30
30 Page 31 32
2002 Health Net of Pennsylvania, Inc. 31
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
Network Benefit
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and
limitations for Plan mental health and substance
abuse benefits will be no greater than for similar
benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost
sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES.
See the instructions
after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse
benefits
All diagnostic and treatment services recommended
by Plan providers and
contained in a treatment plan
that we approve. The treatment plan may
include
services, drugs and supplies described elsewhere in
this
brochure.
Note: Plan benefits are payable only when we
determine the care is
clinically appropriate to treat
your condition and only when you receive the
care
as part of a treatment plan that we approve
Your cost sharing responsibilities are no
greater than for other
illnesses 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
Diagnostic Tests Nothing
Services provided by Hospital or other
facility
Services in approved Alternate Care settings such as
participating hospitals, halfway houses, residential
treatment, full-day hospitalization, facility-based
intensive outpatient
treatment
Nothing 31
31 Page
32 33
2002 Health Net of Pennsylvania,
Inc. 32 Section 5( e)
Network mental health and substance
abuse benefits (continued) You Pay
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.
Network mental health and substance abuse benefits --Continued on next
page. 32
32 Page
33 34
2002 Health Net of Pennsylvania,
Inc. 33 Section 5( e)
Network Benefit --CONTINUED
Preauthorization To be eligible to receive benefits you must
follow your treatment plan and all of our network authorization processes. These
include:
You must call Managed Health Network for a list of participating
providers and for authorization at 1-800-977-7593;
You must receive services from Health Net of Pennsylvania, Inc.
providers
Limitation We may limit your benefits if you do not follow your
treatment plan. 33
33 Page
34 35
2002 Health Net of Pennsylvania,
Inc. 34 Section 5( f)
Section 5 (f). Prescription drug
benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write
the prescription – or – A plan physician or licensed dentist must write the
prescription.
Where you can obtain them. You must fill the prescription at a plan
pharmacy, or by mail for a maintenance medication.
We use a formulary.
The Plan uses a formulary that includes generic and preferred name brand
drugs. The Plan's Pharmacy and Therapeutics Committee meets on a quarterly basis
to review new
medications to be added to or deleted from the formulary.
Reviews for additions to the formulary are based primarily on the following:
1. New drug therapies introduced
2. Changes in existing drug therapies
3. Requests received from Plan physicians
The criteria used are the
safety and efficacy of the drug, other similar products available, and its
relative cost. Deletions are decided by the committee based on low utilization,
other types of
equivalent therapy available, or negative changes in existing therapies. Your
doctor can ask for
exceptions to the formulary. Nonformulary drugs will be
covered when prescribed by a Plan doctor.
We have an open formulary. If your physician believes a name brand product
is necessary or there is no generic available, your physician may prescribe a
name brand drug from a formulary list. This
list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower
cost. To order a prescription drug brochure, call 1-800-736-2096.
Please Note: All brand name drugs that are not listed in the preferred
drug formulary will be
subject to the highest copayment.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed
for up to a 34-day maximum. Drugs are prescribed
by Plan doctors and dispensed in accordance with the Plan's drug formulary.
You pay a $10
copayment per prescription unit or refill for generic
formulary drugs, $20 for preferred brand name,
and $35 for all others. The
cost of prescriptions filled through the Plan's mail order supplier will be
equal to 2 copayments for a 90 day supply.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a name brand. If you receive a name brand drug
when a Federally-approved generic drug is available,
and your physician has not specified Dispense as Written for the name brand
drug, you have to pay the
difference in cost between the name brand drug and
the generic.
Why use generic drugs? To reduce your out-of-pocket expenses! A
generic drug is the chemical equivalent of a corresponding brand name drug.
Generic drugs are less expensive than brand name
drugs; therefore, you may reduce your out-of-pocket costs by choosing to use
a generic drug. 34
34 Page
35 36
2002 Health Net of Pennsylvania,
Inc. 35 Section 5( f)
When you have to file a claim. If
you purchase a prescription in an out-of-network pharmacy, you must pay in full,
and submit a copy of your paid receipt along with a prescription reimbursement
form.
To receive reimbursement forms, please call our Customer Service
Department at 1-800-736-2096.
