Serving: Southeastern Michigan
Enrollment in this Plan is limited. You
must live or work in our Geographic service area to enroll. See page 6 for
requirements.
Enrollment codes for this Plan:
K31 Self Only K32 Self and Family
RI 73-075
For changes in benefits
see page 7.
A Health Maintenance Organization 1
1 Page 2 3
2002 The Wellness Plan
2 Table of Contents
Table of Contents
Introduction………………………………………………………………….........................................................................................
4
Plain
Language.......................................................................................................................................................................................
4
Inspector General Advisory
...................................................................................................................................................................
5
Section 1. Facts about this HMO
plan...................................................................................................................................................
6
How we pay
providers..........................................................................................................................................................
6
Your Rights
..........................................................................................................................................................................
6
Service Area
.........................................................................................................................................................................
6
Section 2. How we change for
2002......................................................................................................................................................
7
Program-wide changes
.........................................................................................................................................................
7
Changes to this Plan
.............................................................................................................................................................
7
Section 3. How you get care
.................................................................................................................................................................
8
Identification
cards...............................................................................................................................................................
8
Where you get covered care
.................................................................................................................................................
8
Plan providers
................................................................................................................................................................
8
Plan
facilities..................................................................................................................................................................
8
What you must do to get covered care
.................................................................................................................................
8
Primary
care...................................................................................................................................................................
8
Specialty
care..............................................................................................................................................................
8-9
Hospital care
..................................................................................................................................................................
9
Circumstances beyond our control
.......................................................................................................................................
9
Services requiring our prior
approval.................................................................................................................................
10
Section 4. Your costs for covered
services..........................................................................................................................................
11
Copayments
.................................................................................................................................................................
11
Deductible....................................................................................................................................................................
11
Coinsurance
.................................................................................................................................................................
11
Your out-of-pocket
maximum............................................................................................................................................
11
Section 5. Benefits
..............................................................................................................................................................................
12
Overview............................................................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals............................... 13-21
(b) Surgical and
anesthesia services provided by physicians and other health care professionals
........................... 22-24
(c) Services provided by a hospital or
other facility, and ambulance
services......................................................... 25-26
(d)
Emergency services/ accidents
............................................................................................................................
27-28
(e) Mental health and substance abuse benefits
.......................................................................................................
29-30
(f) Prescription drug benefits
...................................................................................................................................
31-32
(g) Special features
.......................................................................................................................................................
33
Flexible benefits option
.....................................................................................................................................
33 2
2 Page 3 4
2002 The Wellness Plan 3 Table of Contents
Services
for the deaf and hearing
impaired.....................................................................................................
33
(h) Dental benefits
.......................................................................................................................................................
34
(i) Non-FEHB benesits available to plan members
....................................................................................................
35
Section 6. General exclusions --things we don't cover
.....................................................................................................................
36
Section 7. Filing a claim for covered
services...................................................................................................................................
37
Section 8. The disputed claims process
........................................................................................................................................
38-39
Section 9. Coordinating benefits with other coverage
.................................................................................................................
40-43
When you have…
Other health coverage
.................................................................................................................................................
40
Original Medicare
..................................................................................................................................................
40-41
Medicare managed care plan
......................................................................................................................................
42
TRICARE/ Workers' Compensation/ Medicaid
...........................................................................................................
42-43
Other Government agencies
.............................................................................................................................................
43
When others are responsible for injuries
..........................................................................................................................
43
Section 10. Definitions of terms we use in this brochure
...................................................................................................................
44
Section 11. FEHB facts
.....................................................................................................................................................................
45
Coverage information
.....................................................................................................................................................
45
No pre-existing condition
limitation.......................................................................................................................
45
Where you get information about enrolling in the FEHB
Program........................................................................
45
Types of coverage available for you and your family
............................................................................................
45
When benefits and premiums start
.........................................................................................................................
46
Your medical and claims records are
confidential..................................................................................................
46
When you retire
......................................................................................................................................................
46
When you lose
benefits...................................................................................................................................................
46
When FEHB coverage
ends....................................................................................................................................
46
Spouse equity coverage
..........................................................................................................................................
46
Temporary Continuation of Coverage
(TCC).........................................................................................................
46
Converting to individual
coverage..........................................................................................................................
47
Getting a Certificate of Group Health Plan Coverage
............................................................................................
47
Long term care insurance is coming later in 2002
...............................................................................................................................
48
Index
....................................................................................................................................................................................................
49
Summary of benefits
............................................................................................................................................................................
50
Rates.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 The Wellness Plan 4 Introduction/
Plain Language Advisory
Introduction
The Wellness Plan 2875 W. Grand
Boulevard
Detroit, MI 48202
This brochure describes the benefits of The
Wellness Plan under our contract (CS 1900) 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 7. 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
The Wellness Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel
Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650. 4
4
Page 5 6
2002 The
Wellness Plan 5 Inspector General Advisory
Inspector General Advisory
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
1-800-875-WELL (9355) and
explain the situation. If we do not resolve the
issue, call or write
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States Office of
Personnel Management Office of the Inspector General Fraud Hotline
1900 E
Street, NW, Room 6400 Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program
benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the
person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your agency may also
take
administrative action against you.
Stop health care fraud! 5
5 Page 6 7
2002 The Wellness Plan
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, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan providers, you may
have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will
be available and/ or remain
under contract with us.
How we pay providers
We contract with individual
physicians, medical groups, and hospitals to provide the benefits in this
brochure. These Plan providers accept a negotiated payment from us, and you will
only be responsible for your copayments or coinsurance.
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.
We are Federally Qualified and licensed by the State of Michigan to operate
as an HMO
We have been in existence since 1972.
We are a non-profit HMO
with URAC (also known as the American Accreditation Healthcare Commission).
