3/ 99 This service has
Commendable accreditation from
the NCQA. See
the 2002 Guide for
more information on accreditation.
Enrollment code: JN1 High Option Self Only
JN2 High Option Self and
Family
JN4 Standard Option Self Only JN5 Standard Option Self and Family
For changes in benefits
see page 9.
Special Notice:
Enrollment code SU merged into code P3 and your
benefits are shown in Aetna's brochure RI 73-778.
We will send the brochure
to you before Open Season.
If you were enrolled in Standard Option of codes SU or P3, your enrollment
moved to High Option.
We eliminated some of our service area for 2002. If
you are enrolled in codes KL (Pennsylvania) and
XE (Virginia), you must
select a new plan. You will not have Aetna benefits in 2002. 1
1 Page 2 3
2002 Aetna U. S. Healthcare HMO 2 Table of
Contents
Table of Contents
Introduction
...................................................................................................................................................................
4
Plain Language
..............................................................................................................................................................
4
Inspector General Advisory
..........................................................................................................................................
4
Section 1. Facts about this HMO plan
...........................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Your
Rights..................................................................................................................................................
6
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
........................................................................................................................................
11
Identification cards
....................................................................................................................................
11
Where you get covered
care.......................................................................................................................
11
Plan
providers......................................................................................................................................
11
Plan facilities
.......................................................................................................................................
11
What you must do to get covered
care.......................................................................................................
11
Primary care
........................................................................................................................................
11
Specialty care
......................................................................................................................................
11
Hospital
care........................................................................................................................................
12
Circumstances beyond our
control.............................................................................................................
13
Services requiring our prior approval
........................................................................................................
13
Section 4. Your costs for covered services
..................................................................................................................
14
Copayments
.........................................................................................................................................
14
Coinsurance
.........................................................................................................................................
14
Deductible
...........................................................................................................................................
14
Your out-of-pocket maximum
...................................................................................................................
14
Section 5. Benefits
.......................................................................................................................................................
15
Overview....................................................................................................................................................
15
(a) Medical services and supplies provided by physicians and other health
care professionals
........................................................................................................
16
(b) Surgical and anesthesia services provided by physicians and other health
care professionals
........................................................................................................
26
(c) Services provided by a hospital or other facility, and ambulance services
..................................... 30
(d) Emergency services/
accidents.........................................................................................................
33
(e) Mental health and substance abuse
benefits....................................................................................
36
(f) Prescription drug
benefits................................................................................................................
38 2
2 Page 3 4
2002 Aetna U. S. Healthcare HMO 3 Table of
Contents
(g) Special
features...............................................................................................................................
41
(h) Dental
benefits................................................................................................................................
42
(i) Non-FEHB benefits available to Plan members
............................................................................. 45
Section 6. General exclusions — things we don't
cover.............................................................................................
46
Section 7. Filing a claim for covered
services.............................................................................................................
47
Section 8. The disputed claims
process.......................................................................................................................
48
Section 9. Coordinating benefits with other
coverage.................................................................................................
50
When you have …
Other health coverage
.......................................................................................................................
50
Original Medicare
.............................................................................................................................
50
Medicare managed care
plan.............................................................................................................
52
TRICARE/ Workers' Compensation/ Medicaid
.........................................................................................
53
Other Government agencies
......................................................................................................................
53
When others are responsible for injuries
...................................................................................................
53
Section 10. Definitions of terms we use in this
brochure............................................................................................
55
Section 11. FEHB
facts...............................................................................................................................................
58
Coverage
information................................................................................................................................
58
No pre-existing condition limitation
.................................................................................................
58
Where you get information about enrolling in the FEHB Program
.................................................. 58
Types of coverage
available for you and your
family....................................................................... 58
When benefits and premiums start
....................................................................................................
59
Your medical and claims records are confidential
............................................................................ 59
When you
retire.................................................................................................................................
59
When you lose benefits
.............................................................................................................................
59
When FEHB coverage ends
..............................................................................................................
59
Spouse equity
coverage.....................................................................................................................
59
Temporary Continuation of Coverage (TCC)
...................................................................................
60
Converting to individual coverage
....................................................................................................
60
Getting a Certificate of Group Health Plan
Coverage.......................................................................
60
Long Term Care Insurance is coming later in
2002....................................................................................................
61
Department of Defense/ FEHB Demonstration Project
...............................................................................................
63
Index
...........................................................................................................................................................................
65
Summary of benefits
...................................................................................................................................................
66
Rates............................................................................................................................................................................
68 3
3 Page 4 5
2002 Aetna U. S. Healthcare HMO 4
Introduction/ Plain Language
Introduction
Aetna U. S.
Healthcare, Inc. 1425 Union Meeting Road
P. O. Box 1126, Mail Stop U32A Blue Bell, PA 19422
This brochure describes the benefits you can receive from Aetna U. S.
Healthcare Inc. (MD) under our contract (CS 1766) 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 these
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 plan's 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. "You" means the
enrollee or family member; "we"
means Aetna U. S. Healthcare.
We limit acronyms to ones you know. FEHB is 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 email 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.
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 1-800-537-9384 and explain
the situation.
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE —
202-418-3300 or write to: The United States Office of
Personnel
Management, Office of the Inspector General Fraud Hotline, 1900 E Street, NW,
Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and
tries to obtain benefits. Your agency may also take
administrative action against you. 4
4 Page 5 6
2002 Aetna U. S.
Healthcare HMO 5 Section 1
Section 1. Facts about this HMO
plan
This Plan is a health maintenance organization (HMO). We require
you to see specific physicians, hospitals, and other providers that contract
with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO
because you prefer the plan's benefits, not because a particular provider is
available. You cannot change plans because a provider leaves our Plan. We cannot
guarantee that any one physician,
hospital, or other provider will be available and/ or remain under
contract with us.
How we pay providers Provider Compensation 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.
This is
a direct contract prepayment Plan, which means that participating providers are
neither agents nor employees of the Plan. Rather, they are
independent doctors and providers who practice in their own offices or
facilities. The Plan arranges with licensed providers and hospitals to
provide medical services for both the prevention of disease and the
treatment of illness and injury for benefits covered under the Plan.
Plan providers in our network have agreed to be compensated in various ways.
Many participating primary care physicians (PCPs) are
paid by capitation.
Under capitation, a physician receives payment for a patient whether the
physician sees the patient that month or not.
Specialists, hospitals, primary care physicians and other providers in the
Aetna U. S. Healthcare network may also be paid in the following
ways:
Per individual service (fee-for-service at contracted rates),
Per
hospital day (per diem contracted rates),
Under other capitation methods (a
certain amount per member, per month), and
By Integrated Delivery Systems (" IDS"), Independent Practice Associations ("
IPAs"), Physician Medical Groups (" PMGs"),
Physician Hospital Organizations
(" PHOs"), behavioral health organizations and similar provider organizations or
groups that are
paid by Aetna U. S. Healthcare; the organization or group
pays the physician or facility directly. In such arrangements, that group or
organization has a financial incentive to control the costs of providing
care.
You are encouraged to ask your physicians and other providers how they are
compensated for their services, including whether their specific
arrangements include any financial incentives to control costs. 5
5 Page 6 7
2002 Aetna U. S. Healthcare HMO 6 Section 1
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB
members. You may get information about
us, or 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.
Medical Necessity Covered services include most types of treatment by
PCPs, specialists and hospitals. However, the health plan also
excludes or
limits coverage for some services, including but not limited to cosmetic surgery
and experimental procedures. In addition, in order to be covered, all services,
including the location (type of facility), duration and costs
of services,
must be medically necessary as defined in this Plan and as determined by us.
(See definition on Page 56.)
Direct Access Ob/ Gyn Program This
program allows female members to visit any participating gynecologist for a
routine well-woman exam, including
a Pap smear (if appropriate) and an unlimited number of visits for
gynecologic problems and follow-up care as described in your benefits plan.
Gynecologists may also refer a woman directly for covered gynecologic services
without the patient's having to go back to her participating primary care
physician. If your Ob/ Gyn is part of an Independent Practice Association (IPA),
a Physician Medical Group (PMG) or a similar organization, covered care must
be coordinated through the IPA, the PMG or the similar organization.
Mental Health/ Substance Abuse In most areas, certain behavioral
health care services (e. g., treatment or care for mental disease or illness,
alcohol abuse
and/ or substance abuse) are managed by an independently contracted
organization. This organization makes initial coverage determinations and
coordinates referrals; any behavioral health care referrals will generally be
made to
providers affiliated with the organization, unless your needs for
covered services extend beyond the capability of the affiliated providers. You
can receive information regarding the appropriate way to access the behavioral
health care
services that are covered under your specific plan by calling
Member Services at 1-800-537-9384. As with other coverage determinations, you
may appeal behavioral health care coverage decisions in accordance with the
provisions
of your Plan.
Ongoing Reviews We conduct ongoing
reviews of those services and supplies which are recommended or provided by
health
professionals to determine whether such services and supplies are covered
benefits under this Plan. If we determine that the recommended services and
supplies are not covered benefits, you will be notified. If you wish to appeal
such
determination, you may then contact us to seek a review of the
determination.
Authorization Certain services and supplies under this
Plan may require authorization by us to determine if they are covered benefits
under this Plan.
Patient Management We have developed a patient
management program to assist in determining what health care services are
covered under
the health plan and the extent of such coverage. The program assists members
in receiving the appropriate health care and maximizing coverage for those
health care services.
Only medical directors make decisions denying coverage for services for
reasons of medical necessity. Coverage denial letters delineate any unmet
criteria, standards and guidelines, and inform the provider and member of the
appeal
process.
Our patient management staff uses national guidelines
and resources to guide the precertification, concurrent review and retrospective
review processes. Using the information obtained from providers, patient
management staff utilize
Milliman & Robertson Health Care Management Guidelines when conducting
concurrent review. If there is no applicable Milliman & Robertson Guideline,
patient management staff utilizes InterQual ISD criteria. When applicable,
Medicare National Coverage Decisions are followed for Medicare managed care
members. To the extent certain patient management functions are delegated to
integrated delivery systems, independent practice associations or other provider
groups (" Delegates"), such Delegates utilize criteria that they deem
appropriate.
Precertification Certain health care services, such as
hospitalization or outpatient surgery, require precertification by us to ensure
coverage. When a member is to
obtain services requiring precertification through a Plan provider, this
provider should precertify those services prior to treatment. 6
6 Page 7 8
2002 Aetna U. S. Healthcare HMO 7 Section 1
Concurrent Review The concurrent review process assesses the
necessity for continued stay, level of care, and quality of care for members
receiving inpatient services.
All inpatient services extending beyond the
initial certification period will require Concurrent Review.
Discharge Planning Discharge planning may be initiated at any stage of
the patient management process and begins immediately upon identification of
post-discharge
needs during precertification or concurrent review. The
discharge plan may include initiation of a variety of services/ benefits to be
utilized by the member upon discharge from an inpatient stay.
Retrospective Record Review The purpose of retrospective review is to
retrospectively analyze potential quality and utilization issues, initiate
appropriate follow-up action based on
quality or utilization issues, and review all appeals of inpatient concurrent
review decisions for coverage and payment of health care services. Our
effort to manage the services provided to members includes the retrospective
review of claims submitted for payment, and of medical
records submitted for
potential quality and utilization concerns.
Member Services Representatives from Member Services are trained to
answer your questions and to assist you in using the Aetna
U. S. Healthcare
plan properly and efficiently. After you receive your ID card, you can call the
Member Services toll-free number on the card when you need to:
Ask questions about benefits and coverage.