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 Health Net of Pennsylvania, Inc. 36
Section 5( f)
Benefit Description You pay
Covered medications
and supplies
We cover the following medications and supplies prescribed
by a Plan
physician and obtained from a Plan pharmacy or through our mail
order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except as those listed as
Not covered.
Insulin
Disposable needles and syringes for
the administration of covered
medications
Drugs for sexual dysfunction
(see Prior authorization below)
Oral contraceptive drugs and devices
Growth Hormones
$10 for generic drugs
$20 for preferred brand name
drugs
$35 for all other covered drugs
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them
Nonprescription medicines
Drugs to enhance athletic
performance
Fertility Drugs used as part of excluded infertility
treatment, such as In vitro fertilization.
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
All Charges 36
36 Page 37 38
2002 Health Net
of Pennsylvania, Inc. 37 Section 5( g)
Section 5 (g). Special
features
Feature Description
Flexible benefits option Under the
flexible benefits option, we determine the most effective
way to provide
services.
We may identify medically appropriate alternatives to traditional care and
coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the
future.
The decision to offer an alternative benefit is solely ours, and we
may
withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to
OPM review under the disputed claims process.
Health Net of Pennsylvania, Inc. HealthLine Through Health Net of
Pennsylvania, Inc. 's toll-free HealthLine, registered nurses are available to
provide health care answers for members, 24 hours a
day, every day of the
year. These skilled professionals use their years of
clinical experience and
the extensive computerized medical resources at their
fingertips to assist
members and direct them to the appropriate care.
Health Newsline and Resource
Guide
Members can call a
toll-free number listen to more than 150 pre-recorded
health care topics.
Being Well Magazine Subscriber households receive Being Well,
Health Net of Pennsylvania, Inc. 's exclusive, award winning magazine. 37
37 Page 38 39
2002 Health Net of Pennsylvania, Inc. 38
Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in
this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover
hospitalization for dental procedures only when a non-dental physical impairment
exists which makes hospitalization necessary to safeguard the health of the
patient; we do
not cover the dental procedure unless it is described below.
Be sure to read Section 4, Your costs for covered services, for
valuable information about
how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You Pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.
$10 per office visit
Dental benefits
We have no other dental benefits 38
38 Page 39 40
2002 Health Net of Pennsylvania, Inc. 39
Section 5( i)
Section 5 (i). Non-FEHB Benefits Available to Plan
Members
The benefits described on this page are neither offered nor
guaranteed under the contract with the FEHB Program, but
are made available
to all enrollees and family members who are members of this Plan. The cost of
the benefits described
on this page is not included in the FEHB premium; any
charges for these services do not count toward the FEHB
deductibles, out of
pocket maximum copay charges, etc. These benefits are not subject to the FEHB
disputed claims
procedures.
Women's Health Programs
Preventive Care Health Net of
Pennsylvania, Inc. members have direct access to routine gynecological exams
without a PCP referral. Members also receive
mammography reminders on a
regular basis.
New Mom 's Program Health Net of Pennsylvania, Inc.
offers members a free, comprehensive maternity services program that includes
valuable information concerning
prenatal health, health during pregnancy,
member benefits, money saving
coupons, and a free gift for the new mom and
baby.
Childbirth Class Reimbursement Health Net of Pennsylvania, Inc.
reimburses up to $85 when members attend and complete childbirth classes at
participating hospitals.
AlternaCare SM
Health Net of Pennsylvania, Inc. AlternaCare SM :
This holistic health care program provides benefits for chiropractic
and
acupuncture services; and offers discounts for massage therapy, nutritional
supplements and vitamins. 39
39 Page 40 41
2002 Health Net
of Pennsylvania, Inc. 40 Section 6
Section 6. General
exclusions --things we don't cover
The exclusions in this section apply
to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically
necessary to prevent, diagnose, or
treat your illness, disease, injury or
condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits); or
Services,
drugs, or supplies you receive while you are not enrolled in this Plan; or
Services, drugs, or supplies that are not medically necessary; or
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice; or
Experimental or investigational procedures, treatments, drugs or devices;
or
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; or
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 40
40 Page
41 42
2002 Health Net of Pennsylvania,
Inc. 41 Section 7
Section 7. Filing a claim for covered
services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at
Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital & drug 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 1-800-736-2096.
