For changes in benefits
see page 8.
Enrollment codes for this Plan:
UR1 Self Only UR2 Self and Family
2002
Serving: San Antonio area
Enrollment in this Plan is
limited. You must live or work in our Geographic service area to enroll. See
page 7 for requirements.
RI73-070 1
1 Page
2 3
2002 Humana Health Plan of Texas,
Inc. 2 Table of Contents
Table of Contents
Introduction………………………………………………………………….
............................................................... 4
Plain
Language………………………………………………………………...............................................................
4
Inspector General Advisory……………………………………………………………………………………………. 5
Section 1. Facts about this HMO
plan.......................................................................................................................
6-7
How we pay
providers.................................................................................................................................
6
Who provides my health care?…………………………………………………………………………….. 6
Your
Rights
.................................................................................................................................................
6
Service Area
................................................................................................................................................
7
Section 2. How we change for 2002………………………………………..
............................................................... 8
Program-wide changes
................................................................................................................................
8
Changes to this Plan
....................................................................................................................................
8
Section 3. How you get care …………...
................................................................................................................
9-11
Identification cards
......................................................................................................................................
9
Where you get covered care
........................................................................................................................
9
. Plan providers
........................................................................................................................................
9
. Plan facilities
.........................................................................................................................................
9
What you must do to get covered
care.........................................................................................................
9
. Primary
care...........................................................................................................................................
9
. Specialty
care....................................................................................................................................
9-10
. Hospital care
........................................................................................................................................
10
Circumstances beyond our control
............................................................................................................
11
Services requiring our prior approval
........................................................................................................
11
Section 4. Your costs for covered
services.................................................................................................................
12
. Copayments
.........................................................................................................................................
12
. Coinsurance
.........................................................................................................................................
12
Your out-of-pocket
maximum...................................................................................................................
12
Section 5.
Benefits………………………………………………………….........................................................
13-40
Overview
...................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals ......... 14-22
(b) Surgical and anesthesia services
provided by physicians and other health care professionals...... 23-27
(c)
Services provided by a hospital or other facility, and ambulance
services.................................... 28-30
(d) Emergency services/
accidents
.......................................................................................................
31-32
(e) Mental health and substance abuse benefits
..................................................................................
33-34
(f) Prescription drug
benefits..............................................................................................................
35-37
(g) Special
features...................................................................................................................................
38
. Services for deaf and hearing impaired………………………………………………………. 2
2 Page 3 4
2002 Humana Health Plan of Texas, Inc. 3 Table
of Contents
. High risk pregnancies…………………………………………………………………………
.
Centers of excellence for transplants/ heart surgery/ etc………………………………………
.
24-hour nurse line…………………………………………………………………………….
. Smoking
cessation…………………………………………………………………………….
(h) Dental
benefits....................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
.................................................................................
40
Section 6. General exclusions – things we don't cover
...............................................................................................
41
Section 7. Filing a claim for covered services
............................................................................................................
42
Section 8. The disputed claims process
................................................................................................................
43-44
Section 9. Coordinating benefits with other coverage
................................................................................................
45
When you have…
. Other health
coverage..........................................................................................................................
45
. Original Medicare
.........................................................................................................................
45-48
. Medicare managed care
plan.........................................................................................................
48-49
TRICARE/ Workers' Compensation/
Medicaid...........................................................................................
49
Other Government
agencies.......................................................................................................................
49
When others are responsible for
injuries....................................................................................................
49
Section 10. Definitions of terms we use in this brochure
.......................................................................................
50-51
Section 11. FEHB facts
..........................................................................................................................................
52-54
Coverage information
................................................................................................................................
52
. No pre-existing condition
limitation....................................................................................................
52
. Where you get information about enrolling in the FEHB
Program..................................................... 52
. Types of
coverage available for you and your family
......................................................................... 52
. When benefits and premiums start
......................................................................................................
52
. Your medical and claims records are confidential
..............................................................................
53
. When you retire
...................................................................................................................................
53
When you lose
benefits..............................................................................................................................
53
. When FEHB coverage
ends.................................................................................................................
53
. Spouse equity
coverage.......................................................................................................................
53
. Temporary Continuation of Coverage (TCC)
.....................................................................................
53
. Converting to individual coverage
......................................................................................................
54
. Getting a Certificate of Group Health Plan Coverage
......................................................................... 54
Long term care insurance is coming later in 2002………………………..……………………………………….
55-56
Index............................................................................................................................................................................
57
Summary of
benefits....................................................................................................................................................
58
Rates
..............................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Humana Health Plan of Texas,
Inc. 4 Introduction/ Plain Language
Introduction
Humana Health Plan of Texas, Inc. 8431 Fredericksburg Rd.
San
Antonio, Texas 78229
This brochure describes the benefits of Humana Health
Plan, under our contract (CS 1895) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This brochure
is the
official statement of benefits. No oral statement can modify or
otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and
changes are summarized on page 54. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
. Except for necessary technical terms, we use
common words. For instance, "you" means the enrollee or family
member; "we"
means Humana Health Plan, Inc.
. We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefit 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 fehbpwebcomments@ opm. gov. You may
also write
to OPM at the Office of Personnel Management, Office of Insurance Planning and
Evaluation Division, 1900 E Street, NW Washington, DC 20415-3650. 4
4 Page 5 6
2002 Humana Health Plan of Texas, Inc. 5
Introduction/ Plain Language
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/ 4HUMANA and
explain the situation.
. If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or are no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Humana Health
Plan of Texas, Inc. 6 Section 1
Section 1. Facts about this
HMO plan
This Plan is a health maintenance organization (HMO). We
require you to see specific physicians, hospitals, and other providers that
contract with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the copayments and coinsurance described in this brochure. When you receive
emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO
because you prefer the plan's benefits, not because a particular provider is
available. You cannot change plans because a provider leaves our Plan. We cannot
guarantee that any one physician,
hospital, or other provider will be available and/ or remain under
contract with us.
How we pay providers
We contract with individual
physicians, medical groups, and hospitals to provide the benefits in this
brochure. These Plan providers accept a negotiated payment from us, and you will
only be responsible for your copayments and
coinsurance.
Who provides my health care
Humana Health Plan of
Texas offers members an extensive choice of primary care physicians. Humana
contracts with both private office physicians and with physician networks. When
choosing a physician from one of the
physician networks for your primary care needs, you should expect to receive
all specialty care from providers affiliated with your primary care physician's
network. Obstetricians and gynecologists must be selected from
providers
affiliated with your primary care physician's network. If your physician's
network cannot provide the services you need, your primary care physician will
make arrangements for you to receive the care from an
appropriate provider.
To find out if your primary care physician is affiliated with a certain network,
check the provider directory or call the Plan before you make your selection.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about us, our
networks, providers and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types
of information that we must make available to you. Some of the required
information is listed below.
. Medical case management is a special Humana
program that communicates the provision of care and the management of benefit in
cases of catastrophic illness or injury, transplant management and disease
management.
The program strives to ensure that patients receive the most appropriate,
cost-effective care and also derive maximum advantage from plan benefits.
. Humana has adopted preventative care guidelines based on the United States
Preventative Health Task Force and subscribes to their Healthy People 2000
goals. Our Patterns of Preventative Care (POPC) program monitors the
delivery of well care and uses an automated reminder system to help assure
that our members schedule routine preventative services
. Humana provides
comprehensive disease management programs to plan members. Key to each program
is ongoing education, communication and coordination. Each contracted vendor
offers plan members access to a staff of highly
specialized nurses and
doctors, experienced in the respective disease field. The programs focus on
linking the plan member with a specialized nurse or interdisciplinary team to
ensure an individualized care development approach.
These nurses work
closely with the plan member, member's family, member's primary care physician
(PCP) and other involved providers to provide information, education and
assistance when needed.
. Nationally, Humana has been in the health care business since 1961.
Locally, Humana has been in existence since 1986.