If you want more information about us, call 800-875 WELL (9355), or write to
The Wellness Plan, 2875 W. Grand Boulevard, Detroit, MI 48202. You may also
contact us by fax at 313-202-8670 or visit our website at www. wellplan. com.
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 includes
the following Michigan counties: Genessee, Lapeer, Macomb, Oakland, Shiawassee,
St. Clair and Wayne.
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. 6
6
Page 7 8
2002 The
Wellness Plan 7 Section 2
Section 2. How we change for 2002
Do not rely
on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5 Benefits. Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that does not change
benefits.
Program-wide changes
We
changed the address for sending disputed claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will decrease
by 2.5% for Self Only or 3.2 % for Self and Family.
We now cover certain
intestinal transplants. (Section 5( b))
We no longer limit total blood
cholesterol tests to certain age groups. (Section 5( a))
We changed speech
therapy benefits by removing the requirement that services must be required to
restore functional speech (Section 5( a))
We have expanded our service area to better service you and your family, with
the addition of Lapeer, St. Clair, and Shiawasee counties.
You will be
responsible for your co pay and the difference in cost if you elect to receive a
brand-name drug. (Section 5( f)) 7
7 Page 8 9
2002 The Wellness Plan
8 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 1-800-875-WELL (9355).
Where you get covered care You get care from "Plan providers" and "Plan
facilities." You will only pay copayments, and you will not have to file claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our members. We credential Plan
providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website at www. wellplan. com\
providersearch and includes Primary Care
Physicians, specialists,
pharmacies, urgent care and vision providers.
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. wellplan. com\ providersearch.
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 will need to let us know which Primary Care Physician you select for each
member of your family. If you let us know
by the 10 th of the month, your
change will be effective the first of the following month.
Primary care Your
primary care physician can be a general practitioner, family practitioner,
internist, pediatrician. Your primary care physician will provide most of your
health care, or give
you a referral to see a specialist.
If you want to
change primary care physicians or if your primary care physician leaves the
Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a specialist for
needed care. When you receive a referral from your primary care physician, you
must return to the primary care
physician after the consultation, unless
your primary care physician authorized a certain number of visits without
additional referrals. The primary care physician must provide or
authorize
all follow-up care. Do not go to the specialist for return visits unless your
primary care physician gives you a referral. However, you may obtain gynecology,
mammogram screening, mental health, and vision services without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will work with the specialists and the
Plan to 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. Please
make sure to ask your physician when obtaining highly specialized services
whether or not they need the
Plan's approval.
What you must do to get covered care 8
8 Page 9 10
2002 The Wellness
Plan 9 Section 3
If you are seeing a specialist when you enroll in our Plan,
talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or
she decides to refer you to a specialist,
ask if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a
specialist who does.
Generally, we will not pay for you to see a specialist who does not participate
with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive
services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other
than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your
new
plan.
If you are in the second or third trimester of pregnancy and
you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until
the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician
or specialist will make necessary hospital arrangements and supervise 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 800-875 WELL (9355). If you are new
to the FEHB
Program, we will arrange for you to receive care.
If you
changed from another FEHB plan to us, your former plan will pay for the hospital
stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances,
such as natural disasters, we may have to delay your services or we may be
unable to provide them. In that case, we will make all
reasonable efforts to
provide you with the necessary care. 9
9 Page 10 11
2002 The Wellness
Plan 10 Section 3
Your primary care physician has authority to refer you for
most services. For certain services, however, your physician must obtain
approval from us. Before giving approval,
we consider if the service is
covered, medically necessary, and follows generally accepted medical practice.
We call this review and approval process prior authorization and your
physician must obtain prior authorization for the following services:
Growth
Hormone Therapy Elective Surgery
Organ Tissue Transplants Elective Hospital
Admission
DME (Durable Medical Equipment) Orthopedic and Prosthetic Devices
Your physician obtains this authorization by calling The Wellness Plan.
Services requiring our prior approval 10
10
Page 11 12
2002
The Wellness Plan 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider,
facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
Deductible A deductible is a fixed expense you must incur
for certain covered services and supplies before we start paying benefits for
them. We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must
pay for your care. We do not have coinsurance.
Your catastrophic protection We do not have an out-of-pocket maximum.
out-of-pocket maximum 11
11 Page 12 13
2002 The Wellness
Plan 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our
benefits changed this year and page 50 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the
important things you should keep in mind at the beginning of each subsection.
Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain
claims forms, claims filing advice, or more
information about our benefits, contact us at 800-875-WELL (9355) or at our
website at www. wellplan. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .................................................... 13-21
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................................................. 22-24
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..............................................................................
25-26
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/
accidents..................................................................................................................................................
27-28 Medical emergency Ambulance
(e) Mental health and substance abuse benefits
.............................................................................................................................
29-30
(f) Prescription drug benefits
........................................................................................................................................................
31-32
(g) Special features
.............................................................................................................................................................................
33 Flexible benefits option
Services for the deaf and hearing impaired
(h) Dental benefits
.............................................................................................................................................................................
34
(i) Non-FEHB benefits available to Plan members
...........................................................................................................................
35
Summary of benefits
............................................................................................................................................................................
50 12
12 Page 13
14
2002 The Wellness Plan 13 Section 5( a)
Section
5 (a). Medical services and supplies provided by physicians and other health
care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Benefit Description You pay After the calendar year deductible…
Diagnostic and treatment services You pay
Professional services of
physicians
In physician's office
Office medical consultations
$10 per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Second surgical opinion
Nothing
At home Nothing
Lab, X-ray and other diagnostic tests You pay
Tests,
such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services during your office visit 13
13 Page 14 15
2002 The Wellness Plan 14 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
$10 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
$10 per office visit
Routine pap test
Note: The office visit is covered
if pap test is received on the same day; see Diagnosis and Treatment, above.