Notify us of changes in your
name, address or telephone number.
Change your primary care physician or
office.
Obtain information about how to file a grievance or an appeal.
Confidentiality We protect the privacy of confidential Plan member
medical information. We contractually require that participating
providers
keep member information confidential in accordance with applicable laws.
Furthermore, you have the right to access you medical records from participating
providers, at any time. Aetna U. S. Healthcare (including its affiliates and
authorized agents, collectively (" Aetna U. S. Healthcare") and
participating providers require access to member medical information for a
number of important and appropriate purposes, including claims payment, fraud
prevention,
coordination of care, data collection, performance measurement,
fulfilling state and federal requirements, quality management, utilization
review, research and accreditation activities, preventive health, early
detection and disease
management programs. Accordingly, for these purposes,
members authorize the sharing of member medical information about themselves and
their dependents between Aetna U. S. Healthcare and Plan providers and health
delivery systems.
If you want more information about us, call 1-800-537-9384, or write to 1425
Union Meeting Road, P. O. Box 1126, Mail Stop U32A, Blue Bell, PA 19422. You may
also contact us by fax at 215-775-6550 or visit our website at
www.
aetnaushc. com/ feds. 7
7 Page 8 9
2002 Aetna U. S.
Healthcare HMO 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:
Maryland/ DC/ Northern Virginia
3/ 99 This service has Commendable
accreditation from the NCQA. See the
2002 Guide for more
information on accreditation.
Serving: All of Washington, DC, North and Central Maryland and Northern
Virginia
Enrollment Code:
JN1 High Option Self Only JN2 High Option Self
and Family
JN4 Standard Option Self Only JN5 Standard Option Self and Family
All of Washington, DC; the Maryland counties of Anne Arundel, Baltimore,
Baltimore City, Calvert, Carroll, Cecil, Charles, Frederick, Harford, Howard,
Kent,
Montgomery, Prince George's, Queen Anne's, St. Mary's, Talbot,
Washington, Wicomico and Worcester; The Virginia counties of Arlington,
Caroline, Fairfax,
Fauquier, King George, Loudon, Louisa, Prince William,
Spotsylvania, Stafford and Westmoreland; plus the cities of Alexandria, Fairfax,
Falls Church,
Fredericksburg, Manassas and Manassas Park.
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 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 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
Aetna U. S. Healthcare HMO 9 Section 2
Section 2. How we
change for 2002
Program-wide changes 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.
We changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan Code JN. Your share of the non-postal premium for
High Option will increase by 18.6% for Self Only and increase
by 18.8% for
Self and Family. Your share of the non-postal premium for Standard Option will
increase by 15.3% for Self Only and increase by 15.3% for Self and Family.
Service Area changes: This plan now covers Washington, DC area only.
Enrollment codes KL (in Pennsylvania) and XE (in Virginia) are
being
eliminated and members must select a new plan. You will not have Aetna benefits
in 2002.
Members who enrolled in code SU (Pennsylvania) and code P3 (New
Jersey and Delaware) are being transferred to
the High Option plan described
in Brochure RI 73-778 and enrollment code P3. We will send you that brochure
before Open Season. Please review it for benefit changes.
Benefit changes under High and Standard Options: We now cover certain
intestinal transplants. Section 5( b).
We changed speech therapy benefits by
removing the requirement that services must be required to restore functional
speech. Section 5( a).
We added benefits to cover hearing aids for children. Section 5( a).
We
removed the copay for professional services of a physician during an in-patient
hospital stay. Section 5( a).
We added a $75 copay per date of service for
outpatient surgery. Section 5( c).
We added services for infertility under
Medical and Surgical and Prescription Drug Benefits. Sections 5( a) and 5( f).
We now allow up to a 90-day supply of prescription drugs to be obtained at a
local plan pharmacy. Section 5( f).
We reduced the maximum coverage at a
skilled nursing facility to 90 days. Section 5( c).
We increased the copay
to $75 per emergency room visit. Section 5( d).
We added coverage for air
ambulance. Section 5( d).
We increased the prescription drug cost sharing
per 30-day supply to $10 for generic formulary, $20 for brand name
formulary
and 50% for nonformulary drugs to 50% at local pharmacies. Mail order copays are
$20, $40 and 50% for up to a 90-day supply of drugs. Section 5( f).
We increased the copay for a diaphragm to $20. Section 5( f).
We
increased the copay for Depo Provera to $20 per vial. Section 5( f).
We
increased the copay for certain dental services. Section 5( h).
We added
durable medical equipment to the list of services requiring precertification.
Section 5( a).
We added growth hormone therapy to the list of services
requiring precertification. Section 5( a). 9
9
Page 10 11
2002
Aetna U. S. Healthcare HMO 10 Section 2
We clarified the benefit
for blood or blood plasma. Section 5( c).
We clarified the Preventive care,
adult benefits by removing the entry for blood lead level testing for adults
because it
is a test more typically done for children. Section 5( a).
We no longer limit total blood cholesterol tests to certain age groups.
Section 5( a).
We now cover routing screening for chlamydial infection.
Section 5( a).
We removed the age limit for hearing tests. Section 5( a).
Benefit changes under High Option: We added a copay of $100 per day up
to a maximum of $300 per admission. This applies to medical confinements,
residential treatment facilities and inpatient hospital admissions to treat
mental health and substance abuse. Section 5( e).
We changed the primary
care doctor office visit copay to $15. Section5( a).
We changed the primary
care doctor home visit copay to $20. Section 5( a).
We changed the specialty
care copay to $20. Section 5( a).
We changed the specialty care home visit
copay to $25. Section 5( a).
Benefit changes under Standard Option: We increased a copay to $200
per day up to a maximum of $600 per admission. This applies to medical
confinements,
residential treatment facilities and inpatient hospital
admissions to treat mental health and substance abuse. Section 5( e).
We
changed the primary care doctor office visit copay to $20. Section 5( a).
We
changed the primary care doctor home visit copay to $25. Section 5( a).
We
changed the specialty care office visit copay to $25. Section 5( a).
We
changed the specialty care home visit copay to $30. Section 5( a). 10
10 Page 11 12
2002 Aetna U. S. Healthcare HMO 11 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it whenever you
receive services from a
Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your
ID card, use your copy of the Health
Benefits Election Form, SF-2809, your
health benefits enrollment confirmation (for annuitants), or your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at 1-800-537-9384.
Where you get covered care You get covered care from "Plan providers"
and "Plan facilities." You will only pay copayments or coinsurance, 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 most current information on our
Plan providers is also on
our website at www. aetnaushc. com/ feds.
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
facilities in the provider directory, which we update periodically. The most
current information on our Plan facilities is also on our website at
www.
aetnaushc. com/ feds.
What you must do to get covered care It depends on the type of care
you need. First, you and each family 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. You must select a Plan
provider
who is located in your service area as defined by your enrollment code.
Primary care Your primary care physician can be a general
practitioner, family practitioner, internist or pediatrician. Your primary care
physician will provide or coordinate
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 or visit our website. We will change your primary care
physician to a newly-selected primary care physician.
Specialty care
Your primary care physician will refer you to a specialist for needed care.
If you need laboratory, radiological and physical therapy services, your primary
care
physician must refer you to certain plan providers. Your primary care
physician may refer you to any participating specialist for other specialty
care. When you
receive a referral from your primary care physician, you must
return to the primary care physician after the consultation, unless your primary
care physician
authorized a certain number of visits without additional
referrals. The primary care physician must provide or authorize follow-up care.
Do not go to the
specialist for return visits unless your primary care
physician gives you a referral. However, you may see a Plan gynecologist,
(within an IPA, you must see an IPA-approved
gynecologist), for a routine
well-woman exam, including a pap smear (if appropriate) and an unlimited number
of visits for gynecological problems 11
11 Page 12 13
2002 Aetna U.
S. Healthcare HMO 12 Section 3
and follow-up care as described in
your benefit plan without a referral. You may also see a Plan mental health
provider, Plan vision specialist or a
Plan dentist 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
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does
not
participate with us, you must receive treatment from a specialist who does.
Generally, we will not pay for you to see a specialist who
does not
participate with our Plan.
If you are seeing a specialist and your
specialist leaves the Plan, call your primary care physician, who will arrange
for you to see another
specialist. You may receive services from your current specialist until we
can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
– Terminate our contract with your specialist for
other than cause; or
– Drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
– Reduce our service area and you enroll in another FEHB Plan,
You may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.
If you are in the second or third
trimester of pregnancy and you lose access to your specialist based on the above
circumstances, you can continue to
see your specialist until the end of your postpartum care, even if it is
beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise covered 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 1-800-537-9384. 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. 12
12 Page 13 14
2002 Aetna U. S. Healthcare HMO 13 Section 3
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we
may have to delay your services
or we may be unable to provide them. In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our prior approval Your primary care physician has
authority to refer you for most services.
For certain services, however,
your physician must obtain approval from us. Before giving approval, we consider
if the service is covered, medically
necessary, and follows generally
accepted medical practice.
We call this review and approval process
precertification.
You must obtain approval for certain services such
as:
For artificial insemination you must contact the Infertility Case
Manager at 1-800-575-5999;
You must obtain precertification from your primary care doctor and Aetna U.
S. Healthcare for covered follow-up care with
nonparticipating provider; and
You must contact Customer Service at 1-800-537-9384 for information on
precertification before you have mental health and
substance abuse services.
Your Plan physician must obtain approval
for certain services such as hospitalization and the following services:
Your Plan physician must obtain approval for surgical treatment of morbid
obesity;
For outpatient surgery;
For covered transplant surgery from the
Plan's medical director;
When full-time skilled nursing care is necessary in
an extended care facility;
For ambulance transportation service;
For certain drugs before they can
be prescribed; and
For growth hormone therapy treatment.
You or your
physician must obtain approval for certain durable medical equipment.
Members must call 1-800-537-9384 for authorization. 13
13 Page 14 15
2002 Aetna U. S. Healthcare HMO 14 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. when you receive services.
Example: When you see your primary care physician you pay a copayment of $15
per office visit or $20 when you see a participating specialist for
High
Option and $20 per office visit or $25 when you see a participating specialist
for Standard Option.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 50% of negotiated
charges for nonformulary drugs.
Deductible We do not have a
deductible.
Your catastrophic protection out-of-pocket maximum for
copayments and
coinsurance After your copayments and coinsurance total $1,500 per person or
$3,000 per family enrollment in any calendar year, you do not have to pay any
more for covered services. However, copayments and coinsurance for the
following services do not count toward your out-of-pocket maximum, and
you
must continue to pay copayments and coinsurance for these services:
Prescription drugs
Dental services
Be sure to keep accurate records
of your copayments and coinsurance since you are responsible for informing us
when you reach the maximum. 14
14 Page 15 16
2002 Aetna U.
S. Healthcare HMO 15 Section 5
Section 5. Benefits — OVERVIEW
(See page 9 for how our benefits changed this year and page 66 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. For more information
about our benefits, contact us at 1-800-537-9384 or at our website at
www. aetnaushc. com/ feds
(a) Medical services and supplies
provided by physicians and other health care
professionals................................ 16
Diagnostic and treatment
services Speech therapies
Lab, X-ray, and other diagnostic tests Hearing
services (testing, treatment, and supplies)
Preventive care, adult Vision
services (testing, treatment, and supplies)
Preventive care, children Foot
care
Maternity care Orthopedic and prosthetic devices
Family planning
Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical and occupational therapies Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ............................ 26
Surgical procedures
Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and
maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services
.......................................................... 30
Inpatient
hospital Hospice care
Outpatient hospital or ambulatory surgical center
Ambulance
Extended care benefits/ skilled nursing care facility benefits
(d) Emergency services/
accidents..............................................................................................................................