. Humana is a for profit
corporation which is publicly traded on the New York Stock Exchange (NYSE).
If you want more information about us, call 1-800/ 4HUMANA, or write to the
Plan at P. O. BOX 400040, San Antonio, Texas 78229. You may also contact us by
fax at 210/ 615-3320 or visit our website at www. humana. com. 6
6 Page 7 8
2002 Humana Health Plan of Texas, Inc. 7
Section 1
Service Area
To enroll in this Plan, you must
live in or work in our Service Area. This is where our providers practice. Our
Service Area is:
The Texas counties of Atascosa, Bexar, Blanco, Comal, Frio,
Guadalupe, Karnes, Kendall, Medina and Wilson and Zip codes 78003 and 78063 in
Bandera County.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our Service Area, we will pay only for emergency care
benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.
If you or a covered
family member move outside of our service area, you can enroll in another plan.
If your dependents live out of the area (for example, if your child goes to
college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do not have to
wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page
8 9
2002 Humana Health Plan of Texas,
Inc. 8 Section 2
Section 2. How we change for 2002 Do not
rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5
Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
Program-wide changes
. We now cover routine screening for
chlamydial infection. (Section 5( a))
Changes to this Plan
. Your
share of the non-Postal premium will increase by 8.7% for Self Only and Self and
Family.
. We no longer limit total blood cholesterol tests to certain age
groups. (Section5( a))
. We increased speech therapy benefits by removing the requirement that
services must be required to restore
functional speech. (Section 5( a))
. We now cover certain intestinal transplants. (Section 5( b))
. You pay
a $20 copay for formulary brand name drugs with no generic equivalent or a $40
copay for generic or brand name drugs
not listed on our formulary.
. Smoking cessation programs are covered for up to $100 per member per
lifetime.
. We clarified the orthopedic and prosthetic benefit to include
coverage for foot orthotics.
. We clarified the Preventative 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)) 8
8 Page 9 10
2002 Humana Health Plan of Texas, Inc. 9
Section 3
Section 3. How you get care
Identification cards
We will send you an identification (ID) card when you enroll. You should
carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-800/ 4HUMANA or 1-800/ 448-6262.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and/ 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 list is also on our website at www. humana. com.
. Plan facilities Plan facilities are hospitals and other facilities
in our service area that we
contract with to provide covered services to our
members. We list these in the provider directory, which we update periodically.
The list is also
on our website at www. humana. com.
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 may choose your primary care
physician from our Provider Directory or our website, or you may call us for
assistance.
. Primary care Your primary care physician can be a
family practitioner, internist or
pediatrician. Your primary care physician
will provide most of your health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
. Specialty care Your primary care physician will refer you to a
specialist for needed care.
When you receive a referral from your primary
care physician, you must return to your 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 your return visit unless your
primary care physician gives you a referral. However, you
may see the
following providers without a referral:
. Mental health providers
.
Vision care providers 9
9 Page
10 11
2002 Humana Health Plan of
Texas, Inc. 10 Section 3
. OB/ GYN providers; however, your OB/
GYN must be affiliated with
your primary care physician's specialty network
. Another doctor your primary care physician has designated to provide
patient care when he or she is not available.
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 third trimester of
pregnancy and you lose access to your specialist based on the above
circumstances, you can continue to see your
specialist until the end of your postpartum care, even if it is beyond the 90
days.
. Hospital care Your Plan primary care physician or specialist will
make necessary
hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at 1-800/ 4HUMANA. 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 hospital benefits of the hospitalized
person. 10
10 Page
11 12
2002 Humana Health Plan of
Texas, Inc. 11 Section 3
Circumstances beyond our control
Under certain extraordinary circumstances, such as natural disasters, we may
have to delay your services or we may be unable to provide them.
In that
case, we will make all reasonable efforts to provide you with the necessary
care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from
us. Before giving
approval, we consider if the service is covered, medically necessary, and
follows generally accepted medical practice.
We call this review and approval process precertification. Your physician
must obtain precertification for the following services:
. Growth hormone
therapy .
Organ/ Tissue transplants . All elective medical and surgical
hospitalizations
. MRI of the lumbar .
Uvulopalatopharyngoplasty (UPPP) . Gastric bypass
. All durable medical equipment (DME) over $750 .
Acute rehabilitation
services . Home health care services
. Genetic testing .
Infertility services . Pain Management services
. PET and SPECT scans .
Sclerotherapy . Occupational and Physical
therapies
. Prescription drugs requiring prior authorization
Your physician must obtain our approval before sending you to a hospital,
referring you to a specialist, or recommending follow-up care
from a
specialist. 11
11 Page
12 13
2002 Humana Health Plan of
Texas, Inc. 12 Section 4
Section 4. Your costs for covered
services
You must share the cost of some services. You are responsible
for:
. Copayments A copayment is a fixed amount of money you pay to
the provider,
facility, pharmacy etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit and when you go to the emergency
room you pay a $50 copayment per visit.
. Deductible We do not
have a deductible.
. Coinsurance Coinsurance is the percentage of our
negotiated fee that you must pay for
your care.
Example: In our Plan, you pay 50% of our allowance for infertility services.
Your catastrophic protection out-of-pocket maximum for
copayments and
coinsurance After your copayments or coinsurance total $1,500 per person or
$2,500 per family enrollment in any calendar year, you do not have to pay any
more for covered services. However, copayments for the following services do
not count toward your out-of-pocket maximum, and you must
continue to pay
copayments for these services:
. Prescription drugs
Be sure to keep accurate records of your copayments and coinsurance since you
are responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 Humana Health Plan of Texas, Inc. 13
Section 5
Section 5. Benefits – OVERVIEW (See page 7 for
how our benefits changed this year and page 54 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 sections. To obtain claims forms, claims
filing advice, or more information about our benefits, contact us 1-800/ 4HUMANA
or at our website at www. humana. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .......................... 14-22
. Diagnostic and
treatment services
. Lab, x-ray, and other diagnostic tests
. Preventive
care, adult
. Preventive care, children
. Maternity care
. Family
planning
. Infertility services
. Allergy care
. Treatment therapies
Physical and occupational therapies
. Speech therapy
. Hearing services (testing, treatment, and
supplies) .
Vision services (testing, treatment, and supplies)
. Foot care
. Orthopedic and prosthetic devices
. Durable medical
equipment (DME)
. Home health services
Chiropractic Alternative
treatments
Educational classes and programs
(b) Surgical and anesthesia services
provided by physicians and other health care
professionals....................... 23-27
. Surgical procedures
. Reconstructive surgery
. Oral and
maxillofacial surgery
. Organ/ tissue transplants
. Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services..................................................... 28-30
.
Inpatient hospital
. Outpatient hospital or ambulatory surgical
center
. Extended care benefits/ skilled nursing care
facility benefits .
Hospice care .
Ambulance
(d) Emergency services/ accidents
........................................................................................................................
31-32
. Medical emergency . Ambulance
(e) Mental health and substance abuse benefits
...................................................................................................
33-34
(f) Prescription drug
benefits...............................................................................................................................
35-37
(g) Special
features.....................................................................................................................................................
38
Flexible benefit option . 24-hour nurse line
. Services for deaf and hearing impaired .
High risk pregnancies .
Centers of excellence for transplants/ heart surgery/ etc.
Smoking cessation
(h) Dental
benefits......................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
...................................................................................................
40
Summary of
benefits....................................................................................................................................................
58 13
13 Page 14
15
2002 Humana Health Plan of Texas, Inc. 14
Section 5( a)
Section 5 (a). Medical services and supplies
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care.
. Be sure to read
Section 4, Your costs for covered services, for valuable
information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description
Diagnostic and treatment services You pay
Professional services of physicians
. In physician's office
. In
an urgent care center
. Office medical consultations
. Second surgical
opinion
$10 per office visit
Professional services of physicians
. During a hospital stay
. In a
skilled nursing facility
Nothing
Professional services of physicians
. At home
$10 per house call
Lab, x-ray and other diagnostic tests
Tests, such as:
. Blood
tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
.