Nothing if you receive these services during your 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 and over,
one every calendar year
Note: You do not need a referral from your primary care physician when you
use a participating facility for your routine mammogram.
Nothing if you receive these services during your office visit
Not covered: Physical exams required for obtaining or continuing employment
or insurance, attending schools or camp, or travel. All charges.
Preventive
care, adult You pay
Routine immunizations, such as:
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
Nothing if you receive these during your office visit or at an in-network
facility 14
14 Page
15 16
2002 The Wellness Plan 15 Section
5( a)
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics Nothing if you receive these
during your office visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as:
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
Eye exams through age 17 to determine the need for vision correction. Nothing
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things
to keep in mind:
You may remain in the hospital up to 48 hours after a
regular delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care
of the newborn child during the covered portion of the mother's maternity stay.
We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
Nothing
Not covered: Routine sonograms to determine fetal age, size or sex All
charges. 15
15 Page
16 17
2002 The Wellness Plan 16 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.
$10 per office visit
Not covered:
reversal of voluntary surgical sterilization
genetic
counseling
All charges.
Infertility services You pay
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical
benefits and oral fertility drugs under the prescription drug benefit.
Nothing
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. 16
16 Page
17 18
2002 The Wellness Plan 17 Section
5( a)
Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges.
Treatment therapies You pay
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone marrow transplants
are limited to those transplants listed under
Organ/ Tissue Transplants on page 24.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment. Call 800-875-WELL (9355) for preauthorization. We
will ask you to
submit information that establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment;
otherwise, we will only
cover GHT services from the date you submit the information. If you do not ask
or if we determine GHT is not
medically necessary, we will not cover the GHT
or related services and supplies. See Services requiring our prior approval in
Section 3.
Nothing
Physical and occupational therapies You pay
60 visits per condition for
the services of each of the following:
qualified physical therapists
occupational therapists. Note: We only cover therapy to restore bodily
function when there has
been a total or partial loss of bodily function due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to 18 sessions
Nothing
Not covered:
long-term rehabilitative therapy
exercise programs
All charges. 17
17 Page
18 19
2002 The Wellness Plan 18 Section
5( a)
Speech therapy You pay
60 visits per condition for the services of
a qualified speech therapist Nothing
Hearing services (testing, treatment, and supplies) You pay
First hearing
aid and testing only when necessitated by accidental injury
Hearing for all members to determine the need for hearing correction
Hearing Aids
Note: We will cover one hearing aid every 36 consecutive
months as appropriate.
$10 per office visit
Not covered:
all other hearing testing
hearing aids ordered prior to
coverage effective date
unauthorized services
batteries
replacement
or repair of hearing aids due to theft, misuse, misplacement or damage
All charges.
Vision services (testing, treatment, and supplies) You pay
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery
(such as for cataracts)
Nothing
Eye exam to determine the need for vision correction for children through age
17 and adults
Annual eye refractions
Dialated retinal exam for Diabetes
Note: See Preventive care, children for eye exams for children
Nothing
Not covered:
Eyeglasses or contact lenses
Eye exercises and
orthoptics
Radial keratotomy and other refractive surgery
All charges. 18
18 Page
19 20
2002 The Wellness Plan 19 Section
5( a)
Foot care You pay
Routine foot care when you are under active
treatment for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses, or the free
edge of toenails, and similar routine treatment of conditions of the foot,
except as stated above
Treatment of weak, strained or flat feet or
bunions or spurs; and of any instability, imbalance or subluxation of the foot
(unless the
treatment is by open cutting surgery)
All charges.
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes;
stump hose
Externally worn breast prostheses and surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear
implants, and surgically implanted breast implant
following mastectomy.
Note: We pay internal prosthetic devices as hospital benefits; see Section 5( c)
for payment information. See 5( b)
for coverage of the surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Note: Call us at 800-875-WELL (9355) as soon as your Plan physician
prescribes this equipment. We will make arrangements with a
health care
provider for the equipment at discounted rates. We will tell you more about this
service when you call us.
$10 per office visit
Nothing for the device.
Not covered:
Orthopedic and corrective shoes
Arch supports
Foot
orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets,
trusses, elastic stockings, support hose, and other supportive devices
replacement or repair due to misuse, damage, theft or misplacement
All charges. 19
19 Page
20 21
2002 The Wellness Plan 20 Section
5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, including repair and adjustment, of durable medical equipment prescribed
by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose
monitors; and
insulin pumps.
Note: Call us at 800-875-WELL (9355) as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider to
rent or sell you durable medical equipment at discounted rates and will tell
you more about this service when you call.
$10 per office visit
Nothing for the device.
Not covered:
Motorized wheel chairs (except for quadriplegics)
Personal comfort and convenience items
replacement or repair due to
misuse, damage, theft or misplacement
All charges.
Home health services You pay
Home health care ordered by a Plan physician
and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.),
licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen
therapy, intravenous therapy and medications.
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. 20
20 Page
21 22
2002 The Wellness Plan 21 Section
5( a)
Chiropractic You pay
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application
Note: We limit chiropractic care to 18 visits per member per year. You must
obtain a referral from your Primary Care Physician.
$10 per office visit
Not covered:
Unauthorized care
Visits in excess of 18 per calendar
year
All charges.
Alternative treatments You pay
We do not cover alternative treatments
such as:
naturopathic services
acupuncture
hypnotherapy
biofeedback
All Charges
Educational classes and programs You pay
Coverage is limited to:
Smoking Cessation Contact our Smoking Cessation Resource Center at
1-866-223-0321
(toll-free). Registered Nurses are available to answer your
questions and assist you with obtaining counseling and nicotine replacement
therapy. The nurse may refer you to a contracted Smoking Cessation Program
or you may obtain a referral from your primary care
physician. Please see
the prescription drug benefits for information on copays for prescription
smoking cessation drugs.
