Serving: Tallahassee, Florida area
Enrollment in this Plan is
limited. You must live or work in our Geographic service area
to enroll. See
page 5 for requirements.
Enrollment codes for this Plan:
EA1 Self Only
EA2 Self and Family
2002
For changes
in benefits
see page 6.
RI 73-197
August 14, 2001 -June 26, 2003
This Plan has "Excellent"
accreditation
from NCQA. See the 2002 Guide for
more information on
NCQA. 1
1 Page 2 3
2 2002 Capital Health Plan
Table of
Contents
Introduction
.........................................................................................................................................................................
4
Plain Language
......................................................................................................................................................................
4
Inspector General advisory:
..................................................................................................................................................
4
Section 1. Facts about this HMO plan
.............................................................................................................................
5
How we pay providers
....................................................................................................................................
5
Who provides my health care?
.......................................................................................................................
5
Your Rights
.....................................................................................................................................................
5
Service Area
....................................................................................................................................................
5
Section 2. How we change for 2002
................................................................................................................................
6
Program-wide changes
...................................................................................................................................
6
Changes to this Plan
.......................................................................................................................................
6
Section 3. How you get care
............................................................................................................................................
7
Identification cards
.........................................................................................................................................
7
Where you get covered care
...........................................................................................................................
7
Plan providers
....................................................................................................................................
7
Plan facilities
......................................................................................................................................
7
What you must do to get covered care
...........................................................................................................
7
Primary care
.......................................................................................................................................
7
Specialty care
.....................................................................................................................................
8
Hospital care
.......................................................................................................................................
9
Circumstances beyond our control
...............................................................................................................
10
Services requiring our prior approval
...........................................................................................................
10
If you are referred to a specialist
....................................................................................................................
9
Section 4. Your costs for covered services
....................................................................................................................
10
Copayments
......................................................................................................................................
10
Deductible
........................................................................................................................................
10
Coinsurance
......................................................................................................................................
10
Your out-of-pocket maximum
......................................................................................................................
10
Section 5. Benefits
.........................................................................................................................................................
11
Overview
.......................................................................................................................................................
11
(a) Medical services and supplies provided by physicians and other health
care professionals ............. 12
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ......... 22
(c)
Services provided by a hospital or other facility, and ambulance services
........................................ 26
(d) Emergency services/
accidents
............................................................................................................
29
(e) Mental health and substance abuse benefits
.......................................................................................
31
(f) Prescription drug benefits
...................................................................................................................
33
(g) Special features
...................................................................................................................................
36
(h) Dental benefits
....................................................................................................................................
37
Table of Contents 2
2 Page 3 4
3 2002 Capital
Health Plan
Section 6. General exclusions things we don't cover
...............................................................................................
38
Section 7. Filing a claim for covered services
...............................................................................................................
39
Section 8. The disputed claims process
.........................................................................................................................
40
Section 9. Coordinating benefits with other coverage
..................................................................................................
42
When you have...
Other health coverage
......................................................................................................................
42
Original Medicare
............................................................................................................................
42
Medicare managed care plan
...........................................................................................................
44
TRICARE/ Workers' Compensation/ Medicaid
.............................................................................................
45
Other Government agencies
.........................................................................................................................
45
When others are responsible for injuries
......................................................................................................
45
Section 10. Definitions of terms we use in this
brochure................................................................................................
46
Section 11. FEHB facts
....................................................................................................................................................
47
Coverage information
...................................................................................................................................
47
No pre-existing condition limitation
..............................................................................................
47
Where you get information about enrolling in the FEHB Program
.............................................. 47
Types of coverage
available for you and your family
.................................................................... 47
When benefits and premiums start
..................................................................................................
47
Your medical and claims records are confidential
.......................................................................... 48
When you retire
..............................................................................................................................
48
When you lose benefits
.................................................................................................................................
48
When FEHB coverage ends
............................................................................................................
48
Spouse equity coverage
..................................................................................................................
48
Temporary Continuation of Coverage
(TCC).................................................................................
48
Converting to individual coverage
..................................................................................................
49
Getting a Certificate of Group Health Plan
Coverage.................................................................... 49
Long term care insurance is coming later in 2002
.......................................................................................
50
Index
....................................................................................................................................................................................
52
Summary of benefits
...........................................................................................................................................................
55
Rates
......................................................................................................................................................................
Back cover
Table of Contents 3
3 Page 4 5
4 2002 Capital
Health Plan
Introduction
Capital Health Plan, 2140 Centerville
Place, Tallahassee, Florida 32308
This brochure describes the benefits
of Capital Group Health Services of Florida, Inc., d. b. a. Capital Health Plan
under
our contract (CS 2034) 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 55. 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 Capital Health Plan.
We limit acronyms to
ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the
Office of Personnel Management. If we use others, we tell you what they mean
first.