Non-routine Mammograms
. CAT Scans/ MRI
. Ultrasound
.
Electrocardiogram and EEG
Nothing if you receive these services during your office visit;
otherwise, $10 per visit 14
14 Page 15 16
2002 Humana
Health Plan of Texas, Inc. 15 Section 5( a)
Preventive care,
adult You pay
Routine screenings, such as:
. Total Blood Cholesterol
– once every three years.
. Colorectal Cancer Screening, including .
Fecal occult blood test . Sigmoidoscopy, screening – every five years
starting at age
50
. Prostate Specific Antigen (PSA test) – one annually for men
age
40 and older
. Chlamydial infection screening .
Routine pap test – one annually
Note: The office visit is covered if pap test is received on the same day;
see Diagnostic and treatment services, above.
$10 per office visit
$10 per office visit
Routine mammogram – covered
for women age 35 and older, as follows:
. From age 35 through 39, one during
this five year period
. From age 40 through 64, one every calendar year
. At age 65 and older, one every two consecutive calendar years
. When
prescribed by the doctor as medically necessary to
diagnose or treat
illness.
$10 per office visit
Not covered: physical exams and immunizations required for obtaining or
continuing employment or insurance, attending
schools or camp, or travel.
All charges
Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster –
once every 10 years, ages19
and over (except as provided for under Childhood
immunizations).
. Influenza/ Pneumococcal vaccines, annually, age 65 and over,
or in the
presence of high risk, chronic conditions.
$10 per office visit 15
15 Page 16 17
2002 Humana
Health Plan of Texas, Inc. 16 Section 5( a)
Preventive care,
children You pay
. Childhood immunizations recommended by the American
Academy of Pediatrics Nothing
. Well-child care charges for routine examinations, immunizations
and
care (through age 22)
. Examinations, such as: .
Eye exams through age 17 to determine the need
for vision correction.
. Ear exams through age 17 to determine the need for hearing
correction .
Examinations done on the day of immunizations (through age
22)
$10 per office visit
Maternity care
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
Note: Here are some things to keep in mind:
. You may remain in the
hospital up to 48 hours after a regular
delivery and 96 hours after a
cesarean delivery. We will extend your inpatient stay if medically necessary.
. We cover routine nursery care of the newborn child during the
covered
portion of the mother's maternity stay is provided. We will cover other care of
an infant who requires non-routine
treatment only if we cover the infant under a Self and Family enrollment.
. We pay hospitalization and surgeon services (delivery) the
same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery benefits
(Section 5b).
$10 for initial office visit only; subsequent visits are provided
with no
copay charge
Not covered: Routine sonograms to determine fetal age, size, or sex. All
charges 16
16 Page
17 18
2002 Humana Health Plan of
Texas, Inc. 17 Section 5( a)
Family planning You pay
A
broad range of voluntary family planning services, limited to:
. Voluntary
sterilization
. Surgically implanted contraceptives (such as Norplant)
.
Injectable contraceptive drugs (such as Depo provera)
. Intrauterine devices
(IUDs)
. Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit. See
Section 5 (f).
$10 per office visit
Not covered: reversal of voluntary surgical sterilization All charges
Infertility services
Diagnosis and treatment of infertility,
such as:
. Artificial insemination: .
intravaginal insemination (IVI)
. intracervical insemination (ICI)
. intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug
benefit. See Section 5 (f).
50% of all charges
Not covered:
. Assisted reproductive technology (ART)
procedures, such
as: . in vitro fertilization
. embryo transfer, gamete GIFT and zygote ZIFT .
Zygote
transfer
. services and supplies related to excluded ART procedures
.
cost of donor sperm
. Cost of donor egg
All charges
Allergy care
. Testing and treatment, including test and treatment
materials $10 per office visit
. Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges 17
17 Page 18 19
2002 Humana Health Plan of Texas, Inc. 18
Section 5( a)
Treatment therapies You pay
. Chemotherapy
and radiation therapy
Note: High dose chemotherapy in association with
autologous bone marrow transplants are limited to those transplants listed
under Organ/ Tissue Transplants on page 24.
. Respiratory and inhalation
therapy
. Dialysis – Hemodialysis and peritoneal dialysis
$10 per office visit
. Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy
Nothing
. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: We will only cover Growth Hormone Therapy if the treatment is
precertified and there is a laboratory confirmed
diagnosis of Growth Hormone
Deficiency. You will need to call the precertification telephone number on the
back of your medical
ID (identification) card. We will also ask that your
physician submit information that establishes that the GHT is medically
necessary. GHT must be authorized before you begin treatment.
See
Services requiring our prior approval in Section 3.
$10 per office visit 18
18 Page 19 20
2002 Humana
Health Plan of Texas, Inc. 19 Section 5( a)
Physical &
occupational therapies You pay
. Physical and occupational therapy.
provided by:
. . qualified physical therapists and . .
occupational
therapists.
Note: We only cover therapy to restore bodily function when there has been a
total or partial loss of bodily function due to
illness or injury. 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.
$5 per office visit;
$5 per outpatient visit; and
Nothing per visit
during covered inpatient admission.
. Inpatient cardiac rehabilitation following a heart transplant,
bypass
surgery or a myocardial infarction, is provided for up to 30 sessions. Nothing
. Outpatient cardiac rehabilitation following a heart transplant,
bypass
surgery or a myocardial infarction, is provided for up to 30 sessions. $5 per
office visit
Not covered:
. long-term rehabilitative therapy
.
exercise programs
All charges
Speech therapy
. Speech therapy provided by speech therapists $5
per office visit;
$5 per outpatient visit; and
Nothing per visit during
covered inpatient admission.
Hearing services (testing, treatment, and supplies)
. Hearing
testing for children through age 17
(see Preventive care, children)
$10 per office visit
Not covered:
. all other hearing testing
. hearing
aids, testing and examinations for them
All charges 19
19 Page 20 21
2002 Humana
Health Plan of Texas, Inc. 20 Section 5( a)
Vision services
(testing, treatment, and supplies) You pay
. Diagnosis and treatment of
diseases of the eye.
. Annual eye refractions (to provide a written lens
prescription
for eyeglasses)
. Eye exam to determine the need for vision correction for
children
through age 17 (see Preventive care, children)
. One pair of eyeglasses or contact lenses to correct an
impairment
directly caused by accidental ocular injury or intraocular surgery (such as for
cataracts)
$10 per office visit
Not covered:
. Eyeglasses or contact lenses and, after age 17,
examinations
for them
. Eye exercises and orthoptics
. Radial keratotomy and other
refractive surgery
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
. cutting, trimming or removal of corns, calluses,
or the free
edge of toenails, and similar routine treatment of conditions of
the foot, unless primary medical condition requires such
care
. treatment of weak, strained or flat feet or bunions or
spurs;
and of any instability, imbalance or subluxation of the foot (unless
the treatment is by open cutting surgery)
All charges
Orthopedic and prosthetic devices
. Artificial limbs
. Foot
orthotics
. Orthopedic devices such as braces
. Externally worn breast
prostheses and surgical bras, including
necessary replacements, following a
mastectomy
. Internal prosthetic devices, such as artificial joints and
pacemakers.
NOTE: See 5( b) for coverage of the surgery to insert the device.
. Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
$10 per office visit 20
20 Page 21 22
2002 Humana
Health Plan of Texas, Inc. 21 Section 5( a)
Orthopedic and
prosthetic devices (Continued) You pay
Not covered:
. orthopedic and corrective shoes
. arch supports
. heel pads and heel cups
. lumbosacral supports
.
corsets, trusses, elastic stockings, support hose, and other
supportive
devices
. prosthetic replacements except as required by growth or
change in
medical condition
All charges
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician, such as oxygen and dialysis equipment. Under this benefit,
we also cover:
. Hospital beds
. Wheelchairs
. Crutches
. Walkers
. Insulin
pumps
Nothing
Home health services
. Home health care ordered by a Plan
physician and provided
by a registered nurse (R. N.), licensed practical
nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health aide.