33
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits.........................................................................................................
36
(f) Prescription drug benefits
....................................................................................................................................
38
(g) Special features
....................................................................................................................................................
41
Services for deaf and hearing-impaired
............................................................................................................
41
Informed Health
Line........................................................................................................................................
41
Reciprocity........................................................................................................................................................
41
High-risk pregnancies
.......................................................................................................................................
41
Centers of Excellence for transplants/ surgery etc.
............................................................................................
41
Travel benefit/ services
overseas........................................................................................................................
41
(h) Dental benefits
.....................................................................................................................................................
42
(i) Non-FEHB benefits available to Plan members
..................................................................................................
45
Summary of benefits
...................................................................................................................................................
66 15
15 Page 16
17
2002 Aetna U. S. Healthcare HMO 16
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 covered 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.
I M
P O
R T
A N
T
Benefit Description High Option You pay Standard Option You Pay
Diagnostic and treatment services
Professional services of
physicians
In physician's office
– Office medical consultations
–
Second surgical or medical opinion
– Initial examination of a newborn child
covered under a family enrollment
$15 per primary care physician (PCP) visit
$20 per specialist visit
$20 per primary care physician (PCP) visit
$25 per specialist visit
Professional services of physicians
In an urgent care center for routine
services
In a skilled nursing facility
$15 per PCP visit $20 per specialist visit $20 per PCP visit $25 per
specialist visit
At home $20 per PCP visit $25 per specialist visit $25 per PCP visit $30 per
specialist visit
At home visits by nurses and health aides Nothing Nothing
Lab, X-ray and other diagnostic tests
Test, 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, $15 per
PCP visit, $20 per specialist visit
Nothing if you receive these services during
your office visit;
otherwise, $20 per
PCP visit, $25 per specialist visit 16
16 Page 17 18
2002 Aetna U. S. Healthcare HMO 17 Section
5( a)
Preventive care, adult High Option You pay Standard Option You
pay
Routine screenings, such as:
Total Blood Cholesterol
Colorectal Cancer Screening, including
– Fecal occult blood test
–
Sigmoidoscopy, screening — every five years starting at age 50
Prostate Specific Antigen (PSA test) — one annually for men age 40 and older
Routine Pap test
NOTE: No copay for the pap test if performed on
the same day as the 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
$15 per PCP visit $20 per specialist visit
Nothing if provided during the
office visit
$20 per PCP visit $25 per specialist visit
Nothing if
provided during the office visit
Routine immunizations limited to:
Tetanus-diphtheria (Td) booster — once
every 10 years, ages 19 and over (except as provided for
under childhood immunizations
Influenza/ Pneumococcal vaccines, annually,
age 65 and over
Nothing if provided during the office visit Nothing if provided during the
office visit
Not covered:
Physical exams required for obtaining or
continuing employment or insurance, attending schools or
camp, or travel.
Immunizations and boosters for travel or
work-related exposure.
All charges All charges
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing Nothing
Well-child visits for routine examinations, immunizations and care (up to age
22) $15 per PCP visit $20 per specialist visit $20 per PCP visit $25 per
specialist visit
Examinations, such as:
– Eye exams through age 17 to
determine the need for vision correction.
– Ear exams to determine the need for hearing correction
– Examinations
done on the day of immunizations (up to age 22)
$15 per PCP visit $20 per specialist visit $20 per PCP visit $25 per
specialist visit 17
17 Page
18 19
2002 Aetna U. S. Healthcare HMO
18 Section 5( a)
Maternity care High Option You pay Standard
Option 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 below for other circumstances, such as
extended
stays for you or your baby.
You may remain in the hospital up to 48 hours
after a regular delivery and 96 hours after a cesarean
delivery. We will cover an extended inpatient stay if your Physician
determines it is medically necessary.
We cover routine nursery care of the newborn child during the covered portion
of the mother's 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).
$15 for the first PCP visit only
or $20 for the first specialist
visit only
$20 for the first PCP visit only
or $25 for the first specialist
visit only
Not covered: Routine sonograms to determine fetal age, size or sex All
charges All charges
Family planning
A broad range of
voluntary family planning services, limited to:
Voluntary sterilization
Surgically implanted contraceptives, such as
Norplant
Injectable contraceptive drugs, such as Depo Provera
Intrauterine devices (IUDs)
Diaphragms
NOTE: We cover oral contraceptives and Depo Provera under the
prescription drug benefit.
$15 per PCP visit $20 per specialist
visit
$20 per PCP visit $25 per
specialist
visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges All charges 18
18
Page 19 20
2002
Aetna U. S. Healthcare HMO 19 Section 5( a)
Infertility
services High Option You pay Standard Option You pay
Diagnosis and
treatment of infertility, such as:
Artificial insemination:
–
intravaginal insemination (IVI)
– intracervical insemination (ICI)
–
intrauterine insemination (IUI)
NOTE: Coverage is for 6 cycles.
Artificial insemination must be authorized. You must contact the Infertility
Case Manager at 1-800-575-5999. You must use our select network of
participating Plan infertility providers.
Fertility drugs
NOTE: We cover oral fertility drugs under the
prescription drug benefit.
In vitro fertilization is a covered benefit when the following criteria are
met:
Your oocytes are fertilized with your spouse's sperm
You and your
spouse have a history of infertility of at least 2 years duration
Your infertility is associated with endometriosis, exposure in-utero to
diethylstilbestrol (DES),
blockage of, or surgical removal of, one or both
fallopian tubes, or abnormal male factors, including
oligospermia
contributing to the infertility
You have been unable to attain a successful
pregnancy through a less costly treatment that is
covered by the Plan
NOTE: In-vitro fertilization is limited to a
maximum lifetime benefit of $100,000. This includes the cost of
infertility drugs. We cover oral fertility drugs under the prescription drug
benefit. Injectable fertility drugs are
covered only for in-vitro
fertilization.
50% of all charges 50% of all charges
Infertility services — Continued on the next page 19
19 Page 20 21
2002 Aetna U. S. Healthcare HMO 20 Section
5( a)
Infertility services (Continued) High
Option You pay Standard Option You pay
Not covered:
Infertility services after reversal of voluntary sterilization of
either partner or when the woman
has had a hysterectomy
Infertility treatment when the FSH level
is greater that 19 mIU/ ml
Cost of donor sperm and donor eggs
Assisted Reproductive
Technology (ART) procedures not shown such as embryo transfer (frozen), GIFT,
ZIFT, sex selection, surrogacy, gene therapy, gestational carriers, and
cryopreservation,
including other services and supplies related to the
non-covered ART procedures
Charges associated with care of the donor required for donor egg
retrievals or transfers
Charges associated with cryopreservation
Charges associated with a gestational carrier program or for the
member or the gestational
carrier
Home ovulation prediction kits
Drugs related
to the treatment of non-covered benefits or related to the treatment of
infertility that
are not medically necessary based on current medical standards; including
but not limited to,
GnRH agonists, IVIG; and Injectable infertility
medications not used in in-vitro fertilization
Charges associated with a frozen embryo transfer including thawing charges
Reversal of voluntary, surgically induced sterility
All charges All charges
Allergy care
Testing and treatment
Allergy injection
NOTE: You pay the applicable copay for each doctor visit. Each visit
to a nurse for injection only, you pay
nothing
$15 per PCP visit $20 per specialist
visit, nothing for a visit to a
nurse
$20 per PCP visit $25 per specialist
visit, nothing for a visit to
a nurse
Allergy serum Nothing Nothing 20
20 Page 21 22
2002 Aetna U.
S. Healthcare HMO 21 Section 5( a)
Treatment therapies High
Option You pay Standard Option 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 28.
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
Medical Benefits, office copay applies.
NOTE: We will only cover GHT when we preauthorize the treatment. Call
1-800-245-1206 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.
$20 per specialist visit $25 per specialist visit
Physical, pulmonary and occupational therapies
Two consecutive
months per condition, beginning with the first day of treatment for each of the
following:
– Qualified physical therapies
– Occupational therapy
–
Pulmonary rehabilitation
NOTE: Occupational therapy is limited to
services that assist the member to achieve and maintain self-care
and improved functioning in other activities of daily living. Inpatient
rehabilitation is covered under
Hospital/ Extended Care Benefits.
Cardiac rehabilitation following angioplasty, cardiovascular surgery,
congestive heart failure or a
myocardial infarction is provided for up to 3 visits a week for a total of 18
visits.
Physical therapy to treat temporomandibular joint (TMJ) dysfunction syndrome
$20 per visit, nothing during a
covered inpatient admission
$25 per
visit, nothing during a
covered inpatient admission
Not covered:
Long-term rehabilitative therapy
All charges
All charges 21
21 Page
22 23
2002 Aetna U. S. Healthcare HMO
22 Section 5( a)
Habilitative Therapy High Option You pay
Standard Option You pay
Habilitative services for children under age 19
with congenital or genetic birth defects. Treatment is
provided to enhance the child's ability to function. Services include
occupational therapy, physical
therapy and speech therapy. NOTE: no
day or visit limit applies.
$20 per specialist visit $25 per specialist visit
Speech therapy High Option You pay Standard Option You pay
Two
consecutive months per condition, beginning with the first day of treatment $20
per visit, nothing during a
covered inpatient admission
$25 per visit, nothing during a
covered
inpatient admission
Hearing services (testing, treatment, and supplies)
Covered for
audiological testing and medically necessary treatment for hearing problems $15
per PCP visit $20 per specialist
visit
$20 per PCP visit $25 per
specialist
visit
For minor children, hearing aids, testing, fitting and the examination for
them All charges over $1,400 every
36-month period
All charges over
$1,400 every
36-month period
Not covered:
All other
hearing testing not medically necessary
All charges All charges
Vision services (testing, treatment, and supplies)
Treatment of
eye diseases and injury $15 per PCP visit $20 per specialist
visit
$20
per PCP visit $25 per specialist
visit
Corrective eyeglasses and frames
or contact lenses (hard or soft) per 24 month period. All charges over $100 All
charges over $100
Routine eye refraction based on the following schedule:
– If member wears
eyeglasses or contact lenses: Age 1 through 18 — once every 12-month period
Age 19 and over — once every 24-month period
– If member does not wear
eyeglasses or contact lenses:
To age 45 — once every 36-month period
Age 45 and over — once every
24-month period refractions
NOTE: See Preventive Care, Children, for eye exams for children
$20 per specialist visit $25 per specialist visit 22
22 Page 23 24
2002 Aetna U. S. Healthcare HMO 23 Section
5( a)
Not covered:
Fitting of contact lenses
Eye
exercises
Radial keratotomy and other refractive surgery
All charges All charges
Foot care High Option You pay Standard Option You pay
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 more information.
$15 per PCP
visit $20 per specialist
visit
$20 per PCP visit $25 per specialist
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)
Foot orthotics
Podiatric inserts
All charges All charges
Orthopedic and prosthetic devices
External prosthetic devices
which replace all or part of an internal or external body organ or an external
body part
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a
mastectomy, orthopedic devices such as braces and prosthetic devices such as
artificial limbs
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, defibrillator, and
surgically implanted breast implant following
mastectomy, and lenses following cataract removal. 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.
NOTE: Coverage includes repair and
replacement when due to growth or normal wear and tear.