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:
Health Net, Formerly PHS Health Plans
P. O. Box 981
Bridgeport, CT
06601-0981
Attention: Claims Only
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative
operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 41
41 Page
42 43
2002 Health Net of Pennsylvania,
Inc. 42 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on
your claim or request for
services, drugs, or supplies – including a request for preauthorization:
Step Description
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: Health Net of Pennsylvania, Inc., 1835 Market St., 10 th
Floor, Philadelphia,
PA 19103; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of
our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the
information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
1900 E Street, NW, Washington, DC
20415-3630. 42
42 Page
43 44
2002 Health Net of Pennsylvania,
Inc. 43 Section 8
The Disputed Claims process
(Continued)
Send OPM the following information:
A
statement about why you believe our decision was wrong, based on specific
benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies
of all letters we sent to you about the claim; and
Your daytime phone
number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received
the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
pre-authorization/ prior approval, then call us at
1-800-50-REFER and we
will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so
that they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m.
eastern time. 43
43
Page 44 45
2002
Health Net of Pennsylvania, Inc. 44 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health
care
expenses without regard to fault. This is called "double coverage."
When you
have double coverage, one plan normally pays its benefits in
full as the
primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is
primary
according to the National Association of Insurance
Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free
Part A insurance. (Someone who was a
Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise,
if you are age 65 or older, you
may be able to buy it. Contact 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.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is a Medicare +Choice plan that (Part A or Part B) 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 B
benefits
now. You may go to any doctor, specialist, or hospital that accepts
Medicare. The Original Medicare Plan pays its share and you pay your share.
Some things are not covered under Original Medicare, like prescription
drugs. 44
44 Page
45 46
2002 Health Net of Pennsylvania,
Inc. 45 Section 9
When you are enrolled in Original Medicare along with
this Plan, you
still need to follow the rules in this brochure for us to
cover your care.
Your care must continue to be authorized by your Plan PCP,
or
precertified as required.
We will not waive any of our copayments.
(Primary payer chart begins
on next page.) 45
45 Page
46 47
2002 Health Net of Pennsylvania,
Inc. 46 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) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor
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 …
Please note: If your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare. 46
46
Page 47 48
2002 Health Net of Pennsylvania, Inc. 47 Section 9
Claims
process when you have the Original Medicare Plan – You
probably will
never have to file a claim form when you have both our
Plan and the Original
Medicare Plan.
When we are the primary payer, we process the claim first.
When
Original Medicare is the primary payer, Medicare processes
your claim first.
In most cases, your claims will be coordinated
automatically and we will pay
the balance of covered charges. You
will not need to do anything. To find
out if you need to do
something about filing your claims, call us at
1-800-736-2096 or
visit our website at www.
health. net.
We waive some costs when you have the Original Medicare Plan –
When Original Medicare is the primary payer, we will waive medical
services and supplies provided by physicians and other health care
professionals. If you are enrolled in Medicare Part B, we will waive:
in-patient hospital copay
skilled nursing facility copay
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 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.
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, but we will not waive any of our
copayments. If you
enroll in a Medicare managed care plan, tell us. We
will need to know
whether you are in the Original Medicare Plan or in a
Medicare managed care
plan so we can correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care
plan:
If you are an annuitant or former spouse, you can suspend your
FEHB
coverage to enroll in a Medicare managed care plan eliminating
your FEHB
premium . (OPM does not contribute to your Medicare
managed care plan
premium.) For information on suspending your FEHB
enrollment, contact your
retirement office. If you later want to re-enroll
in the FEHB Program,
generally you may do so only at the next open
season unless you
involuntarily lose coverage or move out of the
Medicare managed care plan's
service area. 47
47 Page
48 49
2002 Health Net of Pennsylvania,
Inc. 48 Section 9
If you do not enroll in If you do not have
one or both Parts of Medicare, you can still be covered Medicare Part A or
Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for 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 called
subrogation. If you need more information, contact us for our
subrogation procedures. 48
48 Page 49 50
2002 Health Net
of Pennsylvania, Inc. 49 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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See 13.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 13.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Any type of care that does not meet the requirements of post-hospital
skilled nursing facility care. Custodial care includes but is not limited to
any type of care where the primary purpose of the total care provided is
to attend to the Member's daily living activities which do not entail or
require the continuing attention of trained medical or paramedical
personnel (for example, assistance in walking, getting in and out of bed,
bathing, dressing, feeding, using the toilet, changes of dressings of
non-infected,
postoperative or chronic conditions, preparation of special
diets, supervision of medication which can be self-administered by the
Member, general maintenance care of colostomy or ileostomy, periodic
turning and positioning in bed; general supervision of exercises which
have been taught to the Member, routine services to maintain other
services which, in the sole determination of the PLAN, based on
medically accepted standards can be safely and adequately self-administered
or performed by the average non-medical person without
the direct
supervision of trained medical or paramedical personnel,
regardless of
whoactually provides the service).