. Services includes intravenous therapy and medications.
Nothing
Not covered:
. nursing care requested by, or for the
convenience of, the
patient or the patient's family;
. home care primarily for personal assistance that does not
include a
medical component and is not diagnostic, therapeutic, or rehabilitative..
All charges 21
21 Page 22 23
2002 Humana
Health Plan of Texas, Inc. 22 Section 5( a)
Chiropractic You
pay
No benefit All charges
Alternative treatments
No benefit All charges
Educational classes and programs
Coverage is limited to:
.
Smoking Cessation – Up to $100 for one smoking cessation
program per member
per lifetime. Nothing
. Primary care visits for smoking cessation $10 per office visit 22
22 Page 23 24
2002 Humana Health Plan of Texas, Inc. 23
Section 5( b)
Section 5 (b). Surgical and anesthesia services
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care.
. Be sure to read
Section 4, Your costs for covered services for valuable
information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
. The amounts listed below are for the charges billed by a physician or
other health care professional for your surgical care. Look in Section 5( c)
for charges associated with the facility (i. e. hospital, surgical
center, etc.).
. YOU MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in
Section 3 to be sure which services require precertification
and identify which surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description
Surgical procedures You pay
A comprehensive range of services, such as:
. Operative procedures
.
Treatment of fractures, including casting Normal pre-and
post-operative care
by the surgeon
. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and
cysts
. Correction of congenital anomalies (see reconstructive
surgery)
. Surgical treatment of morbid obesity – a condition in which an
individual weighs 100 pounds or 100% over his or her normal weight according
to current underwriting standards; eligible
members must be age 18 or over.
. Insertion of internal prosthetic
devices. See 5( a) – Orthopedic
and prosthetic devices for device coverage
information.
. Voluntary sterilization
. Treatment of burns
Nothing
Not covered:
. Reversal of voluntary sterilization
. Routine treatment of conditions of the foot; see Foot care.
All charges 23
23 Page 24 25
2002 Humana
Health Plan of Texas, Inc. 24 Section 5( b)
Reconstructive
surgery You pay
. 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
lymphedemas; .
breast prostheses and surgical bras and replacements (see
Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the
procedure performed on an inpatient basis and remain in the
hospital up to 48 hours after the procedure.
Nothing
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
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
. Reduction of fractures of the jaws or facial bones;
. Surgical
correction of congenital defects such as cleft lip or
cleft palate or severe
functional malocclusion:
. Removal of stones from salivary ducts:
. Excision of leukoplakia or
malignancies;
. Excision of cysts an incision of abscesses when done as
independent procedures;
. Diagnosis and treatment specifically directed toward medical
and
functional disorders of the temporomandibular joint (TMJ): and
. Other surgical procedures that do not involve the teeth or their
supporting structures.
Nothing 24
24 Page
25 26
2002 Humana Health Plan of
Texas, Inc. 25 Section 5( b)
Oral and maxillofacial surgery
(continued) You pay
Not covered:
. Procedures that involve
the teeth or their supporting
structures (such as the periodontal membrane,
gingiva, and alveolar bone)
. oral implants and transplants
All charges 25
25 Page 26 27
2002 Humana
Health Plan of Texas, Inc. 26 Section 5( b)
Organ/ tissue
transplants You pay
Limited to:
. Cornea
. Heart
. Lung:
Single-Double
. Heart/ Lung
. Kidney
. Kidney/ Pancreas
. Liver
. Pancreas
. Allogeneic (donor) bone marrow transplants
. Autologous
bone marrow transplants (autologous stem cell and
peripheral stem cell
support) for the following conditions: acute lymphocytic or non-lymphocytic
leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast
cancer; multiple myeloma; epithelial
ovarian cancer; Wiskott-Aldrich
syndrome; severe combined immunodeficiency syndrome; aplastic anemia; ewings
sarcoma;
and testicular, mediastinal, retroperitoneal and ovarian germ cell
tumors.
. Intestinal transplants (small intestine) and the small intestine
with
the liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
Humana has a National Transplant Network with over 35 facilities within 20
states.
Limited Benefits – Treatment for breast cancer, multiple myeloma,
and epithelial ovarian cancer may be provided in an
NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by the
Plan's medical director in
accordance with the Plan's protocols. Note: We
cover related medical and hospital expenses of the
donor when we cover the
recipient. All transplants must be precertified.
Nothing
Not covered:
. Donor screening tests and donor search expenses,
except those
performed for the actual donor
. Implants of artificial organs
. transplants not listed as
covered
All charges 26
26 Page 27 28
2002 Humana
Health Plan of Texas, Inc. 27 Section 5( b)
Anesthesia You Pay
Professional services provided in –
. Hospital (inpatient)
Nothing
Professional services provided in –
. Hospital outpatient department
. Skilled nursing facility
. Ambulatory surgical center
. Office
Nothing 27
27 Page
28 29
2002 Humana Health Plan of
Texas, Inc. 28 Section 5( c)
Section 5 (c). Services provided
by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
.
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
. Be sure to read Section 4, Your costs for covered services for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
. The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care.
Any costs associated with the professional charge (i. e.,
physicians, etc.) are covered in Section 5( a) or (b).
. YOU 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
Inpatient hospital You pay
Room and board,
such as
. Semiprivate, intensive care or cardiac care accommodations;
.
General nursing care;
. Private accommodations when a Plan doctor determines
it is
medically necessary;
. Private duty nursing when Plan doctor determines medically
necessary;
and
. Meals and special diets.
Note: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate
room rate.
Nothing 28
28 Page
29 30
2002 Humana Health Plan of
Texas, Inc. 29 Section 5( c)
Inpatient hospital (continued)
You pay
Other hospital services and supplies, such as:
. Operating,
recovery, maternity, and other treatment rooms
. Administration of blood or
blood components if not replaced
. Prescribed drugs and medicines
.
Diagnostic laboratory tests and x-rays
. Dressings, splints, casts, and
sterile tray services
. Medical supplies and equipment, including oxygen
. Anesthetics, including nurse anesthetist services
. Take-home items
. Medical supplies, appliances, medical equipment, and any
covered items
billed by a hospital for use at home
Nothing
Not covered:
. Cost of blood and blood components if replaced
. Custodial care
. Non-covered facilities, such as nursing
homes
. personal comfort items, such as telephone,
television,
barber services, guest meals and beds
All charges
Outpatient hospital or ambulatory surgical center
. Operating,
recovery, and other treatment rooms
. Prescribed drugs and medicines
.
Laboratory tests, x-rays, and pathology services
. Administration of blood
or blood components if not replaced
. Pre-surgical testing
. Dressings,
casts, and sterile tray services
. Medical supplies, including oxygen
.
Anesthetics and anesthesia service
Note: We cover hospital services and supplies related to dental procedures
when necessitated by a non-dental physical
impairment. We do not cover the dental procedures.
Nothing
Not covered: Cost of blood and blood components if replaced 29
29 Page 30 31
2002 Humana Health Plan of Texas, Inc. 30
Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You Pay
Extended care benefit:
. Up to 60 days per
calendar year, including .
bed and board; . general nusing care
. drugs, biologicals, supplies and equipment provided by
the facility.
Note: Coverage is provided when full-time skilled nursing care is necessary
and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the
Plan.
Nothing
Not covered: custodial care, rest cures, domiciliary or convalescent care
All charges
Hospice care
Supportive and palliative care for a
terminally ill member is covered in the home or hospice facility. Bereavement
counseling is also covered.
. Up to $3,000 per member per calendar year
for inpatient care.