Nothing Nothing 23
23 Page
24 25
2002 Aetna U. S. Healthcare HMO
24 Section 5( a)
Not covered:
Orthopedic and corrective
shoes not attached to a covered brace
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
All charges All charges
Durable medical equipment (DME) High Option You pay Standard Option You
pay
Rental or purchase, including replacement, repair and adjustment, of
durable medical equipment prescribed by
your Plan Physician, such as oxygen equipment. Under this benefit, we also
cover:
Hospital beds
Wheelchairs
Crutches
Walkers
Insulin pumps
NOTE: Some DME may require precertification by you or your physician.
Nothing Nothing
Not covered:
Elastic stockings and support hose
Bathroom equipment such as bathtub seats, benches, rails and lifts
Home modifications such as stairglides, elevators, and wheelchair ramps
All charges All charges
Home health services
Home health care ordered by a Plan Physician
and provided by nurses and home health aides. Your
Plan Physician will periodically review the program for continuing
appropriateness and need.
Services include intravenous therapy and medications.
Nothing Nothing
Not covered:
Home care primarily for personal assistance that
does not include a medical component and is not
diagnostic, therapeutic or rehabilitative
All charges All charges 24
24 Page 25 26
2002 Aetna U.
S. Healthcare HMO 25 Section 5( a)
Chiropractic care
Chiropractic services up to 20 visits per calendar year
Manipulation
of the spine and extremities
Adjunctive procedures such as ultrasound,
electric muscle stimulation, vibratory therapy and cold pack
application
$15 per PCP visit $20 per specialist
visit
$20 per PCP visit $25 per
specialist
visit
Not covered: Any services not listed above All charges All charges
Alternative treatments
No benefits All charges All charges
Educational classes and programs High Option You pay Standard Option You
pay
Asthma
Diabetes
Congestive heart failure
Low back pain
Coronary artery disease
Also see the Non-FEHB page for our Member Health
Education, Informed Health Line and Intelihealth.
Nothing Nothing 25
25 Page
26 27
2002 Aetna U. S. Healthcare HMO
26 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
covered 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 (c) for
charges associated with the facility (i. e. hospital, surgical center, etc.)
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL PROCEDURES.
I M
P O
R T
A N
T
Benefit Description High Option You pay Standard Option 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. This
procedure must be approved in advance by the HMO.
Insertion of internal prosthetic devices. See 5( a) — Orthopedic and
prosthetic devices for device
coverage information.
Voluntary
sterilization
Treatment of burns
NOTE: Generally, we pay for internal prosthesis (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
$15 per PCP office visit, $20
per specialist visit
$20 per PCP office
visit, $25
per specialist visit
Surgical procedures — Continued on the next page 26
26 Page 27 28
2002 Aetna U. S. Healthcare HMO 27 Section
5( b)
Surgical procedures (Continued) High
Option You pay Standard Option You pay
Not covered: Reversal
of voluntary surgically-induced
sterilization
Surgery primarily for cosmetic purposes
Refractive eye surgery, such as radial keratotomy
Blood
and blood derivatives, except blood derived clotting factors, and the storage of
the patient's own
blood for later administration
All charges All charges
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
– The condition produced a major effect on the member's appearance and
–
The condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common
form or norm. Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate;
birth
marks; webbed fingers; and webbed toes.
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 lymphedema;
– 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.
$20 per specialist visit $25 per specialist visit
Not covered:
Cosmetic surgery — any surgical procedure (or any
portion of a procedure) performed primarily to
improve physical appearance through change in bodily form, except repair
of accidental injury
Surgeries related to sex transformation
All charges All charges 27
27 Page 28 29
2002 Aetna U.
S. Healthcare HMO 28 Section 5( b)
Oral and maxillofacial
surgery High Option You pay Standard Option You pay
Oral surgical
procedures, such as:
Treatment of fractures of the jaws or facial bones;
Surgical correction of congenital defects, such as cleft lip and cleft
palate;
Medically necessary surgical treatment of TMJ;
Removal of stones from
salivary ducts;
Excision of leukoplakia or malignancies;
Removal of bony
impacted wisdom teeth;
Excision of tumors and cysts
Other surgical
procedures that do not involve the teeth or their supporting structures.
$20 per specialist visit $25 per specialist visit
Not covered:
Dental implants
Dental care involved
with the treatment of temporomandibular joint dysfunction
All charges All charges
Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single — Double
Pancreas
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple
organs such as the liver, stomach and pancreas
Skin
Tissue
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
$20 per specialist office visit and
nothing for the surgery
$25 per
specialist office visit and
nothing for the surgery
Organ/ tissue transplants — Continued on the next page 28
28 Page 29 30
2002 Aetna U. S. Healthcare HMO 29 Section
5( b)
Organ/ tissue transplants (Continued) High
Option You pay Standard Option You pay
National Transplant Program (NTP)
— Transplants which are non-experimental or non-investigational are
a covered benefit. Covered transplants must be ordered by your primary care
doctor and plan specialist
physician and approved by our medical director in
advance of the surgery. The transplant must be
performed at hospitals
specifically approved and designated by us to perform these procedures. A
transplant is non-experimental and non-investigational when we have
determined, in our sole discretion, that
the medical community has generally
accepted the procedure as appropriate treatment for your specific
condition.
Coverage for a transplant where you are the recipient includes coverage for the
medical and
surgical expenses of a live donor, to the extent these services
are not covered by another plan or program.
Limited Benefits — Treatment for breast cancer, multiple myeloma and
epithelial ovarian cancer may be provided in
an NCI-or NHI-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.
$20 per specialist office visit and
nothing for the surgery
$25 per
specialist office visit and
nothing for the surgery
Not covered:
Transplants not listed as covered
All charges
All charges
Anesthesia
Professional services provided in —
Hospital
(inpatient)
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing Nothing 29
29 Page
30 31
2002 Aetna U. S. Healthcare HMO
30 Section 5( c)
Section 5 (c). Services provided by a
hospital or other facility, and ambulance services
I M
P O
R T
A
N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine
they are medically necessary.
Plan physicians must provide or arrange
your covered 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
covered care. Any costs associated with the professional charge (i. e.,
physicians, etc.) are covered in Section 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 High Option You pay Standard Option 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.
$100 per day up to a maximum of
$300 per admission
$200 per day up to
a maximum of
$600 per admission
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
The withdrawal, processing
and storage of the patient's own blood for later administration, and the
administration of this blood to the patient
Serum, clotting factors and
immunoglobulins
Blood or blood plasma, if donated or replaced
Dressings,
splints, casts, and sterile tray services
Nothing Nothing
Inpatient hospital — Continued on the next page 30
30 Page 31 32
2002 Aetna U. S. Healthcare HMO 31 Section
5( c)
Inpatient hospital (Continued) High Option
You pay Standard Option You pay
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
Nothing Nothing
Not covered:
Blood and blood derivatives, except blood clotting
factors, and the storage of the patient's own blood
for later administration.
Custodial care, rest cures,
domiciliary or convalescent cares
Personal comfort items, such as telephone and television
All charges All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Radiologic procedures, diagnostic laboratory tests, and X-rays when
associated with a medical
procedure being done the same day
Pathology Services
Administration
of blood, blood plasma, and other biologicals
Blood and blood plasma, if 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.
$75 per day $75 per day
Services not associated with a medical procedure being done the same day,
such as:
Mammogram
Radiologic procedure
Heart catheterization
$20 per specialist visit $25 per specialist visit
Not covered: Blood and blood derivatives, except blood clotting factors,
and the storage of the patient's own
blood for later administration.
All
charges All charges 31
31 Page 32 33
2002 Aetna U.
S. Healthcare HMO 32 Section 5( c)
Extended care benefits/
skilled nursing care facility benefits High Option You pay Standard Option You
pay
Extended care benefit: All necessary services during confinement in
a skilled nursing facility with a 90-day
limit per calendar year when
full-time nursing care is necessary and the confinement is medically appropriate
as
determined by a Plan doctor and approved by the Plan.
Nothing Nothing
Not covered: custodial care All charges All charges
Hospice
care
Supportive and palliative care for a terminally ill member in the
home or hospice facility, including inpatient and
outpatient care and family counseling, when provided under the direction of a
Plan doctor, who certifies the
patient is in the terminal stages of illness,
with a life expectancy of approximately 6 months or less.
Nothing Nothing
Ambulance
Ambulance service ordered or authorized by a Plan doctor
Nothing Nothing
Not covered: Ambulance services for routine transportation to receive
outpatient or inpatient
services.
All charges All charges 32
32 Page 33 34
2002 Aetna U. S. Healthcare HMO 33 Section
5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
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:
If you need emergency care, you
are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency
medical condition is one manifesting itself by acute symptoms of sufficient
severity such that a
prudent layperson, who possesses average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to result in
serious jeopardy to the person's health, or with respect to a
pregnant
woman, the health of the woman and her unborn child.
Whether you are in or
out of an Aetna U. S. Healthcare HMO service area, we simply ask that you follow
the guidelines below when you believe you need emergency care.
Call the local emergency hotline (ex. 911) or go to the nearest emergency
facility. If a delay would not be detrimental to your health, call your primary
care provider. Notify your primary care provider as soon as
possible after
receiving treatment.
After assessing and stabilizing your condition, the
emergency facility should contact your primary care physician so they can assist
the treating physician by supplying information about your medical history.
If you are admitted to an inpatient facility, you or a family member or
friend on your behalf should notify your primary care physician or us as soon as
possible.
What to Do Outside Your Aetna U. S. Healthcare HMO Service Area
Members who are traveling outside their HMO service area or students who
are away at school are covered for emergency and urgently needed care. Urgent
care may be obtained from a private practice physician, a
walk-in clinic, an urgent care center or an emergency facility. Certain
conditions, such as severe vomiting, earaches, sore throats or fever, are
considered "urgent care" outside your Aetna U. S. Healthcare HMO service
area and are covered in any of the above settings.
If, after reviewing
information submitted to us by the provider that supplied care, the nature of
the urgent or emergency problem does not qualify for coverage, it may be
necessary to provide us with additional
information. We will send you an Emergency Room Notification Report to
complete, or a Member Services representative can take this information by
telephone. 33
33 Page
34 35
2002 Aetna U. S. Healthcare HMO
34 Section 5( d)
Follow-up Care after Emergencies All
follow-up care should be coordinated by your PCP. Follow-up care with
nonparticipating providers is only covered
with a referral from your primary
care physician and pre-approval from Aetna U. S. Healthcare. Whether you were
treated inside or outside your Aetna U. S. Healthcare service area, you must
obtain a referral before any follow-up care
can be covered. Suture removal,
cast removal, X-rays and clinic and emergency room revisits are some examples of
follow-up care.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, call you primary care doctor. In
extreme emergencies or 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
your primary care doctor. You or a family member must notify your primary care
doctor as soon as possible after receiving emergency care. It is your
responsibility to ensure that your primary care doctor has been timely notified.
If you need to be hospitalized, the Plan must be notified as soon as
possible. If you are hospitalized in non-Plan facilities and 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-participating
providers must be approved by us 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 as soon as possible. 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-participating providers must be approved by us
or provided by plan providers.
Benefit Description High Option You pay Standard Option You pay
Emergency within our service area
Emergency care at a doctor's
office $15 per PCP visit $20 per specialist
visit
$20 per PCP visit $25 per specialist
visit
Emergency care
as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay
is waived.
