Serving: Northeast Ohio
Enrollment in this Plan is limited. You
must live or work in our
Geographic service area to enroll. See page 7 for
requirements.
Federal Employees Health Benefits Program
RI 73-157
2002
For changes
in benefits
see page
8.
Enrollment code:
L41 Self Only
L42 Self and Family
This Plan has a commendable
accreditation from the NCQA. See
the 2002
Guide for more information
on accreditation. 1
1
Page 2 3
2002 HMO
Health HMO 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
........................................................................................................................................................
7
Section 2. How we change for
2002.....................................................................................................................................
8
Program-wide changes
........................................................................................................................................
8
Changes to this Plan
.......................................................................................................................................
8
Section 3. How you get care
.................................................................................................................................................
9
Identification cards
..............................................................................................................................................
9
Where you get covered
care................................................................................................................................
9
Plan providers
...............................................................................................................................................
9
Plan
facilities.................................................................................................................................................
9
What you must do to get covered
care................................................................................................................
9
Primary care
..................................................................................................................................................
9
Specialty care
..........................................................................................................................................
9-10
Hospital care
..............................................................................................................................................
10
Circumstances beyond our control
..................................................................................................................
11
Services requiring our prior approval
..............................................................................................................
11
Section 4. Your costs for covered services
.......................................................................................................................
12
Copayments................................................................................................................................................
12
Deductible
..................................................................................................................................................
12
Coinsurance................................................................................................................................................
12
Your out-of-pocket maximum
.........................................................................................................................
12
Section 5. Benefits
.............................................................................................................................................................
13
Overview...........................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals.............. 13
(b) Surgical and anesthesia services
provided by physicians and other health care professionals.......... 24
(c)
Services provided by a hospital or other facility, and ambulance
services......................................... 28
(d) Emergency services/
accidents
..............................................................................................................
31
(e) Mental health and substance abuse
benefits....................................................................................
33-34
(f) Prescription drug benefits
................................................................................................................
35-36
(g) Special
features......................................................................................................................................
37
Flexible benefits
option..................................................................................................................
37
Heart Sense
.....................................................................................................................................
37
Baby Link
.......................................................................................................................................
37 2
2 Page 3 4
2002 HMO Health HMO 3 Table of Contents
Breathe
Easy
...................................................................................................................................
37
Transplanting Health
......................................................................................................................
37
(h) Dental
benefits.......................................................................................................................................
38
Section 6. General exclusions --things we don't cover
....................................................................................................
39
Section 7. Filing a claim for covered services
..................................................................................................................
40
Section 8. The disputed claims
process........................................................................................................................
41-42
Section 9. Coordinating benefits with other
coverage......................................................................................................
43
When you have
Other health coverage
................................................................................................................................
43
Original Medicare
................................................................................................................................
43-47
TRICARE/ Workers' Compensation/
Medicaid.........................................................................................
....... 47
Other Government
agencies.............................................................................................................................
48
When others are responsible for injuries
.........................................................................................................
48
Section 10. Definitions of terms we use in this brochure
.................................................................................................
49
Section 11. FEHB
facts......................................................................................................................................................
50
Coverage
information.......................................................................................................................................
50
No pre-existing condition limitation
.......................................................................................................
50
Where you get information about enrolling in the FEHB
Program....................................................... 50
Types of
coverage available for you and your family
............................................................................ 50
When benefits and premiums start
..........................................................................................................
51
Your medical and claims records are confidential
.................................................................................
51
When you
retire.......................................................................................................................................
51
When you lose benefits
....................................................................................................................................
51
When FEHB coverage
ends.....................................................................................................................
51
Spouse equity coverage
..........................................................................................................................
51
Temporary Continuation of Coverage
(TCC)...................................................................................
51-52
Converting to individual coverage
.........................................................................................................
52
Getting a Certificate of Group Health Plan
Coverage...........................................................................
52
Long term care insurance is coming in 2002
.....................................................................................................................
53
Index
........................................................................................................................................................................
54
Summary of benefits
...........................................................................................................................................................
55
Rates
.........................................................................................................................................................
Back cover 3
3 Page
4 5
2002 HMO Health Ohio 4
Introduction/Plain Language
Introduction
Medical Mutual of Ohio,
dba HMO Health Ohio
2060 East Ninth Street
Cleveland, Ohio 44115-1355
This brochure describes the benefits of HMO Health Ohio under our contract
(CS 2015) 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 8. 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 HMO Health Ohio.
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 us at fehbwebcomments@ opm. gov . 4
4 Page 5 6
2002 HMO Health Ohio 5 Introduction/Plain Language
Inspector General Advisory
Stop health care fraud! Fraud
increases the cost of health care for everyone. If you suspect that a physician,
pharmacy, or hospital has charged you for services you did not
receive,
billed you twice for the same service, or misrepresented any
information, do
the following:
Call the provider and ask for an explanation. There may be an error. If
the provider does not resolve the matter, call us at 800/ 522-2066
and
explain the situation.
If we do not resolve the issue, call or write to:
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States Office of Personnel Management,
Office of the Inspector
General Fraud Hotline,
1900 E Street, NW, Room 6400,
Washington, DC
20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID
card if the person tries to obtain
services for someone who is not an eligible
family member, or is no longer
enrolled in the Plan and tries to obtain benefits.
Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 HMO Health Ohio 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.