. Up to $2,000 per member per calendar year for
outpatient care
Note: These services are provided under the direction of a Plan doctor who
certifies that the patient is in the terminal stages of
illness, with a life
expectancy of approximately six months or less.
Nothing
Not covered: independent nursing, homemaker services All charges
Ambulance
. Local professional ambulance service when ordered
or
authorized by a Plan doctor Nothing 30
30
Page 31 32
2002
Humana Health Plan of Texas, Inc. 31 Section 5( d)
Section 5
(d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
. Be sure to read Section 4, Your costs for covered services, for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or surgical
care. Some problems are emergencies because, if not treated promptly, they
might become more serious; examples include deep cuts and broken bones. Others
are emergencies because they are potentially life-threatening,
such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe.
There are many other acute conditions that we may determine are medical
emergencies – what they all have
in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
local
emergency system (e. g., the 911 telephone system) or go to the
nearest hospital emergency room. Be sure to tell the emergency room personnel
that you are a Plan member so they can notify the Plan. You or a family
member must notify the Plan within 48 hours unless it was not reasonably
possible to do so. It is your responsibility to ensure that the Plan has been
timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your admission, unless it was not reasonably
possible to notify the Plan within that time. If you
are hospitalized in a
non-Plan facility 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.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this
Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must
be notified within 48 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If a Plan
doctor believes care can be better provided in a Plan
hospital, you will be transferred when medically feasible with any ambulance
charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided by Plan providers. 31
31 Page 32 33
2002 Humana Health Plan of Texas, Inc. 32
Section 5( d)
Benefit Description
Emergency within our service
area You pay
. Emergency care as an outpatient at a hospital, including
doctor's services
If the emergency results in admission to a hospital, the emergency care copay
is waived.
$50 per visit
. Emergency care at a doctor's office or urgent care center $10 per visit
Not covered: elective care or non-emergency care All charges
Emergency outside our service area
. Emergency care as an
outpatient at a hospital, including
doctor's services
If the emergency results in admission to a hospital, the emergency care copay
is waived.
$50 per visit
. Emergency care at an urgent care center or at a doctor's office $10 per
visit
Not covered:
. elective care or non-emergency care
. emergency care provided outside the service area if the need
for care could have been foreseen before leaving the service area
. medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area
All charges
Ambulance
. Professional ambulance service when ordered or
authorized by
a Plan doctor. See 5( c) for non-emergency service.
Note: Air ambulance is covered only when point of pick-up is inaccessible
by land vehicle; or great distances or other
obstacles are involved in
getting a patient to the nearest hospital with appropriate facilities when
prompt admission is essential
Nothing 32
32 Page
33 34
2002 Humana Health Plan of
Texas, Inc. 33 Section 5( e)
Section 5 (e). Mental health and
substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and
substance
abuse benefits will be no greater than for similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about these benefits:
. All benefits are subject to the definitions, limitations, and
exclusions
in this brochure.
. Be sure to read Section 4, Your costs for covered services for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including 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
Mental health and substance abuse benefits You pay
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve.
The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when
you receive the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness
or conditions.
. Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers
. Medication management
$10 per office visit
. Diagnostic tests Nothing
. Services provided by a hospital or other
facility
. Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
Mental health and substance abuse benefits – Continued on next page.
33
33 Page 34
35
2002 Humana Health Plan of Texas, Inc. 34
Section 5( e)
Mental health and substance abuse benefits
(Continued) You pay
Not covered: services we have not
approved.
Note: OPM will base its review of disputes about treatment plans
on the treatment plan's clinical appropriateness. OPM will generally
not
order us to pay or provide one clinically appropriate treatment plan in favor of
another.
All charges
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes.
Please contact Magellan Behavioral Health at 1-800-473-2422 to obtain
Mental Health/ Substance Abuse treatment services.
Limitation We may limit your benefits if you do not follow your
treatment plan. 34
34 Page
35 36
2002 Humana Health Plan of
Texas, Inc. 35 Section 5( f)
Section 5 (f). Prescription drug
benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
. All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
. Be sure to read Section 4, Your costs for covered services for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
. Who can write your prescription. A licensed physician must write
the prescription.
. Where you can obtain them. You must fill the prescription at a plan
pharmacy, or by mail for a prescribed
maintenance medication. Maintenance
medications are drugs that are generally prescribed for the treatment of long
term chronic sicknesses or injuries.
. We use a Drug List. Our Drug List is a continually updated list of
drug products including strengths,
dispensing limits and any prior
authorization requirements that represent the current clinical judgment of the
members of our Pharmacy and Therapeutics Committee. This committee is comprised
of both physicians
and pharmacists. The Drug List contains both brand name and generic drugs,
all of which have FDA approval. We cover non-Drug List drugs prescribed by a
Plan doctor.
A generic drug is a drug that is manufactured, distributed and available from
several pharmaceutical manufacturers and identified by the chemical name; or as
defined by the national pricing standard used by
us.
A brand name drug
is a drug that is manufactured and distributed by only one pharmaceutical
manufacturer; or as defined by the national pricing standard used by us.
Proposed additions or deletions to the Drug List are welcomed at any time and
will be reviewed by the Committee.
We have an open Drug List. If your
physician believes a name brand product is necessary or there is no generic
available, your physician may prescribe a name brand drug from a formulary list.
This list of name
brand drugs is a preferred list of drugs that we selected
to meet patient needs at a lower cost. To order a prescription Drug List
brochure, call 1-800/ 4-HUMANA or 1-800/ 448-6262.
. These are the dispensing limitations. Prescription drugs dispensed
at a Plan pharmacy will be dispensed
for up to a 30-day supply. You may
receive up to a 90-day supply of a prescribed maintenance medication through our
mail-order program. A generic equivalent will be dispensed if it is available,
unless your
physician specifically requires a name brand. If you receive a name brand
drug when a Federally-approved generic drugs is available, and your physician
has not specified Dispense as Written for the name brand drug,
you have to
pay the difference in cost between the name brand drug and the generic.
.
Why use generic drugs? Generic drugs are lower-priced drugs that are the
therapeutic equivalent to
more expensive brand-named drugs. They must
contain the same active ingredients and must be equivalent in strength and
dosage to the original brand-name product. Generics cost less that the
equivalent brand-name product. The U. S. Food and Drug Administration sets
quality standards for generic drugs to ensure that these drugs meet the same
standards of quality and strength as brand-name
drugs.
You can save
money by using generic drugs. However, you and your physician have the option to
request a name-brand if a generic option is available. Using the most
cost-effective medication saves money.
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 Humana Health Plan of Texas, Inc. 36
Section 5( f)
Benefit Description
Covered medications and
supplies You pay
We cover the following medications and supplies
prescribed by a licensed physician and obtained from a Plan pharmacy or through
our
mail order program:
. Drugs and medicines that by Federal law of the
United States require a physician's prescription for their purchase, except
those listed as Not Covered.. . Insulin
. Disposable needles and
syringes for the administration of covered medications
. Diabetic supplies
including testing agents, lancet devices, alcohol swabs, glucose elevating
agents, insulin delivery
devices , and blood glucose monitors. . Self
administered injectable drugs
. Oral fertility drugs .
Oral
contraceptive drugs and devices . Formulas necessary for treatment of
phenylketonuria or other
inherited diseases . Drugs for sexual dysfunction
Note: Drugs to treat sexual dysfunction are limited. Contact the Plan for
dosage limits. You pay the applicable drug copay up to
the dosage limits,
and all charges after that.
$5 for generic drugs on our Drug List
$20 for brand name drugs with no
generic equivalent on our Drug
List .
$40 for generic or brand name
drugs not on our Drug List .
3 applicable copays for a 90-day supply of prescribed maintenance
drugs,
when ordered through our mail-order program.