$75 per visit $75 per visit
Not covered: Elective care or non-emergency care All charges All charges
Emergency outside our service area
Emergency care at a
doctor's office $20 per specialist visit $25 per specialist visit
Emergency care as an outpatient in a hospital or an urgent care center
NOTE: If the emergency results in admission to a hospital, the copay
is waived.
$75 per visit $75 per visit
Emergency outside our service area — Continued on the next page 34
34 Page 35 36
2002 Aetna U. S. Healthcare HMO 35 Section
5( d)
Emergency outside our service area (Continued)
High Option You pay Standard Option You pay
Not covered:
Elective care or non-emergency care
Emergency care
provided outside the service area if the need for care could have been foreseen
before
leaving the service area
Medical and hospital costs resulting
from a normal full-term delivery of a baby outside the service area.
All charges All charges
Ambulance
Professional ambulance service when medically
appropriate. Air ambulance may be covered. Prior
approval is required.
See 5( c) for non-emergency service.
Nothing for covered care Nothing for covered care
Not covered: air ambulance without prior approval All charges All charges
35
35 Page 36
37
2002 Aetna U. S. Healthcare HMO 36
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
Network Benefit
I M
P O
R T
A N
T
Parity
When you get our approval for services and follow a
treatment plan we approve, cost-sharing and limitations for Plan mental health
and substance abuse benefits
will be no greater than for similar benefits for other illnesses and
conditions.
Here are some important things to keep in mind about these
benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions
after the benefits description below.
I M
P O
R T
A N
T
Description High Option You pay Standard Option You pay
Mental health
and substance abuse benefits
All diagnostic and treatment services
recommended by a Plan provider and contained in a treatment plan that we
approve. The treatment plan may include services, drugs, and supplies
described elsewhere in this brochure.
NOTE: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your
condition and only when you receive the
care as part of a treatment plan that we approve.
Your cost sharing responsibilities
are no greater than for other illness
or
conditions.
Your cost sharing responsibilities
are no greater than for other illness
or
conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists,
psychologists, or clinical social workers
Medication management
$20 per visit $25 per visit
Diagnostic tests $20 per visit $25 per visit
Services provided by a
hospital or other facility
Services in approved alternative care settings
such as partial hospitalization, full-day hospitalization,
facility based intensive outpatient treatment
$20 per outpatient visit $25 per outpatient visit
Inpatient service:
Approved residential treatment facility
Hospital
service
$100 per day up to a maximum of $300
per admission
$200 per day up to
a maximum of $600
per admission
Mental health and substance abuse benefits — Continued on the next page
36
36 Page 37
38
2002 Aetna U. S. Healthcare HMO 37
Section 5( e)
Mental health and substance abuse benefits
(Continued) High Option You pay Standard Option You pay
Not covered:
Services we have not approved
Out
of network mental health and substance abuse services
NOTE: OPM will base its review of disputes about treatment plans on
the treatment plan's clinical
appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment
plan in favor of
another.
All charges All charges
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all the following authorization processes:
Contact Customer Services at 1-800-537-9384 to identify providers and obtain
information on the referral process.
Network limitation We may limit your benefits if you do not obtain a
treatment plan. 37
37 Page
38 39
2002 Aetna U. S. Healthcare HMO
38 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.
Certain drugs require your doctor to get precertification from the Plan
before they can be prescribed under the Plan. Upon approval by the Plan, the
prescription is good for the current calendar year or a specified time
period, whichever is less.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist must
write the prescription.
Where you can obtain them. You must fill
non-emergency prescriptions at a Plan pharmacy for up to a 30-day supply, or at
a participating retail pharmacy or mail order pharmacy for a 31-90 day supply of
medication (if authorized by your physician). Please call Member Services at
1-800-537-9384 for more details on how to use the mail order program. In an
emergency or urgent care situation, you may fill your
covered prescription
at any retail pharmacy. If you obtain your prescription at a participating
pharmacy and request direct reimbursement from us, we will review your claim to
determine whether the claim is
covered under the terms and conditions of
your benefit plan. If you obtain your prescription at a pharmacy that does not
participate with the plan, you will need to pay the pharmacy the full price of
the prescription
and submit a claim for reimbursement subject to the terms
and conditions of the plan.
We use a formulary. Drugs are prescribed
by Plan doctors and dispensed in accordance with the Plan's drug formulary. The
Plan's formulary does not exclude medications from coverage, but requires a
higher
copayment for nonformulary drugs. We cover nonformulary drugs when prescribed
by a Plan doctor at a 50% copayment. For covered nonformulary drugs you pay 50%
of the negotiated rate for the drug between
the Plan and the participating
retail or mail order pharmacy. Certain drugs require your doctor to get
precertification from the Plan before they can be prescribed under the Plan.
Visit our website at
www. aetnaushc. com/ feds to review our
Formulary Guide or call 1-800-537-9384.
Precertification. Your
pharmacy benefits plan includes our precertification program. Precertification
helps encourage the appropriate and cost-effective use of certain drugs. These
drugs must be pre-authorized
by our Pharmacy Management Precertification Unit before they will be covered.
Only your physician or pharmacist in the case of an antibiotic or analgesic can
request prior authorization for a drug.
The precertification program is based upon current medical findings,
manufacturer labeling, FDA guidelines and cost information.
The drugs
requiring precertification are subject to change. Visit our website for the
current Precertification List.
These are the dispensing limitations.
Covered prescription drugs prescribed by a licensed physician or dentist and
obtained at a Participating Plan Pharmacy may be dispensed for up to a 30-day
supply.
Members may obtain a 31-to 90-day supply of covered prescription medication
through mail order or participating retail pharmacy. A generic equivalent will
be dispensed if available, unless your physician
specifically requires a
name brand.
Why use generic drugs? Generics contain the same active
ingredients in the same amounts as their brand name counterparts and must have
been approved by the FDA. By using generic drugs, when available,
most members see cost savings, without jeopardizing clinical outcome or
compromising quality.
When you have to file a claim. Send your
itemized bill( s) to: Aetna U. S. Healthcare, Pharmacy Management, Claim
Processing, P. O. Box 398106, Minneapolis, MN 55439-8106.
Prescription drug benefits — Begin on the next page 38
38 Page 39 40
2002 Aetna U. S. Healthcare HMO 39 Section
5( f)
Benefit Description
High and Standard Option
You pay
Covered medications and supplies
We cover the
following medications and supplies prescribed by a Plan physician or dentist and
obtained from a Plan pharmacy or through our
mail order program:
Drugs for which a prescription is required by Federal
law
Oral contraceptive drugs
Insulin
Disposable needles and syringes
need to inject covered prescribed medication, including insulin
Diabetic supplies limited to lancets, alcohol swabs, urine test strips/
tablets, and blood glucose test strips
Contraceptive drugs and devices
Oral fertility drugs
Nutritional formulas for the treatment of
phenylketonuria, branched-chain ketonuria, galectosemia and homocystinuria when
administered
under the direction of a Plan doctor
Intravenous fluids and medications
for home use, implantable drugs, such as Norplant, IUDs and some Injectable
drugs are covered under
Medical and Surgical Benefits. See Section 5( a) for details.
NOTE:
Injectable fertility drugs are covered only for in-vitro fertilization.
Please refer to Section 5( a), Medical Services and Supplies, Infertility
Services
$10 per covered generic formulary prescription/ refill
(up to a 30 day
supply) or $20 for a 31-to 90-day supply
$20 per covered brand name formulary prescription/ refill
(up to a 30 day
supply) or $40 for a 31-to 90-day supply
50% of the negotiated rate between the Plan and the
participating retail
or mail order pharmacy per covered
non-formulary (generic or brand)
prescription/ refill.
Limited benefits
Drugs to treat sexual dysfunction are limited.
Contact the Plan for dose limits
Depo Provera is limited to 5 vials per calendar year
One diaphragm per
calendar year
50%
$20 copay per vial
$20 per diaphragm
Here are some things to keep in mind about our prescription drug program:
A generic equivalent may be dispensed if it is available, and where allowed
by law.
To request a copy of the Aetna U. S. Healthcare Medication Formulary Guide,
call 1-800-537-9384. The information in the Medication
Formulary Guide is
subject to change. Please visit our website at www. aetnaushc. com/ feds
for current Medication Formulary Guide
information.
Covered
medications and supplies — Continued on the next page 39
39 Page 40 41
2002 Aetna U. S. Healthcare HMO 40 Section
5( f)
Covered medications and supplies (Continued)
High and Standard Option
You pay
Not covered:
Drugs available without a prescription or for which there is a
nonprescription equivalent available, (i. e., an over-the-counter (OTC)
drug)
Drugs obtained at a non-Plan pharmacy except when related
to out-of-area emergency care
Vitamins and nutritional substances that can be purchased without
prescription.
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic
performance.
Smoking-cessation drugs and medication, including, but
not limited to, nicotine patches and sprays.
Drugs used for the purpose of weight reduction (i. e., appetite
suppressants)
All charges 40
40 Page 41 42
2002 Aetna U.
S. Healthcare HMO 41 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Services for the deaf and hearing-impaired
1-800-628-3323
Informed Health Line Provides eligible members with telephone access
to registered nurses experienced in providing information on a variety of health
topics.
Informed Health Line is available 24 hours a day, 7 days a week. You
may call Informed Health Line at 1-800-556-1555, Informed Health Line
nurses cannot diagnose, prescribe medication or give medical advice.
Reciprocity benefit If you need to visit a participating primary care
physician for a covered service, and you are 50 mile or more away from home you
may visit a
primary care physician from our Plan's approved network.
Call 1-800-537-9384 for provider information and location
Select a
doctor from 3 primary care doctors in that area
The Plan will authorize you
for one visit and any tests or X-rays ordered by that primary care physician.
You must coordinate all subsequent visits through your own participating care
physician.
High-risk pregnancies The Aetna U. S. Healthcare Moms-to-Babies
Maternity Management Program TM helps members give their babies a healthy start
with
educational materials and services that complement covered benefits.
This program includes nurse case management, educational materials, one
prenatal and one newborn home nurse visit, breast feeding information and
support, and other benefits.
Centers of Excellence for transplants/ heart
surgery/ etc.
Our National Medical Excellence Program coordinates services for
complicated or rare illnesses and transplants. The National Medical
Excellence Program is unique to Aetna U. S. Healthcare and has been created
for members with particularly difficult conditions such as rare cancers and
other complicated diseases and disorders.
Usually, the recommended
treatment can be found in your area. But if your needs extend beyond your
region, the National Medical Excellence Program
may be available to send you to out-of-area experts.
The first priority
is to determine an appropriate treatment program. If your treatment program
cannot be provided in the local area, we will arrange and
pay for covered care as well as related travel expenses to wherever the
necessary care is available. Prior approval is required.
Travel benefit/ services overseas Our National Medical Excellence
Program is a case management program that provides consistency in the
coordination of care for life threatening
and complex illnesses. This
includes bone marrow and solid organ transplants, investigational and new
technology (when covered), and
unique services that are offered at a limited number of medical facilities.
We also coordinate care for members if they need covered care that is not
available in their local area and if they become ill when traveling
temporarily outside the Continental United States. 41
41 Page 42 43
2002 Aetna U. S. Healthcare HMO 42 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.
Your selected Plan primary care dentist must provide or arrange covered care.
We cover hospitalization for dental procedures only when a nondental
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
No benefits other than those listed
on the following schedule.