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services. See page 13.
Experimental or As determined by the PLAN a drug, device, medical
treatment or investigational services procedure is experimental or
investigational: (i) if the drug or device
cannot be lawfully marketed
without the approval of the U. S. Food and
Drug Administration and approval
for marketing has not been given at
the time the drug or device is
furnished; or (ii) if the drug, device,
medical treatment or procedure, or
the patient informed consent
document utilized with the drug, device,
treatment or procedure, was
reviewed and approved by the treating facility's
Institutional Review
Board or other body serving a similar function, or if
federal law requires
such review and approval; or (iii) if Reliable Evidence
shows that the
drug, device, medical treatment or procedure is the subject
of on-going
phase I and phase II clinical trials, is the research,
experimental study or
investigational arm of on-going phase III clinical
trials, or is otherwise
under study to determine its maximum tolerated dose,
its toxicity, its
safety, its efficacy or its efficacy compared with a
standard means of
treatment or diagnosis; or (iv) if Reliable Evidence shows
that the
prevailing opinion among experts regarding the drug, device,
medical
treatment or procedure is that further studies or clinical trials
are
necessary to determine its maximum tolerated dose, its toxicity, its 49
49 Page 50 51
2002 Health Net of Pennsylvania, Inc. 50 Section 10
safety, its efficacy or its efficacy as compared with a standard means
of
treatment or diagnosis. As used here Reliable Evidence shall mean, only
as determined by the PLAN, published reports and articles in the
authoritative medical and scientific literature; the written protocol or
protocols used by the treating facility or the protocol( s) of another
facility
studying substantially the same drug, device, medical treatment or
procedure; or the written informed consent used by the treating facility or
by another facility studying substantially the same drug, device, medical
treatment or procedure.
Group health coverage Health insurance provided as a benefit to an
employee, which is partially or fully paid by the employer.
Medical necessity Health care services or supplies for prevention,
diagnosis, or treatment which are not excluded or limited by this brochure and
which are:
(a) appropriate for, and consistent with, the symptoms and proper
diagnosis or treatment of the member's illness, injury, disease, or
condition; and
(b) provided for the diagnosis or the direct care and
treatment of the
member's illness, injury, disease or condition; and
(c)
not primarily for the convenience, appearance, or recreation of the
member,
the member's practitioner or another; and
(d) within the standards of good
medical practice within the organized
medical community; and
(e) neither
Experimental or Investigational; and
(f) the most appropriate supply or
level of service which can safely be
provided. For Hospital stays this means
the acute care as an
inpatient is necessary due to the type of covered
services a member
is receiving or the severity of the member's condition and
adequate
care cannot be received as an outpatient or in a less intensive
medical setting
Not all medically necessary and appropriate services or
supplies are
covered. For additional information refer to the Benefits
Sections of this
brochure.
Us/ We Us and we refer to Health Net of Pennsylvania, Inc.
You
You refers to the enrollee and each covered family member. 50
50 Page 51 52
2002 Health Net of Pennsylvania, Inc. 51
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 about enrolling in the or retirement office can answer your
questions, and give you a Guide to
FEHB Program Federal
Employees Health Benefits Plans, brochures for other plans, and other
materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases,
cannot change your enrollment status without information from
your
employing or retirement office.
Types of coverage available 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. 51
51 Page
52 53
2002 Health Net of Pennsylvania,
Inc. 52 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you joined this Plan
premiums
start during Open Season, your coverage begins on the first day of your
first pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on
January 1. If you joined at any other time during the year, your employing
office
will tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for
other forms of coverage, such as Temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will receive
an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary
Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
Temporary Continuation If you leave Federal service, or if you
lose coverage because you no of Coverage (TCC) longer qualify as a family
member, you may be eligible for Temporary
Continuation of Coverage (TCC).