Note: If there is no generic equivalent available, you will still
have to
pay the applicable brand name copay. 36
36 Page 37 38
2002 Humana
Health Plan of Texas, Inc. 37 Section 5( f)
Covered
medications and supplies (Continued) You pay
Not
covered:
. drugs available without a prescription, or for which there
is a
non-prescription equivalent available
. drugs and supplies for cosmetic purposes (such as Rogaine)
.
vitamins, fluoride, nutrients and food supplements even if a
physician
prescribes or administers them (except for the type of formulas listed above as
covered)
. drugs obtained at a non-Plan pharmacy except for out of area
emergencies
. drugs to enhance athletic performance
. smoking cessation
drugs and medications, including nicotine
patches
. any drug used for the purpose of weight control
. medical
supplies such as dressings and antiseptics
All charges 37
37 Page 38 39
2002 Humana
Health Plan of Texas, Inc. 38 Section 5( g)
Section 5 (g).
Special features
Feature Description
24-hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call HumanaFirst at 1-800-622-9529 and talk
with a
registered nurse who will discuss treatment options and answer your health
questions.
Services for deaf and hearing impaired Humana offers telecommunication
devices for the deaf (TDD) and Teletype (TTY) phone lines for the hearing
impaired. Call
1-800-432-7482 to access the service.
High risk pregnancies HumanaBeginnings is an outreach program that
provides high-risk plan members support and educational materials so care
can be actively managed during pregnancy.
Smoking cessation HumanaHealth offers a telephonic smoking cessation
program called "Ready to Quit". Members can call 1-888-QUIT-123 or
1-888-784-8123.
Centers of excellence for transplants/ heart
surgery/ etc.
Members can use any facility that is within Humana's contracted National
Transplant Network. This network has
over 35 transplant facilities located
in more than 20 states. 38
38 Page 39 40
2002 Humana
Health Plan of Texas, Inc. 39 Section 5( h)
Section 5 (h).
Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan dentists must provide or arrange your care.
. We cover
hospitalization for dental procedures only when a 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 You pay
We cover restorative services
and supplies necessary to promptly repair (but not replace) sound natural teeth.
The need
for these services must result from an accidental injury.
Nothing
Dental benefits
We have no other dental benefits. 39
39 Page 40 41
2002 Humana Health Plan of Texas, Inc. 40
Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan
members
The benefits on this page are not part of the FEHB contract or
premium, and you cannot file an FEHB disputed claim about them. Fees you
pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
. Comprehensive preventive and restorative dental services are available
from participating dentists at discounted rates.
. No additional premium required.
. No charge for contact lenses exams and discounts for specified frames
and lenses (including certain contact lenses) at participating optical
providers.
. Discounts for other services are listed in the separate Plan description.
. An additional premium of $15 per year for Self Only or $40 per year
for Self and Family is required.
. Discounts (listed in the separate Plan description) for frames and lenses
(including contacts) at participating vision care providers.
. No additional premium required.
. Discounts available at participating providers for eye exams, frames
and lenses. (see separate plan description on how to locate a provider
nearest you).
. Mail Order Contact Lens Replacement Program .
Vision Correction (LASIK
or PRK) for less than $1,000 per eye. (see separate Plan description on how to
receive the discount)
. No additional premium required.
. Free hearing aid evaluations at participating hearing aid providers.
.
Free follow-up visits and adjustments for hearing aid within 60 days at
participating hearing aid providers.
. Discounts (listed in the separate Plan description) for hearing aids.
.
No additional premium required.
Contact us for additional information concerning specific benefits,
exclusions, limitations, eligible providers and other provisions of each of the
above coverages.
Medicare prepaid plan enrollment – This plan offers
Medicare recipients the opportunity to enroll in the Plan through Medicare. As
indicated on page 45, annuitants and former spouses with FEHB coverage and
Medicare Part B
may elect to drop their FEHB coverage and enroll in a
Medicare prepaid plan when one is available in their area. They may then later
reenroll in the FEHB program. Most Federal annuitants have Medicare Part A.
Those without
Medicare Part A may join this Medicare prepaid plan, but will
probably have to pay for hospital coverage in addition to the Part B premium.
Before you join the plan, ask whether the plan covers hospital benefits and, if
so, what you
will have to pay. Contact your retirement system for
information on dropping your FEHB enrollment and changing to a Medicare prepaid
plan. Contact us at 800/ 238-7157 for information on the Medicare prepaid plan
and the cost of
that enrollment.
Expanded dental benefits . DEN-983
Expanded vision care .
VIS-200
Expanded hearing care . HER-903
. VIS-903
.
Vision One Discount Program 40
40 Page 41 42
2002 Humana
Health Plan of Texas, Inc. 41 Section 6
Section 6. General
exclusions – things we don't cover
The exclusions in this section apply
to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary
to prevent, diagnose, or
treat your illness, disease, injury or condition.
We do not cover the following:
. Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
.
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
. Services, drugs, or supplies that are not medically necessary;
.
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric
practice;
. Experimental or investigational procedures, treatments, drugs or devices;
. Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if
the fetus were carried to term or when the
pregnancy is the result of an act of rape or incest;
. Services, drugs, or supplies related to sex transformations; or
.
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program. 41
41 Page
42 43
2002 Humana Health Plan of
Texas, Inc. 42 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.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians
must file on the form HCFA-1500, Health
Insurance Claim Form. Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 1-800/ 4HUMANA or 1-800/ 448-6262.
When you must file a claim – such as for out-of-area care – submit it on the
HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:
. Covered member's
name and ID number;
. Name and address of the physician or facility that
provided the service
or supply;
. Dates you received the services or supplies;
. Diagnosis;
. Type of
each service or supply;
. The charge for each service or supply;
. A
copy of the explanation of benefits, payments, or denial from any
primary
payer – such as the Medicare Summary Notice (MSN); and
. Receipts, if you paid for your services.
Submit your claims to: Humana Health Plan of Texas P. O. Box 14603
Lexington, Kentucky 40512-4603
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. 42
42 Page
43 44
2002 Humana Health Plan of
Texas, Inc. 43 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: Humana Health Plan of Texas,
ATTN: Member Grievance & Appeals, 8431 Fredericksburg Road, Suite 200, San
Antonio, TX 78229; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
(d) Include
copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial – go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request – go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with
our decision, you may ask OPM to review it.
You must write to OPM within:
. 90 days after the date of our letter upholding our initial decision; or
. 120 days after you first wrote to us – if we did not answer that request
in some way within 30 days; or
. 120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
The disputed claims process – Continued on next page 43
43 Page 44 45
2002 Humana Health Plan of Texas, Inc. 44
Section 8
Step Description
Send OPM the following
information:
. A statement about why you believe our decision was wrong,
based on specific benefit provisions in this
brochure;
. Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical
records, and explanation of benefits (EOB)
forms;
. Copies of all letters you sent to us about the claim;
. Copies of all
letters we sent to you about the claim; and
. Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable
to meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim decision. This information will become
part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM
when OPM decided to uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
Note: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800/ 4HUMANA and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
. If we expedite our review and
maintain our denial, we will inform OPM so that they can give your
claim
expedited treatment too, or
. You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m.
eastern time. 44
44
Page 45 46
2002
Humana Health Plan of Texas, Inc. 45 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under
another group health plan or have automobile insurance that pays
health care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is primary according to
the National Association of Insurance
Commissioners' guidelines.
When we
are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is
Medicare? Medicare is a Health Insurance Program for: . People 65 years of
age and older.
. Some people with disabilities, under 65 years of age.
. People with
end-stage renal disease (permanent kidney failure
requiring dialysis or a
transplant).
Medicare has two parts:
. Part A (Hospital Insurance). Most people do not
have to pay for Part
A. If you or your spouse worked for at least 10 years
in Medicare-covered employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you
are age 65 or older, you
may be able to buy it. Contact 1-800-MEDICARE for more information.
. Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social
Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in
how you get your health care. Medicare managed care plan 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 (Part A or Part B) The Original Medicare
Plan (Original Medicare) is is available
everywhere in the United States. It
is the way everyone used to get Medicare benefits and is the way most people get
their Medicare Part A
and Part B benefits. You may go to any doctor,
specialist, or hospital that accepts Medicare. The Original Medicare Plan pays
its share and
you pay your share. Some things are not covered under Original
Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care.