Dental Benefits High and Standard Option You pay
Service
Diagnostic
Office visit for oral evaluation — limited to 2 visits
per year
Bitewing x-rays — limited to 2 sets of bitewing x-rays per year
Entire x-ray series — limited to 1 entire x-ray series in any 3 year period
Periapical x-rays and other dental x-rays — as necessary
Diagnostic
models
Preventive
Prophylaxis (cleaning of teeth) — limited to 2
treatments per year
Topical fluoride — limited to 2 courses of treatment per
year and to children under age 18
Oral hygiene instruction
Restorative (Fillings)
Amalgam
(primary) 1 surface
Amalgam (primary) 2 surfaces
Amalgam (primary) 3
surfaces
Amalgam (primary) 4 surfaces
Amalgam (permanent) 1 surface
Amalgam (permanent) 2 surfaces
Amalgam (permanent) 3 surfaces
Amalgam (permanent) 4 surfaces
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
$5
Dental Benefits — Continued on the next page 42
42 Page 43 44
2002 Aetna U. S. Healthcare HMO 43 Section
5( h)
Dental Benefits (Continued) High and
Standard Option You pay
Service
Prosthodontics Removable
Denture
adjustments (complete or partial/ upper or lower)
Endodontics
Pulp cap — direct
Pulp cap — indirect
$5
$5
$5
NOTE: The above services are only covered when provided by your
selected participating primary care dentist in accordance with the terms of your
Plan. If rendered by a participating specialist, they are provided
at reduced fees. Pediatric dentists are considered specialists.
Certain other services will be provided by your selected participating
primary care dentist at reduced fees. A partial list appears below. Ask your
selected
participating primary care dentist for a complete schedule of
current reduced member fees. All member fees must be paid directly to the
participating dentist.
Each employee and dependent must select a primary care dentist from the
directory and include the dentist's name on the enrollment or provider selection
form.
The following procedures are also available from your selected
participating primary care dentist up to the maximum fee shown. These same
services received from a participating specialist may require you to pay a
fee that is higher than the stated maximum. Call your selected
participating primary care dentist or participating dental specialist for the
specific fee in your area.
Service
High and Standard Option You pay up to
a maximum fee of
Diagnostic
Sealant — per permanent tooth
Space maintainer
Restorative (Fillings)
Resin (anterior) 1 surface
Resin
(anterior) 2 surfaces
Resin (anterior) 3 surfaces
Resin (anterior) 4 or
more surfaces or incisal angle
Metallic inlay
$35
$560
$110
$145
$175
$190
$725
Prosthodontics, removable
Complete denture, (upper or lower)
Immediate denture (upper or lower)
Partial denture resin base (upper or
lower)
Partial denture cast metal framework with resin base (upper or lower)
Denture repairs
Add tooth to existing partial
Add clasp to existing
partial
$1,025
$1,110
$790
$1,200
$150
$135
$150
Dental benefits — Continued on the next page 43
43 Page 44 45
2002 Aetna U. S. Healthcare HMO 44 Section
5( h)
Dental Benefits (Continued)
Service
High and Standard Option You pay up to
a maximum fee of
Prosthodontics, removable (Continued)
Denture rebase
Denture relines
Interim denture (complete or partial/ upper or lower)
Tissue conditioning
Prosthodontics, fixed
Bridge pontic
Metallic inlay/ onlay
Cast metal retainer for resin bonded prosthesis
Crown porcelain
Crown cast
Recement bridge
Post and core
Oral surgery
Extractions (nonsurgical and tissue impacted)
Anesthesia (general in office, first half-hour session)
$375
$325
$465
$110
$875
$815
$315
$860
$865
$85
$315
$475
$270
Periodontics (Gum treatment)
Gingivectomy per quadrant
Gingival curretage per quadrant
Periodontal surgery
Provisional
splinting
Scaling and root planing per quadrant
Periodontal maintenance
procedure
Endodontics (Root canal)
Therapeutic pulpotomy
Root canals
(anterior, bicuspid, molar) excluding final restoration
Apicoectomy —
anterior
Orthodontics
Pre-orthodontic treatment visit
Fully banded case
(adult age 19 and over)
Fully banded case (child age 18 and under)
$315
$150
$760
$160
$150
$110
$125
$760
$510
$350
$5,625
$5,625
Specific fees vary by area of the country up to the stated maximum. Ask
your primary care dentist for a complete schedule of reduced fees.
Services not received from a participating dental provider are not
covered. We offer no other dental benefits than those shown above. All charges
When you have to file a claim Send your itemized bills to Aetna U. S.
Healthcare, One Imeson Place. 1 Imeson Park Drive, Bldg. 100, Mezz. Floor,
Jacksonville FL 32218. 44
44 Page 45 46
2002 Aetna U.
S. Healthcare HMO 45 Section 5( i)
Section 5 (i). Non-FEHB
benefits available to Plan members
The benefits and programs on this
page are not part of the FEHB contract or premium, and you cannot file an
FEHB disputed claim about them. Fees you pay for these services do not count
toward FEHB deductibles or
out-of-pocket maximums.
Intelihealth InteliHealth. com offers comprehensive health
information which is interactive and easy-to-use. Harvard
Medical School and
the University of Pennsylvania School of Dental Medicine help InteliHealth to
provide trusted and credible health information to its users. InteliHealth
features include: a Drug Resource Center,
Disease and Condition Management
tools, Health Risk Assessments, the Harvard Symptom Scout (an interactive
symptom checker that provides guidance about a variety of symptoms), Daily
Health News
and much more.
Vision One 1 You are eligible to
receive substantial discounts on eyeglasses, contact lenses, Lasik — the laser
vision
corrective procedure, and nonprescription items including sunglasses
and eyewear products through the Vision One Program at more than 4,000 locations
across the country.
This eyewear discount enriches the routine vision care coverage provided in
your health plan, which includes an eye exam from a participating provider. If
your health plan also includes coverage for eyewear such as
prescription
eyeglasses or contact lens, your out-of-pocket expense can be reduced when you
use Vision One discount. You may purchase your eyewear at Vision One locations
at discounted rates, and your allowance will
automatically be applied at
point of purchase. You don't have to submit the receipt for reimbursement. Your
allowance applies to prescription eyeglasses or contact lenses only.
For more information on Vision One eyewear call toll free 1-800-793-8616. For
a referral to a Lasik provider, call 1-800-422-6600.
Fitness Program Aetna U. S. Healthcare offers members access to
discounted fitness services provided by GlobalFit TM . Programs
offer Plan
participants:
Low or discounted membership rates at independent health clubs
contracted with GlobalFit
Discounts on certain home exercise equipment
To determine which program is offered in your area and to view a list of
included clubs, visit the GlobalFit website at www. globalfit. com. If you would
like to speak with a GlobalFit representative, you can call the
GlobalFit Health Club Help Line at 1-800-298-7800.
1 Vision One is a registered trademark of Cole Vision. 45
45 Page 46 47
2002 Aetna U. S. Healthcare HMO 46 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 and we agree, as discussed under
Services Requiring Our Prior Approval on page 13.
We do not cover the following:
Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric practice;
Experimental or investigational procedures,
treatments, drugs or devices;
Procedures, 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;
Procedures, 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. 46
46 Page 47 48
2002 Aetna U.
S. Healthcare HMO 47 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 and 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 1-800-537-9384.
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 medical and
hospital claims to: Aetna U. S. Healthcare, Inc., 1425 Union Meeting Road,
P. O. Box 1125, Blue Bell, PA 19422
Submit your drug claims to: Aetna U. S. Healthcare, Pharmacy
Management, Claim Processing, P. O. Box 398106, Minneapolis, MN
55439-8106
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. 47
47 Page
48 49
2002 Aetna U. S. Healthcare HMO
48 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: Aetna U. S. Healthcare, Inc.,
1425 Union Meeting Road, P. O. Box 1125, Blue Bell, PA 19422; 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 St. NW,
Washington, D. C. 20415-3630.
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. 48
48 Page 49 50
2002 Aetna U. S. Healthcare HMO 49 Section 8
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision,
your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in
which you received the disputed services, drugs or supplies or from the year in
which you were denied precertification or prior
approval. This is the only
deadline that may not be extended.
OPM may disclose the information it
collects during the review process to support their disputed claim decision.
This information will become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800-537-9384 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 III at 202-606-0737
between 8 a. m. and 5 p. m. eastern time.
External Review
If this Plan denied your claim for payment or
services, you can ask us to reconsider your claim. If we still deny your claim,
you can seek an independent external review, before asking OPM to review it, if:
1. The amount of your claim or service is more than $500; and
2. The Plan
denied your claim because it did not consider the treatment medically necessary
or considered it experimental or investigational.
The independent external review will use a neutral, independent physician
with related expertise to conduct the review. The Plan will cover the
professional fee for the review and you will pay the cost to compile and send
your submission
to the Plan.
To request an External Review Form call
1-800-537-9384 within 60 days after receiving the Plan's written notification
that it will uphold its original decision to deny your claim.
The external reviewer will make a decision within 30 days after you send us
all the necessary information with the External Review Request Form. Your
primary care doctor can request an expedited review in cases of "clinical
urgency" where your health would be seriously jeopardized if you waited the
full 30 days. In this case, the external review organization or physician will
make a decision within 72 hours.
To request a detailed description of the external review requirements, call
the Plan's Member Relations Office at 1-800-537-9384. 49
49 Page 50 51
2002 Aetna U. S. Healthcare HMO 50 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 information.
– Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social
Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in
how you get your health care. Medicare+ Choice is the term used to describe the
various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending
on the type of Medicare managed care plan you have.
The Original Medicare
Plan The Original Medicare Plan (Original Medicare) is available everywhere
in the United States. It is the way everyone used to get Medicare benefits and
it is the way most people get their Medicare Part A and Part B benefits. You
may go to any doctor, specialist, or hospital that accepts Medicare.
Medicare pays its share and you pay your share. Some things are not covered
under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. You
must continue to be authorized by your PCP, or precertified as required.
We will not waive any of our copayments or coinsurance.
(Primary
payer chart begins on next page.) 50
50 Page 51 52
2002 Aetna U.
S. Healthcare HMO 51 Section 9
The following chart illustrates
whether Original Medicare or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It
is critical that you tell us if you or a covered
family member has Medicare
coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is … A. When either you —
or your covered spouse — are age 65 or over
and … Original Medicare This
Plan
1) Are an active employee with the Federal government (including
when you or a family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the
Federal government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C.
(or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B
services)
(for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that
you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you — or a covered family member — have
Medicare based on end stage renal disease (ESRD) and …
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare
due to ESRD after Medicare became primary for you under another provision,
C. When you or a covered family member have FEHB and …
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, 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. 51
51
Page 52 53
2002 Aetna U. S. Healthcare HMO 52 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 1-800-537-9384.
We do not waive costs when you
have the Original Medicare Plan — When Original Medicare is the primary
payer, in this case we will
not waive out-of-pocket costs.
Medical services and supplies provided by
physicians and other health care professionals. If you are enrolled in Medicare
Part B, we do not
waive any costs when you have Medicare.
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 or coinsurance 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 even out of the managed care
Plan's network and/ or service
area (if you use our Plan providers), but we will not waive any of our
copayments or coinsurance or deductibles. If you
enroll in a Medicare
managed care plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in the Medicare managed
care plan so we 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
manage care plan service area.
If you do not enroll in Medicare Part A or Part B If you do not have
one or both Parts of Medicare, you can still be covered
under the FEHB Program. We will not require you to enroll in Medicare 52
52 Page 53 54
2002 Aetna U. S. Healthcare HMO 53 Section 9
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 members,
eligible dependent 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 are responsible for your care We do
not cover services and supplies when a local, State, or Federal
Government
agency directly or indirectly pays for them.