Diabetes self-management The Diabetic Care Network (DCN) will assist you in
managing your
diabetes. Please contact us at 800-875-WELL (9355). DCN will
educate you about the disease and how to prevent complications.
DCN will
send you informative literature and reminders by mail. DCN staff may
periodically call you to check on your progress.
Nothing 21
21 Page
22 23
2002 The Wellness Plan 22 Section
5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar
year deductible.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please
refer to the precertification information shown in Section 3 to be sure which
services require precertification and
identify which surgeries require
precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A comprehensive range
of services, such as: Operative procedures
Treatment of fractures, including casting Normal pre-and post-operative care
by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy procedures Removal of tumors and cysts
Correction of congenital
anomalies (see reconstructive surgery) Surgical treatment of morbid obesity --a
condition in which an
individual weighs 100 pounds or 100% over his or her
normal weight according to current underwriting standards; eligible
members
must be age 18 or over Insertion of internal prosthetic devices. See 5( a) –
Orthopedic
and prosthetic devices for device coverage information.
$10 per office visit or
Nothing if the services are performed in a
hospital
Voluntary sterilization
Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per office visit or
Nothing if the services are performed in a
hospital
Not covered: Reversal of voluntary sterilization
Routine treatment of
conditions of the foot; see Foot care.
All charges. 22
22 Page 23 24
2002 The Wellness Plan 23 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.
$10 per office visit or
Nothing if the services are performed in a
hospital
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note:
If you need a mastectomy, you may choose to have the procedure performed on an
inpatient basis and remain in the hospital up to 48
hours after the
procedure.
$10 per office visit or
Nothing if the services are performed in a
hospital
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 You pay
Oral surgical procedures, limited
to: Reduction of fractures of the jaws or facial bones;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia
or malignancies;
Excision of cysts and incision of abscesses when done as
independent procedures; and
Other surgical procedures that do not involve
the teeth or their supporting structures.
$10 per office visit or
Nothing if the services are performed in a
hospital
Not covered: Oral implants and transplants
Procedures that involve the
teeth or their supporting structures (such as the periodontal membrane, gingiva,
and alveolar bone)
All charges. 23
23 Page 24 25
2002 The Wellness
Plan 24 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow
transplants Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic
or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma;
epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
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.
Anesthesia You pay
Professional services provided in –
Hospital
(inpatient) Hospital outpatient department
Skilled nursing facility Ambulatory surgical center
Nothing
Professional services provided in –
Office
$10 per office visit 24
24 Page 25 26
2002 The Wellness Plan 25 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.
We do not have a calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
The amounts listed below are for the charges
billed by the facility (i. e., hospital or surgical center) or ambulance service
for your surgery or care. Any costs associated with the professional
charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board, such
as ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as: Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products Blood or blood plasma, if not donated or replaced
Dressings,
splints, casts, and sterile tray services Medical supplies and equipment,
including oxygen
Anesthetics, including nurse anesthetist services Take-home
items
Medical supplies, appliances, medical equipment, and any covered items
billed by a hospital for use at home (Note: calendar year
deductible
applies.)
Nothing
Not covered: Custodial care
Non-covered facilities, such as nursing
homes, schools Personal comfort items, such as telephone, television, barber
services, guest meals and beds Private nursing care
All charges. 25
25 Page
26 27
2002 The Wellness Plan 26 Section
5( c)
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Prescribed drugs and
medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/ skilled nursing care facility benefits You
pay
Skilled nursing facility (SNF) care:
We cover a comprehensive range of benefits for up to 730 days per confinement
when fulltime skilled nursing care is necessary and
confinement in a SNF 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 You pay Supportive and palliative care for
terminally ill member is covered in
the home and hospice facility. Services
include inpatient and outpatient, and family and counseling. These services are
provided
under the direction of a Plan doctor who certifies that the patient
is in the terminal stages of illness, with a life expectancy of approximately
six months or less
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance You pay
Local professional ambulance service when medically
appropriate Nothing 26
26 Page
27 28
2002 The Wellness Plan 27 Section
5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
We have no calendar year
deductible.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A
medical emergency is the sudden and unexpected onset of a condition or an injury
that you believe endangers your life or could result in serious injury or
disability, and requires immediate medical or surgical care. Some problems are
emergencies
because, if not treated promptly, they might become more serious; examples
include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings,
gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we may determine are medical emergencies – what they all have in
common is the need for quick action.
What to do in case of emergency:
Emergencies within and outside our
service area:
If you are in an emergency situation, please call your Primary
Care Physician. In extreme emergencies, if you are unable to contact your
doctor, contact the local emergency system (e. g. the 911 telephone system) or
got to the nearest hospital
emergency room. Be sure to tell the emergency room personnel that you are a
Plan member so they can notify us. You or a family member should notify the Plan
within 48 hours or the first working day following your admission, unless it was
not
reasonably possible to do so. It is your responsibility to ensure that
we are timely notified. If you are hospitalized in non-Plan facilities and we
believe care can better be provided in a Plan hospital, we will transfer you
when medically feasible
with any ambulance charges covered in full. We only
cover medical emergency services from non-Plan providers if delay in reaching a
Plan Provider would result in death, disability or significant jeopardy to your
condition. 27
27 Page
28 29
2002 The Wellness Plan 28 Section
5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center
Emergency care as an outpatient
or inpatient at a hospital, including doctors' services
$50 per visit
Note: We waive the $50 copay if you are admitted to the hospital
Not covered: Elective care or non-emergency care All charges.