Your
care must continue to be authorized by your Plan PCP. 45
45 Page 46 47
2002 Humana Health Plan of Texas, Inc. 46
Section 9
We will not waive any of our copayments or coinsurance.
Tell us if you or a family member is enrolled in Medicare Part A or B.
Medicare will determine who is responsible for paying medical services
and we will coordinate the payments. On occasion, you may need to file a
Medicare claim form.
(Primary payer chart begins on next page.) 46
46 Page 47 48
2002 Humana Health Plan of Texas, Inc. 47
Section 9
The following chart illustrates whether the Original
Medicare Plan or this Plan should be the primary payer for you according to your
employment status and other factors determined by Medicare. It is critical that
you tell us if you or
a covered family member has Medicare coverage so we
can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you – or
your covered spouse – are age 65 or
over and … Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with
the Federal government when…
a) The position is excluded from FEHB,
b) Or 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,
a) Are an annuitant, or
b) Are an active employee
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee. 47
47 Page
48 49
2002 Humana Health Plan of
Texas, Inc. 48 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, contact us at 1-800/ 4HUMANA.
We will not waive costs when you have Medicare – When Medicare is the
primary payer, we will not waive out-of-pocket costs.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a
Medicare managed care plan. These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you
can only go to doctors, specialists, or hospitals that are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more
about enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a
Medicare managed care plan, the following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In
this case we do not waive any of our copayments, coinsurance, or deductibles for
your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary even out of the managed care
plan's network and/ or service
area (if you use our Plan provider), but we will not waive any of our
copayments. If you enroll in a Medicare
managed care plan, tell us. We will
need to know wether you are in the Original Medicare Plan or in a Medicare
managed care plan so we can
correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your
FEHB coverage and enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare
managed care plan
premium.) For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll
in the FEHB Program,
generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
48
48 Page 49 50
2002 Humana Health Plan of Texas, Inc. 49
Section 9
. 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
Part B and, if you can't get premium-free Part A, we will ask you to enroll
in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
. you need
because of a workplace-related illness or injury that the
Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they must provide; or
. OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital for injuries 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. 49
49 Page
50 51
2002 Humana Health Plan of
Texas, Inc. 50 Section 10
Section 10. Definitions of terms we
use in this brochure
Calendar year January 1 through December 31 of the
same year. For new enrollees, the calendar year begins on the effective date of
their enrollment and
ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 11.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial Care
Services provided to you such as assistance with dressing, bathing,
preparation and feeding of special diets, walking, supervision of
medication which is ordinarily self-administered, getting in and out of bed,
and maintaining continence and are not likely to improve your
condition.
Durable Medical Equipment (DME) Equipment recognized as such by
Medicare Part B, that meets all of the
following criteria:
. it can stand repeated use; and
. it is
primarily and customarily used to serve a medical purpose
rather than being
primarily for comfort or convenience; and
. it is usually not useful to a person in the absence of Sickness or
Injury; and
. it is appropriate for home use; and
. it is related to the patient's
physical disorder; and the equipment must be used in the Member's home.
Experimental or investigational services A drug, biological product,
device, medical treatment, or procedure is
determined to be experimental or
investigational if reliable evidence shows it meets one of the following
criteria:
. when applied to the circumstances of a particular patient is the
subject of ongoing phase I, II or III clinical trials, or
. when applied to the circumstances of a particular patient is under study
with written protocol to determine maximum tolerated dose, toxicity, safety,
efficacy, or efficacy in comparison to conventional alternatives,
or
. is being delivered or should be delivered subject to the approval
and
supervision of an Institutional Review Board as required and defined by
the USFDA or Department of Health and Human Services
. is not generally accepted by the medical community
Reliable evidence
means, but is not limited to, published reports and articles in authoritative
medical scientific literature or regulations and
other official actions and publications issued by the USFDA or the Department
of Health and Human Services. 50
50 Page 51 52
2002 Humana
Health Plan of Texas, Inc. 51 Section 10
Medical necessity
Services necessary for the treatment or product that a licensed Physician or
licensed healthcare provider would provide his or her patient for the
purpose of diagnosing, treating a sickness, illness, disease or its
symptoms.
Morbid Obesity Morbid or clinically severe obesity correlated with a
Body Mass Index (BMI) or 40k/ m2 or with being 100 pounds over ideal body
weight.
Oral Surgery Procedures to correct diseases, injuries and
defects of the jaw and mouth structures.
Participating Provider A
Hospital, Physician, or any other health services provider who has been
designated to provide services to covered members under this plan.
Service Area The geographic area where the Participating Provider
services are available to covered members.
Transplant Services for
pre-transplant; the transplant including any chemotherapy, associated services
and post-discharge services, and treatment of
complications after
transplant.
Us/ We Us and we refer to Humana Health Plan of Texas,
Inc.
You You refers to the enrollee and each covered family member.
51
51 Page 52 53
2002 Humana Health Plan of Texas, Inc. 52
Section 11
Section 11. FEHB facts
No pre-existing condition
We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the
condition
before you enrolled.
Where you can get information See
www. opm. gov/ insure. Also, your employing or retirement office about
enrolling in the can answer your questions, and give you a Guide to
Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
. When you may change your enrollment;
. How you can cover your family
members;
. What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
. When your enrollment ends; and
. When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self
Only coverage is for you alone. Self and Family coverage is for for you and
your family you, your spouse, and your unmarried dependent children under
age 22,
including any foster children or stepchildren your employing or retirement
office authorizes coverage for. Under certain circumstances,
you may also
continue coverage for a disabled child 22 years of age or older who is incapable
of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may
change your enrollment 31 days before to 60 days after that event. The Self and
Family enrollment begins on the first day of the pay period
in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective
on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child
under age 22
marries or turns 22.
If you or one of your family members is enrolled in one
FEHB plan, that person may not be enrolled in or covered as a family member by
another
FEHB plan.
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 tht 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. 52
52 Page 53 54
2002 Humana Health Plan of Texas, Inc. 53
Section 11
Your medical and claims We will keep your medical
and claims information confidential. Only records are confidential the
following will have access to it:
. OPM, this Plan, and subcontractors when
they administer this contract;
. This Plan and appropriate third parties,
such as other insurance plans
and the Office of Workers' Compensation
Programs (OWCP), when coordinating benefit payments and subrogating claims;
. Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;
. OPM and the General Accounting Office when conducting audits;
.
Individuals involved in bona fide medical research or education that
does
not disclose your identity; or
. OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you may be
eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
. When FEHB
coverage ends You will receive an additional 31 days of coverage, for no
additional
premium, when:
. Your enrollment ends, unless you cancel your enrollment, or
. You are a
family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
. Spouse equity If you are divorced from a Federal employee or
annuitant, you may not
coverage continue to get benefits under your
former spouse's enrollment. But, you may be eligible for your own FEHB coverage
under the spouse equity
law. If you are recently divorced or are anticipating a divorce, contact your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, or other
information about your coverage
choices.
. Temporary Continuation
of Coverage (TCC) If you leave
Federal service, or if you lose coverage because you no longer qualify as a
family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are
not able to continue your FEHB enrollment after you retire, if
you lose your
job, if you are a covered dependent child and you turn 22 or marry, etc.
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. 53
53 Page 54 55
2002 Humana Health Plan of Texas, Inc. 54
Section 11
. 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 protection 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 FEHP Program. See also the
FEHBP web site (www.
opm. gov/ insure/ health): refer to the "TCC and HIPAA" frequently asked
question. These highlight HIPAA rules, such
as the requirement that Federal
employees must exhaust any TCC eligibility as one condition for guaranteed
access to individual health
coverage under HIPAA, and have information about
Federal and State agencies you can contact for more information. 54
54 Page 55 56
2002 Humana Health Plan of Texas, Inc. 55
Section 11
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a
high-quality long term care insurance program effective in October 2002. As part
of its educational effort, OPM asks you to consider these questions:
. 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.