When others are responsible for injuries 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 is
called subrogation. If you need more information, contact us for our subrogation
procedures.
The Member specifically acknowledges our right of
subrogation. When we provide health care benefits for injuries or illnesses for
which a third party
is or may be responsible, we shall be subrogated to your rights of recovery
against any third party to the extent of the full cost of all benefits provided
by us, to the fullest extent permitted by law. We may proceed against any
third party with or without your consent.
You also specifically acknowledge our right of reimbursement. This right of
reimbursement attaches, to the fullest extent permitted by law, when we
have
provided health care benefits for injuries or illness for which a third party is
or may be responsible and you and/ or your representative has
recovered any
amounts from the third party or any party making payments on the third party's
behalf. By providing any benefit under this Plan, we
are granted an
assignment of the proceeds of any settlement, judgment or other payment received
by you to the extent of the full cost of all benefits 53
53 Page 54 55
2002 Aetna U. S. Healthcare HMO 54 Section 9
provided by us. Our right of reimbursement is cumulative with and not
exclusive of our subrogation right and we may choose to exercise either
or
both rights of recovery.
You and your representatives further agree to:
Notify us promptly and in
writing when notice is given to any third party of the intention to investigate
or pursue a claim to recover
damages or obtain compensation due to injuries or illness sustained by us
that may be the legal responsibility of a third party; and
Cooperate with us and do whatever is necessary to secure our rights of
subrogation and/ or reimbursement under this Plan; and
Give us a
first-priority lien on any recovery, settlement or judgment or other source of
compensation which may be had from a third party to
the extent of the full
cost of all benefits associated with injuries or illness provided by us for
which a third party is or may be responsible
(regardless of whether
specifically set forth in the recovery, settlement, judgment or compensation
agreement); and
Pay, as the first priority, from any recovery, settlement or judgment or
other source of compensation, any and all amounts due us as
reimbursement
for the full cost of all benefits associated with injuries or illness provided
by us for which a third party is or may be
responsible (regardless of
whether specifically set forth in the recovery, settlement, judgment, or
compensation agreement), unless
otherwise agreed to by us in writing; and
Do nothing to prejudice our rights as set forth above. This includes, but is
not limited to, refraining from making any settlement or
recovery which specifically attempts to reduce or exclude the full cost of
all benefits provided by us.
We may recover the full cost of all benefits provided by us under this Plan
without regard to any claim of fault on the part of you, whether by
comparative negligence or otherwise. No court costs or attorney fees may be
deducted from our recovery without the prior express written consent of
us.
In the event you or your representative fails to cooperate with us, you shall be
responsible for all benefits paid by us in addition to costs and
attorney's
fees incurred by us in obtaining repayment. 54
54
Page 55 56
2002
Aetna U. S. Healthcare HMO 55 Section 10
Section 10.
Definitions of terms we use in this brochure
Calendar year January 1
through December 31 of the same year. For new enrollees, the calendar year
begins on the effective date of their enrollment and ends on
December 31 of
the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 14.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 14.
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Any type
of care provided according to Medicare guidelines, including room and board,
that a) does not require the skills of technical or
professional personnel;
b) is not furnished by or under the supervision of such personnel or does not
otherwise meet the requirements of post-hospital
Skilled Nursing Facility
care; or c) is a level such that you have reached the maximum level of physical
or mental function and such person
is not likely to make further significant
improvement. Custodial Care includes any type of care where the primary purpose
is to attend to your
daily living activities which do not entail or require
the continuing attention of trained medical or paramedical personnel. Examples
include
assistance in walking, getting in and out of bed, bathing, dressing,
feeding, using the toilet, changes of dressings of non infected, post operative
or
chronic conditions, preparation of special diets, supervision of
medication which can be self-administered by you, the general maintenance care
of
colostomy or ileostomy, routine services to maintain other service which,
in our determination, is 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 who actually provides the service,
residential care and adult day care, protective and supportive care
including educational services, rest cures, convalescent care.
Detoxification The process whereby an alcohol or drug intoxicated or
alcohol or drug dependent person is assisted, in a facility licensed by the
appropriate
regulatory authority, through the period of time necessary to
eliminate, by metabolic or other means, the intoxicating alcohol or drug,
alcohol or drug
dependent factors or alcohol in combination with drugs as
determined by a licensed Physician, while keeping the physiological risk to the
patient at a
minimum. 55
55 Page 56 57
2002 Aetna U.
S. Healthcare HMO 56 Section 10
Experimental or
investigational services Services or supplies that are, as determined by us,
experimental. A drug,
device, procedure or treatment will be determined to
be experimental if:
There is not sufficient outcome data available from
controlled clinical trials published in the peer reviewed literature to
substantiate its safety
and effectiveness for the disease or injury involved; or
Required FDA
approval has not been granted for marketing; or
A recognized national
medical or dental society or regulatory agency has determined, in writing, that
it is experimental or for research
purposes; or
The written protocol or protocol( s) used by the treating
facility or the protocol or protocol( s) of any other facility studying
substantially the
same drug, device, procedure or treatment or the written informed consent
used by the treating facility or by another facility studying the
same drug,
device, procedure or treatment states that it is experimental or for research
purposes; or
It is not of proven benefit for the specific diagnosis or treatment of your
particular condition; or
It is not generally recognized by the Medical
Community as effective or appropriate for the specific diagnosis or treatment of
your particular
condition; or
It is provided or performed in special
settings for research purposes.
Medical necessity Also known as medically necessary or medically
necessary services. Services that are appropriate and consistent with the
diagnosis in
accordance with accepted medical standards as described in this
document. Medical Necessity, when used in relation to services, shall have the
same
meaning as Medically Necessary Services. This definition applies only
to the determination by us of whether health care services are Covered
Benefits under this Plan.
Reasonable charge The charge for a Covered Benefit which we determine
to be the prevailing charge level made for the service or supply in the
geographic area where it
is furnished. We may take into account factors such
as the complexity, degree of skill needed, type or specialty of the provider,
range of services
provided by a facility, and the prevailing charge in other
areas in determining the Reasonable Charge for a service or supply that is
unusual
or is not often provided in the area or is provided by only a small
number of providers in the area. 56
56 Page 57 58
2002 Aetna U.
S. Healthcare HMO 57 Section 10
Referral Specific
directions or instructions from your PCP, in conformance with our policies and
procedures, that direct you to a participating provider for
medically
necessary care.
Respite care Care furnished during a period of time when your family
or usual caretaker cannot, or will not, attend to the your needs.
Urgent care Covered benefits required in order to prevent serious
deterioration of a your health that results from an unforeseen illness or injury
if you are
temporarily absent from the our service area and receipt of the
health care service cannot be delayed until your return to the service area.
Us/ we Us and we refer to Aetna U. S. Healthcare, Inc.
You
You refers to the enrollee and each covered family member. 57
57 Page 58 59
2002 Aetna U. S. Healthcare HMO 58 Section
11
Section 11. FEHB facts
No pre-existing condition limitation
We will not refuse to cover the treatment of a condition that you had
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information about enrolling in the
FEHB Program
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures for other plans, and other materials you need
to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your employing or
retirement office.
Types of coverage available for you and your family Self Only coverage
is for you alone. Self and Family coverage is for you, your
spouse, and your
unmarried dependent children under age 22, including any foster children or
stepchildren your employing or retirement office authorizes
coverage for.
Under certain circumstances, you may also continue coverage for a disabled child
22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is
born or becomes an eligible family member. When you change to Self
and Family because you marry, the change is effective on the first day of the
pay
period that begins after your employing office receives your enrollment
form, benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family member
is no longer eligible to receive health benefits, nor will we. Please tell us
immediately when you add or remove family members from your coverage for any
reason, including divorce, or when your child under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another FEHB
plan. 58
58 Page
59 60
2002 Aetna U. S. Healthcare HMO
59 Section 11
When benefits and premiums start The
benefits in this brochure are effective on January 1. If you joined this
Plan during Open Season, your coverage begins on the first day of your first
pay period that starts on or after January 1. Annuitants coverage and
premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage.
Your medical and claims records are confidential We will keep your
medical and claims information confidential. Only the
following will have
access to it:
OPM, this Plan, and subcontractors when they administer this
contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when
coordinating
benefit payments and subrogating claims;
Law enforcement officials when
investigating and/ or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as Temporary Continuation of
Coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity coverage If you are divorced from a Federal employee or
annuitant, you may not continue to get benefits under your former spouse's
enrollment. But, you
may be eligible for your own FEHB coverage under the
spouse equity law. If you are recently divorced or are anticipating a divorce,
contact your ex-spouse's
employing or retirement office to get RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary Continuation
of
Coverage and Former Spouse Enrollees, or other information about your
coverage choices. 59
59 Page
60 61
2002 Aetna U. S. Healthcare HMO
60 Section 11
Temporary Continuation of Coverage (TCC) If
you leave Federal service, or if you lose coverage because you no longer
qualify as a family member, you may be eligible for Temporary Continuation
of Coverage (TCC). For example, you can receive TCC if you are not able to
continue your FEHB enrollment after you retire, if you lose your Federal
job, if you are a covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation
of Coverage and Former Spouse Enrollees, from
your employing or retirement office or from www. opm. gov/ insure. It explains
what you have to do to enroll.
Converting to individual coverage You may convert to a non-FEHB
individual policy if:
Your coverage under TCC or the spouse equity law ends.
If you canceled your coverage or did not pay your premium, you cannot convert;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days after you receive
this
notice. However, if you are a family member who is losing coverage, the
employing or retirement office will not notify you. You must apply in
writing
to us within 31 days after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we will
not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) is a
Federal
law that offers limited Federal protections for health coverage availability and
continuity to people who lose employer group coverage.
If you leave the FEHB Program, we will give you a Certificate of Group Health
Plan Coverage that indicates how long you have been enrolled with us.
You
can use this certificate when getting health insurance or other health care
coverage. Your new plan must reduce or eliminate waiting periods, limitations,
or exclusions for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan. If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27,
Temporary Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB website
(www. opm. gov/ insure/ health), refer to the "TCC and HIPPA" frequently
asked questions. These highlight HIPAA rules, such as the requirement that
Federal
employees must exhaust any TCC eligibility as one condition for
guaranteed access to individual health coverage under HIPAA, and have
information about
Federal and State agencies you can contact for more
information. 60
60 Page
61 62
2002 Aetna U. S. Healthcare HMO
61 LTC Insurance
Long Term Care Insurance Is Coming Later in
2002!
The Office of Personnel Management (OPM) will sponsor a
high-quality long term care insurance program effective in October 2002. As part
of its educational effort, OPM asks you to consider these questions:
What
is long term care (LTC) insurance? It's insurance to help pay for long term
care services you may need if you can't take care of yourself because of an
extended illness or injury, or an
age-related disease such as Alzheimer's.
LTC insurance can provide broad, flexible benefits for nursing home care,
care in an assisted living facility, care in your home, adult day care,
hospice care, and more. LTC insurance can supplement care provided by
family members, reducing the burden you place on them.
I'm healthy. I won't need long term care. Or, will I? Welcome to the
club!
76% of Americans believe they will never need long term care, but the
facts are that about half of them will. And it's not just the old folks.
About 40% of people needing long term care are under age 65. They may need
chronic care due to a serious accident, a stroke, or developing multiple
sclerosis, etc.
We hope you will never need long term care, but everyone should have a
plan just in case. Many people now consider long term care insurance to
be vital to their financial and retirement planing.