Your Rights
HMO Health Ohio is a mixed model prepayment plan that
provides care through a network of doctors, using groups of
doctors, staff
model arrangements, and IPA systems. Both primary care and specialist doctors
are part of the network.
Different members of the same family may select
different centers or doctors.
OPM requires that all FEHB Plans provide certain information to their FEHB
members. You may get information
about us, our networks, providers, and
facilities. OPM's FEHB website ( www. opm. gov/ insure ) lists the specific
types
of information that we must make available to you. Some of the
required information is listed below.
Medical Mutual of Ohio is the oldest health insurance company in Ohio. HMO
Health Ohio has been in existence since January 1, 1992.
HMO Health Ohio
has over 28,000 participating physicians. Medical Mutual of Ohio has been
awarded three-year Commendable accreditation status HMO Health Ohio by
the National Committee for Quality Assurance (NCQA), a leading independent
evaluator of health plans.
If you want more information about us, call 800/
522-2066, or write to HMO Health Ohio, P. O. Box 6018, Cleveland,
Ohio
44101, Attn: HMO Member Services. You may also contact us by fax at 216/
694-2910 or visit our website at
http:// www. mmoh. com . 6
6 Page 7 8
2002 HMO Health Ohio 7 Section 1
Service Area
To enroll in this plan, you must live in or work in our service area.
This is where our providers practice.
Our service area is:
The Ohio
counties of Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Holmes,
Huron, Lake, Lorain,
Medina, Portage, Richland, Stark, Summit, Tuscarawas
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
dependants live out of the are (for example,
if your child goes to college in a another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page
8 9
2002 HMO Health Ohio 8 Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5
Benefits. Also, we edited and clarified language throughout the
brochure; any language change not shown here is a
clarification that does
not change benefits.
Program-wide changes
We removed the requirement that services
must be needed to restore functional speech from the speech therapy benefit.
(Section 5 (a))
Changes to this Plan
Your share of the non-Postal premium will
increase by 26 % for Self Only or 61.6 % for Self and Family.
There will
be a $10 copayment for all office visits. Currently, the office visit copayment
only applies to primary care physician office visits.
The Plan will provide one eye refraction including lens prescription, every
year for a $10 copayment. Currently, the Plan provide one eye refraction
including lens prescription, every two years, and does not charge a copayment
for this service.
The Plan will no longer pay up to $45 every other year toward the cost of
one pair of corrective eyeglasses and frames or for one pair of contact lenses.
The prescription copayment will change from $5 per prescription or refill
to $10 per prescription or refill for generic drugs or $20 per prescription unit
or refill for brand name drugs. If the member requests a name brand
drug
when a Federally-approved generic drug is available, and the member's physician
has not specified Dispense
as Written for the name brand drug, the member
will pay the difference in cost between the name brand drug and
the generic,
as well as the generic copayment.
The Plan will implement a mail order prescription program that will allow
members to receive a 90-day supply of drugs for two times the applicable
prescription copayment.
The Plan will provide rehabilitative therapy for the greater of 20 visits
or up to two months per condition. Currently, the Plan provides rehabilitative
therapy for up to two months per condition.
We now cover certain
intestinal transplants (Section 5( b)) 8
8 Page 9 10
2002 HMO Health Ohio
9 Section 3
Section 3. How you get care
Identification cards We
will send you an identification (ID) card. You should carry your ID card with
you at all times. You must show it whenever you receive
services from a Plan
provider, or obtain 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
800/
522-2066.
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.
Both primary care and specialist doctors are part of the network.
Different members of the same family may select different centers or
doctors.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. (www. mmoh. com)
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically. The list is also
on our website. (www. mmoh. com)
What you must do to get covered care The first and most important
decision each member must make is the
selection of a primary care doctor.
The decision is important since it is
through this doctor that all other
health services, particularly those of
specialists, are obtained. It is the
responsibility of your primary care
doctor to obtain any necessary
authorizations from the Plan before
referring you to a specialist or making
arrangements for hospitalization.
Services of other providers are covered
only when there has been a
referral by a member's primary care doctor.
Primary care Your primary care physician can be a physician, or group
of physicians, trained in family or general practice, internal medicine,
pediatrics or
osteopathic medicine who has a contractual obligation with HMO
Health
Ohio to provide the primary care services listed in this brochure.
Your
primary care physician will provide most of your health care, or give
you
a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. However, you may see a Plan Obstetrician/
Gynecologist or vision provider
without a referral. For mental conditions
and substance abuse call SuperMed
Behavioral Health Care Management
Department at 800/ 258-3186.
Here are other things you should know about specialty care: 9
9 Page 10 11
2002 HMO Health Ohio 10 Section 3
If you need to
see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician
will develop a treatment plan that
allows you to see your specialist for
a certain number of visits without
additional referrals. Your primary
care physician will use our criteria when
creating your treatment plan
(the physician may have to get an authorization
or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment
from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until
we can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB) Program and you
enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan, you may be able
to continue seeing your specialist for up to 90
days after you receive
notice of the change. Contact us, or if we
drop out of the program, contact
your new Plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise 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/ 522-2066. If you
are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the hospital benefit of the hospitalized
person; we cover your other non-hospital care. 10
10 Page 11 12
2002 HMO Health Ohio 11 Section 3
Circumstances
beyond our control Under certain extraordinary circumstances, such as
natural disasters, we may have to delay your services or we may be unable to
provide them.