Emergency
outside our service area You pay
Emergency care at a doctor's office $10 per
office visit
Emergency care at an urgent care center
Emergency care as an outpatient
or inpatient at a hospital, including doctors' services
$50 per visit
Note: We waive the $50 copay if you are admitted to the hospital
Not covered:
Elective care or non-emergency care
Emergency care
provided outside the service area if the need for care could have been foreseen
before leaving the service area
All charges.
Ambulance You pay
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Air ambulance
Nothing
Not covered: non-emergency ambulance transport All charges. 28
28 Page 29 30
2002 The Wellness Plan 29 Section 5( e)
Section 5
(e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no greater than for similar benefits for other
illnesses
and conditions.
Here are some important things to keep in mind about these
benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
We do not have a calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You Pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit
Mental health and substance abuse benefits -continued on next page 29
29 Page 30 31
2002 The Wellness Plan 30 Section 5( e)
Mental
health and substance abuse benefits (continued) You pay
Diagnostic tests
Nothing if you receive these services
during your office visit; otherwise.
$10 per office visit.
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
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.
Prior authorization To be eligible to receive these benefits you must obtain
a treatment plan.
You do not need a referral for behavioral health services.
You may contact the Plan provider directly. The provider that you select will
develop a treatment plan
for you that you must follow.
If you live in the Tri-county area (Wayne,
Oakland, and Macomb counties), you may contact the Managed Care Group by dialing
1-800-570-3990. If you live
in the Flint area, contact The Wellness Plan
providers at Insight by dialing 1-800-327-8989. If you live in the Muskegon
area, you may contact mental health
providers at 231-724-3699. For all other
counties, you may select a provider from our provider directory or www.
wellplan. com.
Limitation We may limit your benefits if you do not obtain a treatment plan.
30
30 Page 31 32
2002 The Wellness Plan 31 Section 5( f)
Section 5
(f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We
cover prescribed drugs and medications, as described in the chart beginning on
the next page.
All benefits are subject to the definitions, limitations and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
We do not have a calendar year deductible.
Any drug on our formulary that
has a prior authorization status requires the prescribing Physician submit to
the plan a prior authorization request form.
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 plan
physician must write the prescription.
Where you can obtain them. You may
fill the prescription at a Plan pharmacy.
We use a formulary. We call it The
Wellness Plan Performance Drug List. The list includes classes of widely used
drug products that we prefer. You may obtain a copy of the 2001-2002 Wellness
Plan Clinical
Formulary and Prescribing Guidelines by calling us. The drugs
selected have been carefully reviewed and provide excellent choices from the
standpoint of safety and cost effectiveness. We cover non-formulary drugs
when your Plan doctor prescribes them as long as the drugs are medically
necessary and appropriate.
These are the dispensing limitations.
Prescription drugs prescribed by a Plan or referral doctor and obtained at a
Plan Pharmacy will be dispensed for up to a 35-day supply or 100 unit doses,
whichever is greater, or one
commercially prepared unit. You pay a $5. 00
copay per prescription unit or refill.
The Plan pharmacy will dispense a
generic equivalent, if it is available, unless your physician specifically
requires a name brand. If you receive a name brand drug when a
Federally-approved generic drug is
available, and your physician has not
specified that it is medically necessary or Dispense as Written (DAW) for the
name brand drug, you will be responsible for the co pay and the difference
between the ingredient
cost of the brand name and generic product.
Why
use generic drugs? Generic drugs contain the same active ingredients and are
equivalent in strength and dosage to the original brand name product. Generic
drugs cost you and your plan less money than a
name-brand drug.
When you
have to file a claim. Please keep a copy of your pharmacy receipt and send it to
our Customer Services Department for processing. If you need additional
assistance you may phone them at 800-875-9355. 31
31
Page 32 33
2002
The Wellness Plan 32 Section 5( f)
Benefit Description You pay
Covered
medications and supplies
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a Plan pharmacy or through our
mail order
program: Drugs and medicines that by Federal law of the United States
require a physician's prescription for their purchase, except those listed
as Not covered
Insulin (up to 3 vials per copay) Disposable needles and
syringes for the administration of covered
medications Drugs for sexual
dysfunction (please contact us about dosage
limitations and Prior
authorization) Contraceptive drugs and devices
Infertility drugs
Diabetic supplies, including glucose test tablets and
test tapes, Benedict's solution, or equivalent, acetone test tablets, glucose
monitors and meters.
$5. 00 per prescription unit or refill
Covered medications and supplies You pay
Not covered:
Drugs and
supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription medicines
Medical Supplies such as
dressings and antiseptics
Smoking Cessation drugs if you are not in a
program
All charges. 32
32 Page
33 34
2002 The Wellness Plan 33 Section
5( g)
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the
most effective way to provide services.
We may identify medically
appropriate alternatives to traditional care and coordinate other benefits as a
less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Services for deaf and hearing impaired Hearing impaired members may contact
The Wellness Plan at 313-874-8256. 33
33 Page 34 35
2002 The Wellness
Plan 34 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We have no calendar year
deductible.
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. 34
34 Page 35 36
2002 The Wellness Plan 35 Section 5( i)
Section 5(
i). Non-FEHB benefits available to Plan members
The benefits on this page
are not part of the FEHB contract or premium, and you cannot file an FEHB
disputed claim about them. Fees you pay for these services do not count toward
FEHB deductibles or out-of-pocket
maximums.