. 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.
. Yes, it can be very expensive. A year in a nursing home can exceed
$50,000. Home care for only three 8-hour shifts a week can exceed $20,000 a
year. And that's before inflation!
. Long term care can easily exhaust your savings. Long term care
insurance can protect your savings.
. Not FEHB. Look at the "Not covered" blocks in sections 5( a) and
5( c) of your FEHB brochure. Health plans don't cover custodial care or a
stay in an assisted living facility or a continuing need for a
home health aide to help you get in and out of bed and with other activities
of daily living. Limited stays in skilled nursing facilities
can be covered
in some circumstances. . Medicare only covers skilled nursing home care (the
highest level of
nursing care) after a hospitalization for those who are
blind, age 65 or older or fully disabled. It also has a 100 day limit.
.
Medicaid covers long term care for those who meet their state's
poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance can provide
choices of care and preserve your independence.
. Employees will
get more information from their agencies during the
LTC open enrollment
period in the late summer/ early fall of 2002. . Retirees will receive
information at home.
. Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
.
How are YOU planning to pay for the future custodial or chronic care you may
need? .
You should consider buying long-term care insurance.
What is long term care (LTC) insurance?
I'm healthy. I won't need long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for this new
insurance coverage? 55
55 Page 56 57
2002 Humana
Health Plan of Texas, Inc. 56 Section 11
. Our toll-free
teleservice center will begin in mid-2002. In the
meantime, you can learn
more about the program on our web site at www. opm. gov/ insure/ ltc. How can
I find out more about the program NOW? 56
56
Page 57 58
2002
Humana Health Plan of Texas, Inc. 57 Index
Index
Do
not rely on this page; it is for your convenience and may not show all pages
where the terms appear.
Allergy tests................................
17 Alternative treatment .................. 22
Allogenetic (donor) bone
marrow transplant…………………… 26
Ambulance............................ 30, 32
Anesthesia............................. 27, 29
Autologous bone marrow
transplant ............................. 26
Blood and blood plasma
............. 29 Breast cancer screening .............. 15
Casts
........................................... 29 Changes for
2001.......................... 8
Chemotherapy.............................
18 Childbirth.................................... 16
Chiropractic……………………..
22 Cholesterol tests.......................... 15
Claims......................................... 42 Coinsurance
.......................... 12, 50
Colorectal cancer screening........ 15
Congenital anomalies ................. 24
Contraceptive devices and drugs
....................... 17, 36
Coordination of benefits ........ 45-49
Covered services......................... 50
Covered
providers............... 6, 9, 10 Crutches......................................
21
Definitions ............................. 50-51 Dental
care.................................. 39
Diagnostic services
............... 14, 29 Dialysis ....................................... 18
Disputed claims review ......... 43-44 Donor expenses (transplants)...... 26
Dressings .................................... 29 Durable medical equipment
(DME) ................................. 21 Effective date of
enrollment ....... 52
Emergency............................. 31-32
Experimental or investigational .. 50
Eyeglasses................................... 20 Family
planning.......................... 17
Fecal occult blood test
................ 15 Foot care ..................................... 20
General Exclusions..................... 41 Hearing services
......................... 19
Home health services............ 14, 21 Hospice
care ............................... 30
Home nursing
care...................... 21 Hospital ................................. 28-29
Immunizations....................... 15-16
Infertility ..................................... 17 Inhospital physician
care ...... 14, 23
Inpatient Hospital Benefits .... 28-29 Insulin
......................................... 36
Laboratory and
pathological services .......................... 14, 29
Machine
diagnostic tests ............................... 14, 29
Magnetic
Resonance Imagings (MRIs) ................................. 14
Mail-order
prescription drugs .................................... 36
Mammograms
........................ 14-15 Maternity Benefits ...................... 16
Medicaid ..................................... 49 Medical
necessity........................ 51
Medicare
................................ 45-49 Members
....................................... 6
Mental Conditions/ Substance Abuse
Benefits................ 33-34
Newborn
care.............................. 16 Non-FEHB Benefits....................
40
Nurse Licensed Practical Nurse .......... 21
Nurse
Anesthetist...................... 29 Registered Nurse....................... 21
Obstetrical care................. 10, 16 Occupational
therapy.............. 19
Office visits................................. 14
Oral and maxillofacial
surgery ................................. 24
Orthopedic devices ................ 20-21
Out-of-pocket expenses
.............. 12 Outpatient facility care................ 29
Oxygen........................................ 29 Pap test
.................................. 14-15
Physical examination .............
15-16 Physical therapy.......................... 19
Physician.................................. 9-10 Preventive care,
adult.................. 15
Preventive care, children............. 16
Prescription drugs .................. 35-37
Preventive services
................ 15-16 Prior approval ............................. 11
Prostate cancer screening............ 15 Prosthetic devices
.................. 20-21
Psychologist ................................ 33 Radiation
therapy........................ 18
Room and board.....................
28-29 Second surgical opinion.............. 14
Skilled nursing
facility care ........ 30 Speech therapy............................ 19
Splints ......................................... 29 Sterilization
procedures .............. 17
Subrogation................................. 49
Substance abuse ..................... 33-34
Surgery................................... 23-27
Anesthesia........................... 27
Oral
................................ 24-25 Outpatient ...........................
27
Reconstructive .................... 24 Syringes
...................................... 36
Temporary continuation of
coverage .......................... 53
Transplants.................................. 26 Treatment therapies……………..
18
Vision services............................ 20 Well child
care............................ 16
Wheelchairs
................................ 21 Workers' compensation .............. 49
X-rays................................ 14, 29 57
57 Page 58 59
2002 Humana Health Plan of Texas, Inc. 58
Rates
Summary of benefits for Humana Health Plan of Texas, Inc. –
2002
. Do not rely on this chart alone. All benefits are provided
in full unless indicated and are subject to the
definitions, limitations,
and exclusions in this brochure. On this page we summarize specific expenses we
cover; for more detail, look inside.
. If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from the
cover on your enrollment form. .
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office.......... Office
visit copay: $10 primary care;
$10 specialist 14
Services provided by a hospital:
.
Inpatient.....................................................................................
.
Outpatient..................................................................................
Nothing
Nothing
28
29
Emergency benefits:
. In-and out-of-area (emergency room)
......................................
. In-and out-of-area (at a doctor's office or urgent care center).....
$50 per visit
$10 per visit
32
32
Mental health and substance abuse treatment...............................
Regular cost sharing 33-34
Prescription drugs: .
Generic formulary drugs
...........................................................
. Brand name formulary
drugs.....................................................
. Non formulary drugs…………………………………………
. Maintenance drugs (90-day supply) when ordered through
our mail-order
program.............................................................
$5 copay
$20 copay
$40 copay
3 applicable copays
36
36
36
36
Dental Care .
Accidental injury
benefit........................................................... Nothing 39
Vision Care (annual eye refractions to provide a written lens prescription
for eyeglasses).......................................................... $10
per visit 20
Special features: TDD and TTY phone lines; Reciprocity Benefit;
HumanaBeginnings; National Transplant Network; HumanaHealth and HumanaFirst
38
Protection against catastrophic costs (your out-of-pocket maximum)
....................................................................................
Nothing after $1,500/ per person or $2,500/ per family enrollment per
year.
Some costs do not count toward this protection.
12 58
58 Page
59
2002 Humana Health Plan of Texas, Inc. 59 Rates
2002 Rate Information for Humana Health Plan of Texas
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 and
Tool & Die employees (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. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only UR1 $77.24 $25.75 $167.36 $55.79 $91.40 $11.59
Self and
Family UR2 $198.56 $66.18 $430.20 $143.40 $234.96 $29.78 59