Is long term care expensive? 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.
But won't my FEHB plan, Medicare or Medicaid cover my long term
care?
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.
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. 61
61 Page 62 63
2002 Aetna U. S. Healthcare HMO 62 LTC
Insurance
When will I get more information on how to apply for this
new
insurance coverage?
Employees will get more information from their agencies during the LTC
open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
How can I find out more about the program NOW? 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. 62
62 Page 63 64
2002 Aetna U. S. Healthcare HMO 63 DoD/ FEHB
Demonstration Project
Department of Defense/ FEHB Demonstration
Project
What is it? The Department of Defense/ FEHB Demonstration
Project allows some active and retired uniformed service members and their
dependents to
enroll in the FEHB Program. The demonstration will last for
three years and began with the 1999 open season for the year 2000. Open season
enrollments will be effective January 1, 2002. DoD and OPM have set up some
special procedures to implement the Demonstration Project, noted
below.
Otherwise, the provisions described in this brochure apply.
Who is eligible DoD determines who is eligible to enroll in the FEHB
Program. Generally, you may enroll if:
You are an active or retired
uniformed service member and are eligible for Medicare;
You are a dependent
of an active or retired uniformed service member and are eligible for Medicare;
You are a qualified former spouse of an active or retired uniformed service
member and you have not remarried; or
You are a survivor dependent of a
deceased active or retired uniformed service member; and
You live in one of
the geographic demonstration areas.
If you are eligible to enroll in a plan
under the regular Federal Employees Health Benefits Program, you are not
eligible to enroll under the
DoD/ FEHBP Demonstration Project.
The demonstration areas Dover AFB, DE Commonwealth of Puerto Rico Fort
Knox, KY Greensboro/ Winston Salem/ High Point, NC
Dallas, TX Humboldt
County, CA area
New Orleans, LA Naval Hospital, Camp Pendleton, CA
Adair
County, IA
When you can join You may enroll under the FEHB/ DoD Demonstration
Project during the 2001 open season, November 12, 2001, through December 10,
2001. Your
coverage will begin January 1, 2002. DoD has set-up an
Information Processing Center (IPC) in Iowa to provide you with information
about
how to enroll. IPC staff will verify your eligibility and provide you
with FEHB Program information, plan brochures, enrollment instructions and
forms. The toll-free phone number for the IPC is 1-877-DOD-FEHB
(1-877-363-3342).
You may select coverage for yourself (Self Only) or for you and your family
(Self and Family) during open season. Your coverage will begin
January 1,
2002. If you become eligible for the DoD/ FEHB Demonstration Project outside of
open season, contact the IPC to find out how to enroll
and when your
coverage will begin. 63
63 Page
64 65
2002 Aetna U. S. Healthcare HMO 64 DoD/ FEHB Demonstration Project
DoD has a web site devoted to the Demonstration Project. You can view
information such as their Marketing/ Beneficiary Education Plan,
Frequently
Asked Questions, demonstration area locations and zip code lists at www. tricare. osd. mil/ fehbp. You
can also view information about
the demonstration project, including
"The 2002 Guide to Federal Employees Health Benefits Plans Participating in
the DoD/ FEHB
Demonstration Project," on the OPM web site at www. opm. gov.
Temporary Continuation of Coverage (TCC) See Section 11, FEHB Facts;
it explains temporary continuation of
coverage (TCC). Under this DoD/ FEHB
Demonstration Project the only individual eligible for TCC is one who
ceases to be eligible as a "member
of family" under your self and family
enrollment. This occurs when a child turns 22, for example, or if you divorce
and your spouse does not qualify to
enroll as an unremarried former spouse
under title 10, United States Code. For these individuals, TCC begins the day
after their enrollment in the
DoD/ FEHB Demonstration Project ends. TCC
enrollment terminates after 36 months or the end of the Demonstration Project,
whichever occurs first.
You, your child, or another person must notify the
IPC when a family member loses eligibility for coverage under the DoD/ FEHB
Demonstration
Project.
TCC is not available if you move out of a DoD/
FEHB Demonstration Project area, you cancel your coverage, or your coverage is
terminated for
any reason. TCC is not available when the demonstration project ends.
Other features The 31-day extension of coverage and right to convert
do not apply to the DoD/ FEHB Demonstration Project. 64
64 Page 65 66
2002 Aetna U. S. Healthcare HMO 65 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the item appears.
Accidental injury, 27, 42 Allogeneic bone marrow
transplants, 28
Alternative treatment, 24
Ambulance, 9, 13, 30, 32, 34, 35 Anesthesia, 26,
29, 31, 44
Autologous bone marrow transplant, 21, 28
Blood and blood
plasma, 31 Casts, 30, 31
Catastrophic protection, 14, 67 Changes for 2002, 9
Chemotherapy, 21 Chiropractic, 24
Cholesterol tests, 10 Claims, 7, 11,
47, 48, 49, 51, 52,
59 Coinsurance, 5, 11, 14, 47, 50,
52, 55, 67
Colorectal cancer screening, 17
Congenital anomalies, 26, 27 Contraceptive
devices and drugs, 18,
39 Covered charges, 52
Crutches, 24
Deductible, 14, 47
Definitions, 16, 26, 30, 33, 36, 38, 42, 55, 66
Dental care, 28, 66 Disputed claims review, 9, 48, 49
Dressings, 30, 31,
40, 55 Durable medical equipment
(DME), 9, 13, 24 Educational classes
and programs,
25 Emergency, 5, 8, 9, 33, 34, 35,
38, 40, 46, 47, 66
Experimental or investigational, 46, 49
Eyeglasses, 22, 66 Family
planning, 18
Fecal occult blood test, 17 General exclusions, 4,
16, 26, 30,
33, 36, 38, 42, 46, 60, 66 Hearing services, 22
Home
health services, 24 Hospice care, 32, 61
Hospital, 4, 5, 9, 10, 12, 18, 21,
24, 26, 27, 29, 30, 31, 34, 35,
36, 47, 50, 53, 63, 66 Immunizations,
5, 17
Infertility, 9, 13, 19, 20, 39 Insulin, 24, 39
Mail Order
Prescription Drugs, 9, 38, 39, 66
Mammograms, 16 Medicaid, 53, 61
Medically necessary, 6, 13, 16, 18, 20, 21, 22, 26, 28, 30, 34,
38, 42,
46, 49, 56, 57 Medicare, 6, 16, 26, 30, 33, 36,
38, 42, 47, 50, 51, 52, 55,
61, 63
Members, 6, 7, 9, 11, 13, 26, 33, 38, 41, 53, 58, 61, 63, 68
Nurse, 16, 20, 31, 41 Nurse Anesthetist, 31
Registered Nurse, 41
Occupational therapy, 21
Office visits, 5 Oral and maxillofacial surgery,
28,
29 Orthopedic devices, 23
Oxygen, 24, 31
Pap test, 16, 17 Physical therapy, 11, 21
Physician, 4, 5, 6, 7,
9, 11, 12, 13, 14, 16, 18, 24, 26, 29, 33, 34,
38, 39, 41, 47, 49, 51, 55
Precertification, 6, 7, 9, 13, 24,
30, 38, 49 Prescription drugs, 14, 38,
47, 50,
52, 66, 67 Preventive care, adult, 10, 17
Preventive care,
children, 17, 22 Prior approval, 13, 21, 35, 41, 46,
49 Prosthetic devices,
23, 26, 27
Radiation therapy, 21 Room and board, 30, 55
Second
surgical opinion, 16 Skilled nursing facility care, 9, 16,
29, 32, 55
Speech therapy, 9, 22
Splints, 30 Subrogation, 53, 54
Substance abuse,
6, 10, 13, 36, 37, 66
Surgery, 6, 13, 18, 21, 22, 23, 26, 27, 28, 29, 30,
41, 44, 66
Oral, 28, 44 Outpatient, 6, 9, 13
Reconstructive, 26, 27
Syringes, 39
Temporary continuation of coverage, 59, 60, 64
Transplants, 9, 21, 28, 29, 41, 66 Treatment therapies, 21
Vision
services, 22 Wheelchairs, 24
X-rays, 16, 30, 31, 34, 41, 42 65
65 Page 66 67
2002 Aetna U. S. Healthcare HMO 66 Summary
of Benefits
Summary of Benefits for Aetna U. S. Healthcare —
2002
Do not rely on this chart alone. All benefits are provided
in full unless indicated and are subject to the definitions,
limitations,
and exclusions in this brochure. On this page we summarize specific expenses we
cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover
on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits High Option You Pay Standard Option You Pay Page
Medical
services provided by physicians: Diagnostic and treatment services provided in
the office...............................................................
Office visit copay: $15 primary care;
$20 specialist
Office visit
copay: $20 primary care;
$25 specialist 16
Services provided by a
hospital:
Inpatient..................................................................
Outpatient ...............................................................
$100 per day up to a maximum of $300 per
admission
$75 per visit
$200 per day up to a maximum of $600 per
admission
$75 per visit
30
30
Emergency benefits: In-area
....................................................................
Out-of-area .............................................................
$75 per visit
$75 per visit
$75 per visit
$75 per visit
33
33
Mental health and substance abuse treatment .............. Regular cost
sharing Regular cost sharing 36
Prescription drugs
........................................................ 30 day supply: $10 per
generic formulary;
$20 per brand name formulary; 2 times
formulary copay
for 31-to 90-day supply
through mail order pharmacy. 50% of the
negotiated rate between the Plan and the
participating retail or mail
order pharmacy
for nonformulary prescription/ refill
30 day supply: $10 per generic formulary;
$20 per brand name formulary; 2
times
formulary copay for 31-to 90-day supply
through mail order
pharmacy. 50% of the
negotiated rate between the Plan and the
participating retail or mail order pharmacy
for nonformulary
prescription/ refill
39
Dental Care
.................................................................. Variable
copays Variable copays 42
Vision Care
.................................................................. $20 copay per
visit. Up to $100 reimbursement
for eyeglasses or contacts per 24 month
period
$25 copay per visit. Up to $100 reimbursement
for eyeglasses or contacts
per 24 month
period
22
Special Features: Services for the deaf and hearing-impaired, reciprocity
benefit, high risk pregnancies,
and Centers of Excellence for transplants/
heart surgery/ etc.
Contact Plan Contact Plan 41 66
66 Page 67 68
2002 Aetna U. S. Healthcare HMO 67 Summary
of Benefits
Protection against catastrophic costs (your out-of-pocket
maximum)................................... Nothing after $1,500/ Self Only or
$3,000/ Family enrollment per year.
Copayments and coinsurance towards
prescription drugs and dental services do not
count towards these
limits.
Nothing after $1,500/ Self Only or
$3,000/ Family enrollment per year.
Copayments and coinsurance towards
prescription drugs and dental
services do not
count towards these limits.
14 67
67 Page
68
2002 Aetna U. S. Healthcare HMO 68 Rates
2002 Rate Information for Aetna U. S. Healthcare
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, see 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
Washington, DC, North and Central Maryland and Northern Virginia
High
Option Self Only JN1 $97.86 $33.87 $212.03 $73.39 $115.52 $16.21
High Option Self and Family JN2 $223.41 $81.28 $484.06 $176.10 $263.75
$40.94
Standard Option Self Only JN4 $71.92 $23.97 $155.82 $51.94 $85.10
$10.79
Standard Option Self and Family JN5 $168.29 $56.09 $364.62 $121.54
$199.14 $25.24
17681-9/ 01 68