Our brochure and other FEHB plans brochures have the same format
and similar descriptions to help you compare
plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit OPMs
Rate Us feedback area at
www.opm.gov/insure or e-mail OPM at fehbwebcomments@opm.gov. You may also write
to
OPM at the Office of Personnel Management, Office of Insurance Planning
and Evaluation Division, 1900 E Street, NW
Washington, DC 20415-3650.
Inspector General Advisory
Fraud increases the cost of health care
for everyone. If you suspect that a
physician, pharmacy, or hospital has
charged you for services you did not
receive, billed you twice for the same
service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error. If
the provider does not resolve the matter, call us at 850/ 383-3311 and explain
the situation.
If we do not resolve the issue, call or write
THE
HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of
Personnel Management
Office of the Inspector General Fraud Hotline
1900
E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate anyone
who uses an ID card if the person tries to obtain
services for someone who
is not an eligible family member, or is no longer
enrolled in the Plan and
tries to obtain benefits. Your agency may also take
administrative action
against you.
Introduction/ Plain Language/ Advisory
Stop health care fraud! 4
4 Page 5 6
5 2002 Capital
Health Plan Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other
providers that contract with
us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the
copayments, and coinsurance
described in this brochure. When you receive emergency services from non-Plan
provid-ers,
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 employ physicians and contract with
individual physicians, medical groups, and hospitals to provide the benefits in
this brochure. These Plan providers accept a negotiated payment from us, and
you will only be responsible for your
copayments or coinsurance when you
follow Plan procedures for accessing care.
Who provides my health care?
Capital Health Plan, as a mixed model
prepaid direct service health plan, offers members a choice of primary care
physicians at many different locations in the greater Tallahassee area.
Members choose a primary care physician and
receive their basic care
(prevention and treatment) from this doctor. The Plan offers internal medicine
doctors, family
practice doctors and pediatricians as primary care
physicians. Laboratory tests and X-rays, as well as referrals to
specialists
and for hospital services, are authorized and coordinated by your primary care
physician.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information about
us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types of
information that we must make available to you.
Some of the required information is listed below.
We operate under a State of Florida Certificate of Authority and are
federally qualified under Title XIII, PHSA.
19 years in existence
Not-for-Profit Corporation
If you want more information about us, call 850/ 383-3311, or write to
Capital Health Plan, 2140 Centerville Place,
Tallahassee, FL 32308. You may
also contact us by fax at 850/ 383-3590 or visit our website at www.
capitalhealth. com.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. This is where our providers practice. Our service
area is:
Gadsden, Jefferson, Leon and Wakulla counties.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we
will pay only for emergency
care benefits. We will not pay for any other health care services out of our
service area
unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents
live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-
service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do
not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 5
5 Page 6
7
6 2002 Capital Health Plan Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5
Benefits. Also, we edited and clarified language throughout the
brochure; any language change not shown here is a
clarification that does
not change benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
We changed speech therapy benefits by
removing the requirement that services must be required to restore func-tional
speech. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a)) We now cover certain intestinal transplants. (Section 5( b))
Your share of the non-Postal premium will increase by 21.3% for Self Only
or 28.6% for Self and Family.
We clarified the Preventive care, adult
benefits by removing the entry for blood lead level testing for adults because
it is a test more typically done for children. (Section 5( a))
We clarified the durable medical equipment benefit to show that we cover a
comprehensive range of items. (Section 5( a)) 6
6
Page 7 8
7 2002
Capital Health Plan Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it whenever you
receive services from a Plan provider, or fill a
prescription at a Plan
pharmacy. Until you receive your ID card, use your
copy of the Health
Benefits Election Form, SF-2809, your health benefits
enrollment
confirmation (for annuitants), or your Employee Express
confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 850/
383-
3311.
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.
You must select a primary care physician to direct all of your
medical
care. Capital Health Plan offers you a choice of primary care
physicians
at many different locations in the greater Tallahassee area.
We list Plan providers in the provider directory, which we update
frequently. The list is also on our website, www. capitalhealth. 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
frequently. The list is also on
our website, www. capitalhealth. com.
Primary care physicians offices in
our two health centers at Centerville
Road and Governors Square
Boulevard also offer the convenience of lab,
x-ray, vision care and/ or
pharmacy services.
It depends on the type of care you need. First, you and each family
member must choose a primary care physician. This decision is impor-tant
since your primary care physician provides or arranges for most of
your
health care. Capital Health Plan's Directory of Physicians and
Service
Providers lists the primary care physicians and their office
locations. You can make your selections from this list. This directory is
provided to all new members at the time of enrollment and upon request
by calling CHP's Member Services Department at 850/ 383-3311 or on
our
website at www. capitalhealth. com. This directory is subject to
change and
is updated on a regular basis. On occasion, some physicians
may not accept
new patients. CHP's Member Services staff will gladly
assist you with your
selection of a primary care physician.