In that case, we will make all reasonable efforts to provide
you with the
necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from
us. Before giving
approval, we consider if the service is covered,
medically necessary, and
follows generally accepted medical practice.
We call this review and approval process precertification. Your physician
must obtain approval before sending you to a hospital, referring you to a
specialist, or recommending follow-up care. 11
11
Page 12 13
2002
HMO Health Ohio 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services.
Example: You pay a copayment of $10 per office visit.
Deductible
We do not have a deductible.
Coinsurance We do not have
coinsurance.
Your out-of-pocket maximum Your out-of-pocket expenses for benefits
under this Plan are limited to the stated copayments required for a few
benefits. 12
12 Page
13 14
2002 HMO Health Ohio 13 Section 5
Section 5. Benefits OVERVIEW
(See page 7 for how our
benefits changed this year and page 57 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. To obtain claims forms, claims filing advice, or more information
about our benefits,
contact us at 800/ 522-2066 or at our website at www.
mmoh. com.
(a) Medical services and supplies provided by physicians and
other health care professionals 14-23
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
Rehabilitative 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 ........................... 24-27
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/
tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
.......................................................... 28-30
Inpatient hospital
Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance
(d) Emergency services/
accidents................................................................................................................................
31-32
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
..........................................................................................................
33-34
(f) Prescription drug
benefits.......................................................................................................................................
35-36
(g) Special features
............................................................................................................................................................
37
Flexible Benefits Option
Baby Link
Breathe Easy
Heart Sense
Transplanting Health
(h) Dental benefits
.............................................................................................................................................................
38
Summary of benefits
...........................................................................................................................................................
55 13
13 Page 14
15
2002 HMO Health Ohio 14 8Section 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
Diagnostic and treatment services
Professional services of physicians
In physician's office
In
an urgent care center
Office medical consultations
Second surgical
opinion (in office)
$10 per office visit
Professional services of physicians
During a hospital stay
In a
skilled nursing facility
Nothing
Professional services of physicians
At home
Nothing
Diagnostic and treatment services --Continued on next page 14
14 Page 15 16
2002 HMO Health Ohio 15 8Section 5(a)
Lab,
X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these
services during your office visit;
otherwise, $10 per office visit
Preventive care, adult
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
Nothing if you receive these
services during your office visit;
otherwise, $10 per office visit
Prostate Specific Antigen (PSA test) one annually for men age 40 and
older
Routine pap test
Note: The office visit is covered if pap test is
received on the same day;
see Diagnosis and Treatment, above.
Routine mammogram covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster
once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Not
covered: Physical exams required for obtaining or continuing
employment or
insurance, attending schools or camp, or travel.
All charges. 15
15 Page 16 17
2002 HMO Health Ohio 16 8Section 5(a)
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics $10 per office visit
Well-child care charges for routine examinations, immunizations and care
(up to age 22)
Examinations, such as:
-Eye exams through age 17 to
determine the need for vision correction.
-Ear exams through age 17 to determine the need for hearing correction
-Examinations done on the day of immunizations ( up to age 22) 16
16 Page 17 18
2002 HMO Health Ohio 17 8Section 5(a)
Maternity
care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things
to keep in mind:
You do not need to pre-certify your normal delivery.
You may remain
in the hospital up to 48 hours after a regular delivery and 96 hours after a
cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery
care of the newborn child during the covered portion of the mother's maternity
stay. We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$10 per office visit; initial visit
only
Not covered: Routine sonograms to determine fetal age, size or sex All
charges.
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Injectable contraceptive drugs
(such as Depo provera)
Intrauterine devices (IUDs)
Diaphrams
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)
$10 per office visit 17
17 Page 18 19
2002 HMO Health
Ohio 18 8Section 5(a)
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
Fertility drugs
Cost of donor sperm
Cost of
donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 18
18 Page 19 20
2002 HMO Health Ohio 19 8Section 5(a)
Treatment
therapies You pay
Chemotherapy and radiation therapy
Note: High
dose chemotherapy in association with autologous bone
marrow transplants are
limited to those transplants listed under
Organ/ Tissue Transplants on page
27.
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.
$10 per office visit 19
19 Page 20 21
2002 HMO Health
Ohio 20 8Section 5(a)
Physical and occupational therapies You pay
Physical therapy, and occupational therapy --
For the greater of 20
visits or up to two months per condition, on an inpatient or outpatient basis,
if significant improvement can be
expected within two months, for each of the following:
-qualified
physical therapists and
-occupational therapists.
Note: We only cover
therapy to restore bodily function when there
has been a total or partial
loss of bodily function due to illness or
injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, provided at a Plan facility as
prescribed by your primary care doctor.
$10 per office visit
Nothing per visit during covered
inpatient
admission.
Not covered:
Long-term rehabilitative therapy
Exercise programs
All charges.
Speech therapy
Speech Therapy --
For the greater of 20 visits
or up to two months per condition
$10 per office visit
Nothing per visit
during covered
inpatient admission.
Hearing services (testing, treatment, and supplies)
Hearing evaluations $10 per office visit
Not covered:
hearing aids, testing and examinations for them
All charges. 20
20 Page
21 22
2002 HMO Health Ohio 21 8Section
5(a)
Vision services (testing, treatment, and supplies) You pay
In addition to the medical and surgical benefits provided for diagnosis
and
treatment of diseases of the eye, the Plan provides certain vision care
benefits from Plan providers:
One eye refraction, including lens
prescription, every year.