The Wellness Plan offers a discount dental program for all enrollees. The
program is offered through Dental Preferred Provider Organization ( DPPO) and
extends discounts ranging from 20% -50% depending on the reason
for the
visit. The Wellness Plan will provide members with a discount fee schedule and a
list of participating dental providers. In addition, we also offer the following
Wellness Programs designed to keep you well… Stress
Management, Smoking
Cessation, Diabetes Education, Weight Control, Childbirth, and Hypertension
Education. Call 800-875-WELL (9355). 35
35 Page 36 37
2002 The Wellness
Plan 36 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury,
or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric practice;
Experimental or investigational procedures,
treatments, drugs or devices;
Services, drugs, or supplies related to
abortions, except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or
incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program. 36
36 Page
37 38
2002 The Wellness Plan 37 Section 7
Section 7. Filing a claim for covered services
When you see Plan
physicians, receive services at Plan hospitals and facilities, or obtain your
prescription drugs at Plan pharmacies, you will not have to file claims. Just
present your identification card and pay your co-payment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, hospital and prescription 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 800-875-WELL (9355).
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:
The
Wellness Plan 2875 W. Grand Boulevard
Detroit, MI 48202 Attn: Customer
Services Department
Prescription Drugs You do not have to file claims. Simply use your Plan
identification card at Plan pharmacies and pay the appropriate copy.
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. 37
37 Page
38 39
2002 The Wellness Plan 38 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: The Wellness Plan, 2875 W. Grand Boulevard,
Detroit, MI 48202, Attn: Customer Services Department; 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. 38
38 Page 39 40
2002 The Wellness Plan 39 Section 8
The Disputed
Claims process (Continued)
Send OPM the following information:
A
statement about why you believe our decision was wrong, based on specific
benefit provisions in this brochure;
Copies of documents that support your
claim, such as physicians' letters, operative reports, bills, medical records,
and explanation of benefits (EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific
written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control.
5 OPM will review your disputed claim request and will use the information it
collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no other administrative
appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the
review process to support their disputed claim decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was before OPM when
OPM decided to
uphold or overturn our decision. You may recover only the
amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that may cause
permanent loss of bodily functions or death if not treated as soon as possible),
and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at 800-875-WELL (9355) and we
will expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 39
39
Page 40 41
2002
The Wellness Plan 40 Section 9
Section 9. Coordinating benefits with other
coverage
When you have other health coverage You must tell us if you are
covered or a family member is covered under another group health plan or have
automobile insurance that pays health care expenses without regard to
fault.
This is called "double coverage."
When you have double coverage, one plan
normally pays its benefits in full as the primary payer and the other plan pays
a reduced benefit as the secondary payer. We, like
other insurers, determine
which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65
years of age and older.
Some people with disabilities, under 65 years of
age.
People with End-Stage Renal Disease (permanent kidney failure requiring
dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment,
you should be able to qualify for premium-free Part A insurance. (Someone who
was a Federal employee on January 1, 1983 or since automatically
qualifies.)
Otherwise, if you are age 65 or older, you may be able to buy it. Contact
1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices
in how you get your health care. Medicare + Choice is the term used to describe
the various health plan choices available
to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and is
the way most people
get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay
your share. Some things
are not covered under Original Medicare, like prescription drugs.
When you are enrolled in 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 and you still pay applicable
copayments.
The Original Medicare Plan (Part A or Part B) 40
40
Page 41 42
2002
The Wellness Plan 41 Section 9
(Primary payer chart begins on next page.)
The following chart illustrates whether the Original Medicare Plan or this Plan
should be the primary payer for you according to your employment status and
other factors determined by Medicare. It is critical that
you tell us if you
or a covered family member has Medicare coverage so we can administer these
requirements correctly.
Primary Payer Chart
Then the primary payer is…
A. When either you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Areanactiveemployee with
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you..)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that
you are unable
to return to duty,
(except for claims related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare
based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD coordination
period and are still eligible for Medicare due to ESRD,
3) Become eligible
for Medicare due to ESRD after Medicare became primary for you under another
provision,
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare 41
41
Page 42 43
2002
The Wellness Plan 42 Section 9
Claims process when you have the Original
Medicare Plan --You probably will never have to file a claim form when you have
both our Plan and the Original Medicare Plan.
When we are the primary payer,
we process the claim first.
When Original Medicare is the primary payer,
Medicare processes your claim first.
In most cases, your claims will be
coordinated automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you
need to do something about filing your claims, call us at 800-875-WELL (9355)
OR visit us at our website at www. wellplan. com.
We do not waive costs when you have the Original Medicare Plan--When Original
Medicare is the primary payer, you still pay all applicable copays under your
FEHB
coverage.
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 another plan's Medicare managed care plan:
You may enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan.
We will still provide benefits when your Medicare
managed care plan is primary, even out of the managed care plan's network and/
or service area (if you use our Plan
providers), but we will not waive any
of our copayments, coinsurance, or deductibles. If you enroll in a Medicare
managed care plan, tell us. We will need to know whether you
are in the
Original Medicare Plan or in a Medicare managed care plan so we can correctly
coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are
an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a
Medicare
managed care plan, eliminating your FEHB premium. (OPM does not
contribute to your Medicare managed care plan premium.) For information on
suspending your FEHB
enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of Medicare, you
can still be covered under the Medicare Part A or Part B FEHB Program. We will
not require you to enroll in Medicare Part B and, if you can't
get
premium-free Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE coverage. 42
42 Page 43 44
2002 The Wellness Plan 43 Section 9
Workers'
Compensation We do not cover services that:
you need because of a
workplace-related illness or injury that the Office of Workers' Compensation
Programs (OWCP) or a similar Federal or State agency determines they
must provide; or
OWCP or a similar agency pays for through a third party
injury settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other
Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or
indirectly pays for them.
When others are responsible When you receive money to compensate you for
medical or hospital care for injuries 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. 43
43 Page
44 45
2002 The Wellness Plan 44 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.
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 Unskilled care that can be provided by an individual who does
not have medical training. Examples of custodial care would be help with walking
and getting out of bed and
assistance with daily living activities such as
feeding, dressing and personal hygiene.