For example, you can receive TCC if
you are not able to continue your FEHB
enrollment after you retire, if
you lose your job, if you are a covered
dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct. 52
52 Page
53 54
2002 Health Net of Pennsylvania, Inc. 53 Section 11
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the
RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from
your employing or retirement office or from www. opm. gov/ insure.
It
explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity
law ends (If you
canceled your coverage or did not pay your premium, you
cannot
convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not
notify
you. You must apply in writing to us within 31 days after you are
no
longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a
Federal law that offers limited Federal protections for
health coverage
availability and continuity to people who lose employer
group coverage. If
you leave the FEHB Program, we will give you a Certificate
of Group Health
Plan Coverage that indicates how long you have been enrolled
with us. You
can use this certificate when getting health insurance or other health
care
coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the
information in
the certificate, as long as you enroll within 63 days of
losing coverage under this
Plan. If you have been enrolled with us for less
than 12 months, but were
previously enrolled in other FEHB plans, you may
also request a
certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health);
refer to the "TCC and
HIPAA" and frequently asked questions. These
highlight HIPAA rules,
such as the requirement that Federal employees
must exhaust any TCC
eligibility as one condition for guaranteed access to
individual health
coverage under HIPPA, and have information about Federal
and State
agencies you can contact for more information. 53
53 Page 54 55
2002 Health Net of Pennsylvania, Inc. 54
Long Term Care Insurance
Long Term Care Insurance Is Coming Later
in 2002!
The Office of Personnel Management (OPM) will sponsor a
high-quality long term care insurance program
effective in October 2002. As
part of its educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need
if
you can't take care of yourself because of an extended illness or
injury, or
an age-related disease such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home
care, care in an assisted living
facility, care in your home, adult day
care, hospice care, and more. LTC can
supplement care provided by
family members, reducing the burden you place on
them.
Welcome to the club!
76% of Americans believe they will never need
long term care, but
the facts are that about half them will. And it's not
just the old
folks. About 40% of people needing long term care are under age
65. They may need chronic care due to a serious accident, a stroke,
or
developing multiple sclerosis, etc.
We hope you will never need long term
care, but everyone should have a plan just in case. Many people now consider
long term care
insurance to be vital to their financial and retirement planing.
Yes,
it can be very expensive. A year in a nursing home can exceed $50,000. Home care
for only three 8-hour shifts a week can exceed
$20,000 a year. And that's
before inflation!
Long term care can easily exhaust your savings. Long
term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial
care or a stay
in an assisted living facility or a continuing need for a
home health aide
to help you get in and out of bed and with other
activities of daily living.
Limited stays in skilled nursing facilities
can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest
level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It also has a 100 day limit.
Medicaid
covers long term care for those who meet their state's poverty guidelines, but
has restrictions on covered services and
where they can be received. Long term care insurance can provide
choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need?
You should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage? 54
54 Page 55 56
2002 Health Net of Pennsylvania, Inc. 55 Long Term Care Insurance
Our toll-free teleservice center will begin in mid-2002. In the
meantime, you can learn more about the
program on our web site at
www. opm. gov/ insure/ ltc.
How can I find out more about the
program NOW? 55
55 Page 56 57
2002 Health Net of Pennsylvania, Inc. 56
Index
Index
Do not rely on this page; it is for your
convenience and may not show all pages where the terms appear.