$10 per office visit
Not covered:
Corrective lenses or frames
Eye
exercises and orthoptics
Sunglasses
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat
feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot (unless the
treatment is by open cutting surgery)
All charges. 21
21 Page 22 23
2002 HMO Health
Ohio 22 8Section 5(a)
Orthopedic and prosthetic devices You pay
Orthopedic devices, such as braces; foot orthotics
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.
Nothing
Not covered:
arch supports
heel pads and heel
cups
trusses, elastic stockings, support hose, and other supportive
devices
All charges.
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/ 522-2066 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.
Nothing
Not covered:
Specially designed wheel chairs for use in
sporting events
All charges. 22
22 Page 23 24
2002 HMO Health
Ohio 23 8Section 5(a)
Home health services
Home health services
of nurses and health aides, including intravenous fluids and medications, when
prescribed by your Plan
doctor, who will periodically review the program
from continuing
appropriateness and need.
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.
Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application
$10 per office visit
Not covered: All charges.
Alternative treatments
Acupuncture by a doctor of medicine or osteopathy for: anesthesia, pain relief
$10 per office visit
Not covered:
Naturopathic services Hypnotherapy
Biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation drugs and medication, including nicotine patches
Diabetes self-management
$10 per office visit 23
23 Page 24 25
2002 HMO Health
Ohio 24 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. Any costs associated with the facility charge (i. e.
hospital, surgical center, etc.) are covered in Section 5 (c).
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;
Nothing for hospital visits
Surgical procedures continued on next page. 24
24 Page 25 26
2002 HMO Health Ohio 25 Section 5(b)
Surgical
procedures (Continued) You pay
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
Nothing for hospital visits
Not covered:
Reversal of voluntary sterilization
Surgery primarily for cosmetic purposes
Routine treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
-the
condition produced a major effect on the member's appearance and
-the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks;
webbed fingers; and webbed toes.
$10 per office visit
Nothing for hospital visits 25
25 Page 26 27
2002 HMO Health Ohio 26 Section 5(b)
Reconstructive surgery (Continued) You pay
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
Nothing for hospital visits
Not covered:
Cosmetic surgery any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones; Surgical
correction of 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
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
Dental care involved in treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome
All charges. 26
26 Page 27 28
2002 HMO Health
Ohio 27 Section 5(b)
Organ/ tissue transplants You pay
Limited
to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/
Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic
bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach, and pancreas
National Transplant Program (NTP) Ohio
Department of Health and Ohio Organ Transplant Consortium
Limited Benefits Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
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
Office
Nothing 27
27 Page
28 29
2002 HMO Health Ohio 28 Section 5(c
)
Section 5 (c). Services provided by a hospital or other
facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care. Any
costs
associated with the professional charge (i. e., physicians, etc.) are covered
in
Sections 5( a) or (b).
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 private nursing care
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 Medical supplies, appliances, medical equipment,
and any covered
items billed by a hospital for use at home
Nothing
Not covered:
Custodial care, rest cures, domiciliary or
convalescent care Non-covered facilities, such as schools
Personal comfort items, such as telephone, television, barber Services,
guest meals and beds
Private nursing care
All charges. 28
28 Page 29 30
2002 HMO Health
Ohio 29 Section 5(c )
Outpatient hospital or ambulatory surgical
center
Operating, recovery, and other treatment rooms Prescribed
drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology
services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services
and supplies related to dental
procedures when necessitated by a non-dental
physical impairment. We
do not cover the dental procedures.
Nothing 29
29 Page
30 31
2002 HMO Health Ohio 30 Section 5(c
)
Extended care benefits/ skilled nursing care facility benefits
You pay
Extended care benefit:
The Plan provides a comprehensive
range of benefits for up to 100 days
per calendar year when full-time
skilled nursing care is necessary and
confinement in a skilled nursing
facility is medically appropriate as
determined by a Plan doctor and
approved by the Plan. All necessary
services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a Plan
doctor.
Nothing
Not covered:
Custodial care, rest cures, domiciliary or
convalescent care
Personal comfort items, such as telephone and
television
All charges
Hospice care
Supportive and palliative care for a terminally ill
member is covered in
the home or hospice facility. Services include
inpatient and outpatient
care, and family counseling, and durable medical
equipment; these
services are provided under the direction of a Plan doctor
who certifies
that the patient is in the terminal stages of illness, with a
life expectancy
of approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when
medically appropriate Nothing 30
30 Page 31 32
2002 HMO Health
Ohio 31 Section 5(d )
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe
endangers your life or could result in serious
injury or disability, and requires immediate medical or
surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more
serious; examples include deep cuts and broken bones. Others are
emergencies because they are
potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability
to
breathe. There are many other acute conditions that we may determine are medical
emergencies what
they all have in common is the need for quick action.
What to do in case of emergency:
If you are in an emergency
situation, please call your primary care doctor. In extreme emergencies, if you
are unable to contact your doctor, contact the local emergency system (e.
g., the 911 telephone system) or
go to the nearest hospital emergency room.