Deductible A deductible is a fixed amount of covered expenses you must incur
for certain covered services and supplies before we start paying benefits for
those services. We do not have
a deductible. See page 11.
Any drug, device, supply, treatment, procedure, or equipment that:
a.
Hasn't yet been approved by the Food and Drug Administration (FDA) and can't be
lawfully marketed without such approval;
b. Is the subject of a current investigational new drug or new device
application on file with the FDA;
c. Is part of a Phase 1 or Phase II
clinical trial;
d. Hasn't been demonstrated to be a safe or effective
treatment in comparison to conventional alternatives;
e. Is described as experimental, investigational, or research by informed
consent or patient information documents;
f. Is being delivered or should be
delivered subject to approval and supervision by an Institutional Review Board
based on Federal regulations; and
g. Most experts agree further study is
needed.
Medical necessity Services and Supplies furnished to you that:
Are
medically required and medically appropriate for the diagnosis and treatment of
your illness or injury; or
Are consistent with professionally recognized
standards of health care; and Do not involve costs that are excessive in
comparisons with alternative services
that would effectively treat your
condition, illness, or injury
Us/ We Us and we refer to The Wellness Plan
You You refers to the
enrollee and each covered family member.
Experimental or investigational services 44
44
Page 45 46
2002
The Wellness Plan 45 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 can answer about enrolling in the your questions, and give
you a Guide to Federal Employees Health Benefits Plans,
FEHB Program
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. 45
45 Page
46 47
2002 The Wellness Plan 46 Section
11
When benefits and The benefits in this brochure are effective on January
1. If you joined this Plan premiums start during Open Season, your coverage
begins on the first day of your first pay period that
starts on or after
January 1. Annuitants' coverage and premiums begin on January 1. If you joined
at any other time during the year, your employing office will tell you the
effective date of coverage.
Your medical and claims We will keep your medical and claims information
confidential. Only the following records are confidential will have access to
it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
Law enforcement officials when investigating and/ or
prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB Program.
Generally, you must have been enrolled in the FEHB Program for the last five
years of your Federal service. If you
do not meet this requirement, you may
be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will receive an
additional 31 days of coverage, for no additional premium, when:
Your
enrollment ends, unless you cancel your enrollment, or
You are a family
member no longer eligible for coverage.
You may be eligible for spouse
equity coverage or Temporary Continuation of Coverage.
Spouse equity If you
are divorced from a Federal employee or annuitant, you may not coverage continue
to get benefits under your former spouse's enrollment. But, you may be eligible
for your own FEHB coverage under the spouse equity law. If you are recently
divorced or are anticipating a divorce, contact your ex-spouse's employing or
retirement office to
get RI 70-5, the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees, or other information about your
coverage choices.
TCC If you
leave Federal service, or if you lose coverage because you no longer qualify as
a family member, you may be eligible for Temporary Continuation of Coverage
(TCC).
For example, you can receive TCC if you are not able to continue your
FEHB enrollment after you retire, if you lose your job, if you are a covered
dependent child and you turn 22
or marry, etc.
You may not elect TCC if
you are fired from your Federal job due to gross misconduct. 46
46 Page 47 48
2002 The Wellness Plan 47 Section 11
Enrolling in
TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees, from your employing or retirement office or
from www. opm. gov/ insure. It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if: individual
coverage
Your coverage under TCC or the spouse equity law ends (If you
canceled your coverage or did not pay your premium, you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to convert. You must apply in writing to us within 31 days after you receive
this notice.
However, if you are a family member who is losing coverage, the employing or
retirement office will not notify you. You must apply in writing to us within 31
days
after you are no longer eligible for coverage.
Your benefits and
rates will differ from those under the FEHB Program; however, you will not have
to answer questions about your health, and we will not impose a waiting
period or limit your coverage due to pre-existing conditions.
Getting a
Certificate of The Health Insurance Portability and Accountability Act of 1996
(HIPAA) is Group Health Plan Coverage a Federal law that offers limited Federal
protections for health coverage availability and
continuity to people who
lose employer group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group Health Plan Coverage that indicates
how long you have
been enrolled with us. You can use this certificate when getting health
insurance or other health care coverage. Your new plan must reduce or eliminate
waiting
periods, limitations, or exclusions for health related conditions
based on the information in the certificate, as long as you enroll within 63
days of losing coverage under this Plan.
If you have been enrolled with us
for less than 12 months, but were previously enrolled in other FEHB plans, you
may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB web site
(www. opm.
gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked question.
These highlight HIPAA rules, such as the requirement that Federal employees must
exhaust any TCC eligibility as one condition for guaranteed access to
individual health coverage under HIPAA, and have information about Federal and
State agencies you can
contact for more information. 47
47 Page 48 49
2002 The Wellness Plan 48 Long Term Care
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. It
can supplement care provided by family members, reducing the burden you place on
them.
Welcome to the club! 76% of Americans believe they will never need
long term care, but the facts are that
about half them will. And it's not
just the old folks. About 40% of people needing long term care are under age 65.
They may need chronic care due to a serious
accident, a stroke, or
developing multiple sclerosis, etc. We hope you will never need long term care,
but everyone should have a plan just in
case. Many people now consider long
term care insurance to be vital to their financial and retirement planing.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's
before inflation! Long term care can easily exhaust your savings.
Long term care insurance can
protect your savings.
Not FEHB. Look at the
"Not covered" blocks in sections 5( a) and 5( c) of your FEHB brochure. Health
plans don't cover custodial care or a stay in an assisted
living facility or
a continuing need for a home health aide to help you get in and out of bed and
with other activities of daily living. Limited stays in skilled nursing
facilities can be covered in some circumstances. Medicare only covers
skilled nursing home care (the highest level of nursing care)
after a
hospitalization for those who are blind, age 65 or older or fully disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who meet
their state's poverty guidelines, but has restrictions on covered services and
where they can be received. Long term
care insurance can provide choices of
care and preserve your independence.