Accidental injury 29
Allergy tests 18 Alternative treatment 22
Allogeneic (donor) bone marrow
transplant 25 Ambulance 28, 30
Anesthesia 26
Autologous bone marrow transplant 25 Biopsies 23
Blood and blood plasma 27
Breast cancer screening 16 Casts 23, 27
Catastrophic protection 13
Changes for 2002 9 Chemotherapy 25
Childbirth 17
Chiropractic 22 Cholesterol tests 16
Claims 41
Coinsurance 13 Colorectal cancer screening 16
Congenital anomalies 23
Contraceptive devices and drugs 17, 36
Coordination of benefits 44
Covered charges 10
Covered providers 10
Crutches 21
Deductible
13 Definitions 49
Dental care 38
Diagnostic services 15 Disputed claims review 42
Donor expenses (transplants) 25
Dressings 27 Durable medical equipment
(DME) 21
Educational classes and programs 22
Emergency 29 Experimental or
investigational 49
Eyeglasses 20
Family planning 17 Fecal occult blood test 16
General Exclusions 40
Hearing services 20 Home health
services 22
Hospice care 28
Home nursing care 22 Hospital 27
Immunizations 16
Infertility 18 In hospital physician care 15
Inpatient Hospital Benefits 27
Insulin 36 Laboratory and
pathological services
15
Machine diagnostic tests 15
Magnetic Resonance Imagings (MRIs) 15
Mail Order Prescription Drugs 34
Mammograms 16 Maternity Benefits 17
Medicaid 48
Medically necessary 50 Medicare 44
Mental Conditions/ Substance Abuse
Benefits 31 Neurological
testing 15
Newborn care 17
Non-FEHB Benefits 39 Nurse
Licensed Practical Nurse 22
Nurse Anesthetist 27 Nurse Practitioner 7
Registered Nurse 22
Nursery charges 17 Obstetrical care 17
Occupational therapy 19
Ocular injury 20 Office visits 15
Oral and maxillofacial surgery 25
Orthopedic devices 21 Out-of-pocket
expenses 13
Outpatient facility care 28
Oxygen 19 Pap test 16
Physical examination 16
Physical therapy 19 Physician 7
Pre-admission testing 28
Precertification 12 Preventive care, adult 16
Preventive care, children 16
Prescription drugs 34 Preventive services 16
Prior approval 12
Prostate cancer screening 16 Prosthetic devices 21
Psychologist 31
Radiation therapy 19 Renal dialysis 19
Room and board 27
Second surgical opinion 15 Skilled nursing
facility care 28
Smoking cessation 22
Speech therapy 19
Splints 27 Sterilization procedures 17
Subrogation 48
Substance abuse 31 Surgery 23
Anesthesia 26 Oral 25
Outpatient 23 Reconstructive 24
Syringes 36 Temporary continuation of coverage
52
Transplants
25 Treatment therapies 19
Vision services 20
Well child care 16 Wheelchairs 21
Workers' compensation 48
X-rays 15 56
56
Page 57 58
2002
Health Net of Pennsylvania, Inc. 57 Summary
Summary of
Benefits for Health Net of Pennsylvania, Inc. -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 form the cover on you enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment
services provided in the office……………….. Office visit copay; $10 primary care;
$10 specialist 15
Services provided by a hospital:
Inpatient…………………………………………………………………..
Outpatient………………………………………………………………...
Nothing
$10 per office visit
27
23
Emergency benefits:
In-area……………………………………………………………………
Out-of-area………………………………………………………………
$50 per admission; waived if admitted
$50 per admission; waived if admitted
29
29
Mental health and substance abuse treatment……………………………….. Regular cost
sharing. 31
Prescription drugs……………………………………………………………. $10 for generic drugs
$20 for preferred brand name
drugs
$35 for all other covered drugs
34
Dental Care…………………………………………………………………… No benefit. 38
Vision
Care…………………………………………………………………… No benefit. 20
Special features: Health Net
of Pennsylvania, Inc. HealthLine, Health Newsline & Resource Guide, Being
Well
Magazine
37
Protection against catastrophic costs (your out-of-pocket maximum)………..
Nothing after $500/ Self Only or
$1500/ Family enrollment per year
Some costs do not count toward this
protection
13 57
57 Page
58 59
2002 Health Net of Pennsylvania,
Inc. 58
NOTES 58
58 Page 59
2002 Health Net of Pennsylvania, Inc.
59
2002 Rate Information for
Health Net of Pennsylvania, Inc.
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 271 $97.86 $52.91 $212.03 $114.64 $115.52 $35.25
High Option
Self and Family 272 $223.41 $130.94 $484.06 $283.70
$263.75 $90.60
High Option
Self Only 2K1 $96.88 $32.29 $209.90 $69.97 $114.64 $14.53
High Option
Self and Family 2K2 $223.41 $93.62 $484.06 $202.84 $263.75
$53.28 59