Emergencies within our service area:
Be sure to tell the emergency
room personnel that you are a Plan member so they can notify the Plan. You
or a family member should notify the Plan within 48 hours, unless it was not
reasonably possible to do so.
It is your responsibility to ensure that the
Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day
following your admission, unless it was not
reasonably possible to notify the Plan within that time. If you
are
hospitalized in non-Plan facilities and Plan doctors believe care can be better
provided in a Plan
hospital, you will be transferred when medically feasible
with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a
Plan provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by
the Plan or provided by Plan providers.
The Plan pays reasonable charges for emergency services to the extent the
services would have been
covered if received from Plan providers.
Emergencies outside our service area:
Benefits are available for
any medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day
following your admission, unless it was not
reasonably possible to notify the Plan within that time. If a
Plan doctor
believes care can be better provided in a Plan hospital, you will be transferred
when medically
feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by 31
31 Page 32 33
2002 HMO Health
Ohio 32 Section 5(d )
the Plan or provided by Plan providers.
The
Plan pays reasonable charges for emergency care services to the extent the
services would have been
covered if received from Plan providers.
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 Nothing
Emergency care as an outpatient at a
hospital, including doctors' services.
Note: If the emergency results in admission to a hospital, the emergency
care copay is waived.
$50 copay per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office $10 per office visit
Emergency
care at an urgent care center Nothing
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services.
Note: If the emergency results in admission to a hospital, the emergency
care copay is waived.
$50 copay per visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could
have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of
a baby outside the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
Air ambulance when ordered or authorized by a Plan doctor
See 5( c) for non-emergency service.
Nothing 32
32 Page
33 34
2002 HMO Health Ohio 33 Section 5(e
)
Section 5 (e). Mental health and substance abuse benefits
I
M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than for
similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
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 33
33 Page 34 35
2002 HMO Health Ohio 34 Section 5(e )
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in
approved alternative care settings such as partial
hospitalization, half-way
house, residential treatment, full-day
hospitalization, facility based
intensive outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the
treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one
clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all the following authorization processes:
This may be arranged by calling the SuperMed Behavioral Health Care
Management Department at 800/ 258-3186. It is not necessary to obtain a
referral from your primary care doctor. 34
34
Page 35 36
2002
HMO Health Ohio 35 Section 5(f)
Section 5 (f). Prescription drug benefits
I M
P O
R
T A
N T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
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
There are important features you should be aware of. These include:
Who can write your prescription. A plan or referral physician must
write the prescription.
Where you can obtain them. You must fill
the prescription at a plan pharmacy, except for out-of-area emergencies, or by
mail for a maintenance medication.
We use a formulary. Drugs are prescribed by Plan doctors and
dispensed in accordance with the Plan's drug formulary. A formulary is a list of
selected FDA approved, prescription medications
reviewed by an independent
Pharmacy and Therapeutics Committee brought together by Merck-Medco
Managed
Care, L. L. C. These drugs are made by many different pharmaceutical
manufacturers, including Merck & Co., Inc. We cover non-formulary drugs
prescribed by a Plan
doctor.
We have an open formulary. If your physician believes a name brand product is
necessary or there
is no generic available, you physician may prescribe a
name brand drug from a formulary list. This
list of name brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower
cost. To order a prescription drug brochure call 800/ 491-1961.
Mail Order Program. To receive mail order prescription drug
benefits, you mail your prescription order and the prescription drug deductible
amount which is specified above to a contracting mail
order pharmacy. No benefits are payable if your prescription order is sent to
a pharmacy other than
a contracting mail order pharmacy. The contracting
mail order pharmacy will fill your prescription
order and send you up to a
90-day supply of the mail order prescription drug which your physician
has
prescribed. The contracting mail order pharmacy will dispense the medication and
mail it to you
within 72 hours. If you fail to receive the mail order
prescription drug within ten days after you
mailed in your prescription
order, call the contracting mail order pharmacy directly to determine the
status of the prescription order.
These are the dispensing limitations. Prescription drugs obtained at
a Plan pharmacy will be dispensed for up to a 30-day supply. You pay a $10 copay
per prescription unit or refill for generic
drugs or for name brand drugs when a generic substitution is not permissible.
When a generic
substitution is permissible (i. e., generic drug is available
and the prescribing doctor does not require
the use of a name brand drug),
but you request the name brand drug, you pay the price difference
between
the generic and name brand drug, as well as a $20 copay per prescription unit or
refill.
Prescription drugs obtained by using the mail order prescription drug program
will be dispensed for
up to a 90-day supply. You pay a $20 copay for all
generic drugs and a $40 copay for all name brand
drugs.
Why use generic drugs? To reduce your out-of-pocket expenses! A
generic drug is the chemical equivalent of a corresponding brand name drug.
Generic drugs are less expensive than brand name
drugs; therefore, you may reduce your out-of-pocket costs by choosing to use
a generic drug.
When you have to file a claim. You should contact
Merck-Medco at 800/ 417-1961 for prescription drug claim forms. You should
submit all claims to Paid Prescriptions, P. O. Box 709, Lee Summit,
MO 64063. Normally, when you use plan pharmacies, you will not have to file
claims.