Employees will get more information
from their agencies during the LTC open enrollment period in the late summer/
early fall of 2002.
Retirees will receive information at home.
Our
toll-free teleservice center will begin in mid-2002. In the meantime, you can
learn more about the program on our web site at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are YOU
planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care (LTC) insurance?
I'm healthy. I won't need long
term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or Medicaid
cover
my long term care?
When will I get more information on how to apply for this new
insurance
coverage?
How can I find out more about the program NOW? 48
48 Page 49 50
2002 The Wellness Plan 49 Index
Index
Do not
rely on this page; it is for your convenience and may not show all pages where
the terms appear
Accidental injury 27, 28, 34 Allergy tests 17
Alternative treatment 21
Allogeneic (donor) bone marrow
transplant 24
Ambulance 26, 28 Anesthesia
24
Autologous bone marrow transplant 24
Biopsies 22 Blood and blood plasma
25, 26
Breast cancer screening 14 Casts 22, 25, 26
Catastrophic
protection 11 Changes for 2002 7
Chemotherapy 17 Childbirth 15
Chiropractic 21 Cholesterol tests 14
Circumcision 15 Claims 37, 38, 39
Coinsurance 11, 44 Colorectal cancer screening 14
Congenital anomalies
22 Contraceptive devices and drugs 16
Coordination of benefits 40, 41
Covered charges 8, 11, 44
Covered providers 8-9, 11, 44 Crutches 20
Deductible 11 Definitions 44
Dental care 34 Diagnostic services 13
Disputed claims review 38-39 Donor expenses (transplants) 24
Dressings
26 Durable medical equipment
(DME) 20 Educational classes and programs 21
Effective date of enrollment 46 Emergency 27
Experimental or
investigational 44 Eyeglasses 18
Family planning 16
Fecal occult blood test 14 General Exclusions 36
Hearing services 15, 18
Home health services 20
Hospice care 26 Home nursing care 20
Hospital
25, 26, 28 Immunizations 14-15
Infertility 16 Inhospital physician care
22-24
Inpatient Hospital Benefits 25 Insulin 20
Laboratory and
pathological services 13
Machine diagnostic tests 13 Magnetic Resonance
Imagings
(MRIs) 13 Mail Order Prescription Drugs 32
Mammograms 14
Maternity Benefits 15
Medicaid 43 Medical necessity 44
Medicare 40, 42
Mental Conditions/ Substance Abuse
Benefits 29-30 Newborn care 15
Non-FEHB Benefits 35 Nurse
Licensed Practical Nurse 20 Registered Nurse
20, 21
Obstetrical care 15 Occupational therapy 17
Ocular injury 18
Office visits 11
Oral and maxillofacial surgery 23 Orthopedic devices 19
Ostomy and catheter supplies 32 Out-of-pocket expenses 11
Outpatient
facility care 26 Oxygen 20
Pap test 14 Physical examination 14
Physical
therapy 17 Preauthorization 29
Precertification 25 Pre-Existing Condition 45
Preventive care, adult 14
Preventive care, children 15
Prescription drugs 31-32 Preventive services
14-15
Prior approval 30 Prostate cancer screening 14
Prosthetic devices
22 Psychologist 29
Psychotherapy 29 Radiation therapy 17
Renal dialysis
17 Room and board 25
Second surgical opinion 13 Skilled nursing facility
care 26
Smoking cessation 21 Speech therapy 18
Splints 22, 25, 26
Sterilization procedures 16, 22
Subrogation 43 Substance abuse 29-30
Surgery 22-24 Anesthesia 24
Oral Maxillofacial 23 Outpatient 26
Reconstructive 23 Syringes 32
Temporary continuation of coverage 46
Transplants 24 Treatment therapies 17
Vision services 18 Wheelchairs 20
Workers' compensation 43 X-rays 13 49
49
Page 50 51
50
50 Page 51 52
2002 The Wellness Plan 50 Summary of Benefits
Summary of benefits for the The Wellness Plan 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 13-21
Services provided by a hospital:
Inpatient
............................................................................
Outpatient
.........................................................................
Nothing
Nothing
25
26
Emergency benefits:
In-area
...............................................................................
Out-of-area........................................................................
$50 per visit
$50 per visit
27-28
27-28
Mental health and
substance abuse treatment ....................... Regular cost sharing. 29-30
Prescription
drugs...................................................................
Up
to a 35 day supply or 100 unit supply, whichever is less
$5. 00 per
prescription unit or refill 31-32
Dental
Care.............................................................................
No Benefit
All charges 34
Vision
Care.............................................................................
Annual eye refraction
$10 per office visit 18
Special features:
Flexible benefits option, Services for the deaf and
hearing impaired
33
Protection against catastrophic costs (your out-of-pocket
maximum)............................................... Stated copays 11 51
51 Page 52 53
52
52 Page 53 54
2002 The Wellness
Plan 51 Notes
Notes 53
53 Page 54 55
54
54 Page 55
2002 The
Wellness Plan
2002 Rate Information for The Wellness Plan
Non-Postal
rates apply to most non-Postal enrollees. If you are in a special enrollment
category, refer to the FEHB Guide for that category or contact the agency that
maintains your health benefits enrollment.
Postal rates apply to career
Postal Service employees. Most employees should refer to the FEHB Guide for
United States Postal Service Employees, RI 70-2. Different postal rates apply
and special FEHB guides are
published for Postal Service Nurses, RI 70-2B;
and for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only K31 $ 68.28 $ 22.76 $147.94 $ 49.31 $ 80.80 $ 10.24
Self and
Family K32 $185.72 $ 61.91 $402.40 $134.13 $219. 77 $27.86 55