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 HMO Health Ohio 36 Section 5(f)
Benefit
Description You pay
Covered medications and supplies
We cover the
following medications and supplies prescribed by a Plan
physician and
obtained from a Plan pharmacy or through our mail order
program:
Drugs for which a prescription is required by Federal Law
Insulin
Disposable needles and syringes for the administration of covered
medications
Contraceptive drugs and devices
Smoking cessation drugs and
medication, including nicotine patches
Growth Hormone
Limited benefits:
Sexual dysfunction drugs have dispensing limitations.
Contact the Plan for details.
30-day supply at a Plan pharmacy
$10 copay per prescription or
refill
for generic drugs
$20 copay per prescription or refill
for formulary name brand drugs
Up to a 90-day supply through the mail order program
$20 copay per
prescription or refill
for generic drugs
$40 copay per prescription or refill
for formulary name brand drugs
Not covered:
Drugs available without a prescription or for
which there is a nonprescription equivalent available.
Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies.
Vitamins and nutritional substances that can be
purchased without a prescription.
Medical supplies such as
dressings and antiseptics
Fertility drugs
Drugs for
cosmetic purposes
Drugs to enhance athletic performance
Diabetic supplies, including glucose test tablets and test tape, Benedict's
solution, or equivalent, and acetone test tablets
All Charges 36
36 Page 37 38
2002 HMO Health
Ohio 37 Section 5(g)
Section 5 (g). Special features
Feature
Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the
future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Congestive Heart Failure (Heart Sense) For any of your health
concerns, 24 hours a day, 7 days a week, you may call 1-877-726-2715 and talk
with a cardiac nurse disease manager who will set up a program of telephone and
home visit( s) that
will help you learn more about your condition and how to
manage
your symptoms.
Maternity Care (Baby Link) For any of your health concerns, 24 hours a
day, 7 days a week, you may call 1-800-338-4114 and talk with a maternity care
nurse who can answer your questions and provide necessary information and
additional resources that you may need concerning maternity care,
during
and after pregnancy.
Respiratory/ Asthma Disease (Breathe Easy) For any of your health
concerns, 24 hours a day, 7 days a week, you may call 1-800-224-6906 and talk
with a disease specific case manager who will discuss treatment, monitor
progress and individualize care.
Transplants (Transplanting
Health)
For any of your health concerns, 24 hours a day, 7 days a week, you
may
call 1-800-922-1154 Ext. 734 or 813 and talk with a case manager
who will
discuss treatment, answer questions and provide necessary
information. 37
37 Page 38 39
2002 HMO Health Ohio 38 Section 5(h)
Section 5
(h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
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
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. These services must be initiated within 90 days from
the date of the
accident. We do not cover services necessary because of
injury as a result of
chewing or biting.
Nothing.
Dental benefits
We have no other dental benefits. 38
38 Page 39 40
2002 HMO Health Ohio 39 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 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. 39
39 Page 40 41
2002 HMO Health
Ohio 40 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at
Plan pharmacies, you will
not have to file claims. Just present your identification card and pay your
copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 800/ 522-2066.
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 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:
HMO Health Ohio, P. O. Box 6018, Cleveland, Ohio 44101, Attn: HMO Member
Services. You may also
contact us by fax at 216/ 694-2910, or visit our
website
http:// www. mmoh. com .
Prescription drugs Submit your claims to: Paid Prescriptions, P. O.
Box 709, Lee Summit, MO 64063.
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. 40
40 Page
41 42
2002 HMO Health Ohio 41 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: HMO Health Ohio, P. O. Box 6018, Cleveland, Ohio 44101; 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 arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you
or your medical provider for more information. If we ask your provider, we will
send you a copy of our request go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due.
We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1990 E Street,
NW, Washington, D. C.
20415-3630.
Send OPM the following information:
A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim. 41
41 Page 42 43
2002 HMO Health
Ohio 42 Section 8
Note: You are the only person who has a right to file a
disputed claim with OPM. Parties acting as your representative,
such as
medical providers, must include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons
beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which 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/ 522-2066 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. 42
42
Page 43 44
2002
HMO Health Ohio 43 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.
If we pay second, we will determine our allowance. After the first plan
pays, we will pay either what is left of our allowance or our regular
benefit, whichever is less. We will not pay more than our allowance. If
we are the secondary payer, we may be entitled to receive payment from
your primary plan.
What is Medicare? Medicare is a Health Insurance Program for:
-People 65 years of age and older.
-Some people with disabilities, under
65 years of age.
-People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
-Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered
employment, you should be able to qualify for premium-free
Part A
insurance. (Someone who was a Federal employee on January
1, 1983 or since
automatically qualifies.) Otherwise, if you are age 65
or older, you may be
able to buy it. Contact 1-800-MEDICARE for
more information.
-Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for
Medicare, you may have choices in how you get
your health care. Medicare +
Choice is the term used to describe the
various health plan choices
available to Medicare beneficiaries. The
information in the next few pages
shows how we coordinate benefits with
Medicare, depending on the type of
Medicare managed care plan you
have.
The Original Medicare Plan The Original Medicare Plan (Original
Medicare) is available everywhere in (Part A or Part B) 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. 43
43 Page 44 45
2002 HMO Health Ohio 44 Section 9
When you are
enrolled in this Plan and Original Medicare, you still need
to follow the
rules in this brochure for us to cover your care. Your Plan
PCP must
continue to authorize your care.
We will waive some copayments. (see page 46)
(Primary payer chart
begins on next page.) 44
44 Page 45 46
2002 HMO Health
Ohio 45 Section 9
The following chart illustrates whether "The Original
Medicare Plan" or this Plan should be the primary payer for
you
according to your employment status and other factors determined by Medicare. It
is critical that you tell us if
you or a covered family member has Medicare
coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you --or
your covered spouse --are age 65 or over and
Original Medicare This Plan
1) Are an active employee with the
Federal government (including
when you or a family member are eligible for
Medicare solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB
b) Or, the position is not excluded from FEHB
Ask your employing office
which of these applies to you.
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for
Part B
services)
(for other
services)
6) Are a former Federal employee receiving
Workers' Compensation
and the Office of Workers' Compensation Programs has
determined
that you are unable to return to duty,
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare based on end
stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD
coordination period and are
still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary for
you under another provision,
C. When you or a covered family member have FEHB and
1) Are
eligible for Medicare based on disability, 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. 45
45
Page 46 47
2002
HMO Health Ohio 46 Section 9
Claims process when you have the Original
Medicare Plan --You probably will never have to file a claim form when you
have both our Plan and Medicare.
When we are the primary payer, we process
the claim first.
When Original Medicare is the primary payer, Medicare
processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will
not need to do anything. To find out if you need to do something
about
filing your claims, call us at 800/ 522-2066, or visit
our website http://
www. mmoh. com.
We waive some costs when you have the Original Medicare Plan --When
Original Medicare is the primary payer, we will waive some out-of-
pocket
costs, as follows:
Our office visit copays
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 .
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. 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. 46
46 Page 47 48
2002 HMO Health Ohio 47 Section 9
If you do
not enroll in If you do not have one or both Parts of Medicare, you can
still be covered Medicare Part A or Part B under the FEHB Program. We
will not require you to enroll in Medicare
Part B and, if you can't get
premium-free Part A, we will not ask you to
enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about
TRICARE
coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the
Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first. 47
47 Page 48 49
2002 HMO Health Ohio 48 Section 9
When other
Government agencies We do not cover services and supplies when a local,
State, are responsible for your care or Federal Government agency
directly or indirectly pays for them.
When others are responsible
When you receive money to compensate you for 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. 48
48 Page 49 50
2002 HMO Health
Ohio 49 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial Care Treatment or services that are mainly to
help the patient with daily living activities
Experimental or A drug, device or medical treatment or procedure is
experimental or investigational services investigational:
If the
drug or device does not have required Food and Drug Administration (FDA)
approval.
If reliable evidence shows that the drug, device, medical
treatment or procedure is the subject of on-going phase I, II, III clinical
trials or is
under study to determine maximum tolerated does, toxicity,
safety,
efficacy, or efficacy as compared with the standard means of
treatment or
diagnosis.
Group Health Coverage Health care coverage that a member is eligible
for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies.
Medical necessity A service, supply or Prescription Drug that is
required to diagnose or treat a Condition and which HMO Health Ohio determines
is:
appropriate with regard to the standards of good medical practice;
not primarily for your convenience or the convenience of a Provider; and
the most appropriate supply or level of service which can be safely provided to
you.
When applied to the care of an Inpatient, this means that your medical
symptoms or condition requires that the services cannot be safely or
adequately provided to you as an Outpatient. When applied to
Prescription Drugs, this means the Prescription Drug is cost effective
compared to alternative Prescription Drugs, which will produce
comparable effective clinical results.
Plan Allowance The amount a Contracting Institutional Provider or a
Participating Professional Provider has agreed with HMO Health Ohio to accept as
payment in full for Covered Services.
Us/ We Us and we refer to HMO Health Ohio.
You You refers
to the enrollee and each covered family member. 49
49
Page 50 51
2002
HMO Health Ohio 50 Section 11
Section 11. FEHB facts
No pre-existing
condition We will not refuse to cover the treatment of a condition that you
had limitation before you enrolled in this Plan solely because you had
the condition
before you enrolled.
Where you can get information
See www. opm. gov/ insure. Also, your employing or retirement office
about enrolling in the can answer your questions, and give you a Guide
to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases,
cannot change your enrollment status without information from
your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or
retirement office authorizes
coverage for. Under certain circumstances,
you may also continue coverage
for a disabled child 22 years of age or
older who is incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from
your coverage for any reason, including divorce, or when your child
under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 50
50 Page
51 52
2002 HMO Health Ohio 51 Section 11
When benefits and The benefits in this brochure are effective on
January 1. If you joined premiums start this Plan during Open Season, you
coverage begins on the first day of
your first pay period that starts on or
after January 1. Annuitants'
coverage and premiums begin on January 1. If
you joined at any other
time during the year, your employing office will
tell you the effective
date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and the
Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you
may be
eligible for other forms of coverage, such as Temporary Continuation
of
Coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary
Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not
coverage continue to get benefits under your
former spouse's enrollment. But, you may be eligible for your own FEHB coverage
under the spouse equity
law. If you are recently divorced or are anticipating a divorce, contact
your ex-spouse's employing or retirement office to get RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.
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. 51
51 Page
52 53
2002 HMO Health Ohio 52 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 You may be entitled to continued coverage
through the Health Insurance Group Health Plan Coverage Portability and
Accountability Act of 1996 (HIPAA). This Federal law
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.
Get OPM pamphlet RI 79-27, Temporary Continuation of Coverage
(TCC) under
the FEHB Program. It highlights 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 it has
information about Federal and State agencies you can
contact for more
information. 52
52 Page
53 54
2002 HMO Health Ohio 53
Long Term Care Insurance
Long Term Care Insurance Is Coming Later
in 2002!
The Office of Personnel Management (OPM) will sponsor a
high-quality long term care insurance program
effective in October 2002. As
part of its educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or
injury, or an
age-related disease such as Alzheimer's.
LTC insurance can provide broad,
flexible benefits for nursing home care, care in an assisted living facility,
care in your home, adult day
care, hospice care, and more.
Welcome to the club! 76% of Americans believe they will never need long
term care, but
the facts are that about half of them will. And it's not just
the old
folks. About 40% of people needing long term care are under age
65. They may need chronic care due to a serious accident, a stroke,
or
developing multiple sclerosis, etc.
We hope you will never need long term
care, but everyone should have a plan just in case.
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?
Im healthy. I wont need
long term care. Or, will I?
Is long term care expensive?
But wont my FEHB plan,
Medicare or
Medicaid cover
my long term care?
When will I get more informatio
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 53
53 Page 54 55
2002 HMO Health Ohio 54 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 31 Allergy tests 18
Allogenic (donor) bone marrow
transplant 27
Alternative treatment 23
Ambulance 30,32
Anesthesia 27
Autologous bone marrow
transplant
27
Biopsies 24 Blood and blood plasma 15,28
Breast cancer screening 15
Casts 29
Changes for 2001 8
Chemotherapy 19
Childbirth 17
Chiropractic 23
Cholesterol tests
15
Claims 40
Colorectal cancer screening 15
Congenital anomalies 24
Contraceptive devices and drugs
17
Coordination of benefits 43
Covered charges 9
Covered providers 9
Crutches 22
Definitions
49 Dental care 38
Diagnostic services 14,34
Disputed claims review 41
Donor expenses
(transplants) 27
Dressings 22,28
Durable medical equipment
(DME) 22
Educational classes and programs 23
Effective date of enrollment 51
Emergency 31
Experimental or investigational
49
Eyeglasses 21
Family
planning 17
General Exclusions 39
Hearing services 20
Home health services 23
Hospice care 30
Home nursing care 23
Hospital 10,28
Immunizations 15,16 Infertility 17
Inhospital physician care 24
Inpatient Hospital Benefits 28
Insulin
36
Laboratory and pathological services 15
Machine diagnostic tests 15 Magnetic Resonance Imagings
(MRIs) 15
Mammograms 15
Maternity Benefits 17
Medicaid 47
Medically
necessary 49
Medicare 43
Members 50
Mental Conditions/ Substance
Abuse Benefits 33
Newborn care 17 Nurse Midwife 17
Occupational therapy 20 Office visits 14
Oral and maxillofacial
surgery 26
Orthopedic devices 22 Out-of-pocket expenses 12
Outpatient
facility care 29 Oxygen 29
Pap test 15
Physical examination 15 Physical therapy 20
Physician 9 Precertification
34
Preventive care, adult 15 Preventive care, children
16 Prescription
drugs 35
Preventive services 15,16 Prostate cancer screening
15
Prosthetic devices 22
Psychologist 33 Radiation therapy 19
Renal
dialysis 19 Room and board 28
Skilled nursing facility care 30
Smoking cessation 23,36 Speech therapy 20
Sterilization procedures 17
Subrogation 48
Substance abuse 34 Surgery 24
Anesthesia 27 Oral 26
Outpatient 24 Reconstructive 25
Syringes 36 Temporary
continuation of
coverage 51-52 Transplants 27
Vision services
21 Well child care 16
Wheelchairs 22 Workers' compensation 47
X-rays 15 54
54 Page
55 56
2002 HMO Health Ohio 55 Summary
Summary of benefits for the HMO Health Ohio 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 14-
Services provided by a hospital:
Inpatient
................................................................................................
Outpatient..............................................................................................
Nothing
Nothing for outpatient hospital or
ambulatory surgical center
28
29
Emergency benefits:
In-area
..................................................................................................
Out-of-area...........................................................................................
$50 per hospital emergency room
visit, nothing per urgent care
center
visit for services that are
covered benefits of this Plan. If
the
emergency results in
admission to a hospital, the
emergency care copay
is waived.
31-
32
32
Mental health and substance abuse
treatment......................................... Regular cost sharing
33-
34
Prescription
drugs......................................................................................
$10 copay for generic drugs
$20 copay for name brand drugs
$20 copay for
generic drugs mail
order
$40 copay for name brand drugs
mail order
35-
36
Dental
Care............................................................................................
Accidental injury benefit; you
pay nothing. 38
Vision
Care............................................................................................
Every two years, one refraction;
$10 copay per office visit 21
Special features: Disease Management Programs; Heart Sense, Babylink, Breathe
Easy, Transplant Health 37
Protection against catastrophic costs
(your
out-of-pocket maximum)
............................................................
Your out-of-pocket expenses for
benefits under this Plan are limited
to the stated copayments for a few
benefits.
12 55
55 Page
56
2002 HMO Health Ohio 56 Rates
2002 Rate Information
for
HMO Health Ohio
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 L41 $96.60 $32.20 $209.30 $69.77 $114.31 $14.49
Self and
Family L42 $223.41 $106.04 $484.06 $229.75 $263.75 $65.70 56