Primary care Your primary care physician can be a family
practitioner, internist or
pediatrician. Your primary care physician will
provide most of your
health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
What you must do
to get covered care 7
7
Page 8 9
8 2002
Capital Health Plan Section 3
Specialty care Your primary care
physician will refer you to a specialist for needed care.
When you receive a
referral from your primary care physician, you must
return to the primary
care physician after the consultation, unless your
primary care physician
authorized a certain number of visits without
additional referrals. The
primary care physician must provide or
authorize all follow-up care. Do not
go to the specialist for return visits
unless your primary care physician
gives you a referral. However, you
may see a Plan optometrist, chiropractor,
or podiatrist for covered
services without a referral. Female members may
also see a Plan
gynecologist for an annual routine exam only without a
referral. You may
see a Plan dermatologist for up to five visits per year
without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic,
complex, or serious
medical condition, your primary care physician
will develop a treatment plan
that allows you to see your specialist
for a certain number of visits
without additional referrals. Your
primary care physician will use our
criteria when creating your
treatment plan (the physician may have to get an
authorization or
approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment
from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you
enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days
after you receive
notice of the change. Contact us or, if we drop out
of the Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days. 8
8 Page 9 10
9 2002 Capital
Health Plan Section 3
1) We process routine visits to specialists
through an automated system.
You can confirm your referral and obtain your
referral number within 3
to 5 working days by dialing 850/ 383-3530 and
following the instruc-tions
given.
2) Once you receive authorization, your primary care physician's
staff will schedule your appointment with the specialist. Many times,
however, your physician will ask you to schedule the appointment
yourself. If you schedule your own appointment, please allow five (5)
working days for the necessary records to arrive at the specialist's office.
If your appointment is scheduled within five (5) working days from the
date your primary care physician refers you, you will want to make
arrangements to hand-carry any required records or x-rays.
3) Your referral to the specialist will be for a specific number of
visits
and is valid for sixty (60) days.
4) If the specialist recommends additional services, office visits,
diagnostics tests, surgery, hospitalization, or other specialty care, you
MUST call your primary care physician for authorization before such
services are scheduled.
5) However, routine lab tests do not require authorization from your
primary care physician. The physician ordering the lab tests will give you
appropriate lab orders and directions.
6) X-rays may be done at Capital Health Plan's x-ray departments
located at 2140 Centerville Place in Tallahassee or 1491 Governors
Square Boulevard in Tallahassee, unless other arrangements have been
made by your primary care physician.
7) If you have any questions regarding the referral system, please
call
CHP's Member Services Department at 850/ 383-3311.
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 850/ 383-3311. If you
are
new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center;
or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized person.
If you are referred to a specialist 9
9
Page 10 11
10
2002 Capital Health Plan
Circumstances beyond our control
Under certain extraordinary circumstances, such as natural disasters, we
may have to delay your services or we may be unable to provide them.
In
that case, we will make all reasonable efforts to provide you with the
necessary care.
Services requiring our
prior approval Your primary care physician
has authority to refer you for most services.
For certain services (such as
sending you to a hospital, referring you to a
specialist, or recommending
follow-up care), 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 practices.
We call this review and approval process utilization management. Your
physician must obtain authorization for services such as
:
specialty care
hospital care
diagnostic services
all surgeries
Mental Health/ Substance Abuse care
Growth Hormone Therapy
Section 4. Your costs for covered services
You must share the cost
of some services. You are responsible for:
Copayments A copayment
is a fixed amount of money you pay to the provider, facility, pharmacy, etc.,
when you receive services.
Example: When you see your primary care physician you pay a co-payment
of
$10 per office visit and when you go in the hospital, you pay
$100 per
admission.
Deductible We do not have a deductible.
Coinsurance We do not have
coinsurance.
Your catastrophic protection
out-of-pocket maximum
for copayments
Section 4
Your out-of-pocket maximum for benefits under this Plan is limited to
$1,500/ Self Only or $3,000/ Self and Family per year. You must pay the
copayment when you receive services. You are responsible for keeping
records and submitting to the Plan when you reach the maximums. 10
10 Page 11 12
11 2002 Capital Health Plan
Inpatient
hospital
Outpatient hospital or ambulatory surgical center
Section 5. Benefits OVERVIEW
(See page 6 for how our benefits
changed this year and page 55 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at
the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us at
850/ 383-3311
or at our website at www. capitalhealth. com.
(a) Medical services and supplies provided by physicians and other health
care professionals ................................ 12-21
Section 5
Diagnostic and treatment services
Lab, X-ray,
and other diagnostic tests
Preventive care, adult
Preventive care,
children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational
therapies
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ............................. 22-25
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/
tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
........................................................... 26-28
Extended
care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance
(d) Emergency services/ accidents
...............................................................................................................................
29-30
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
.........................................................................................................
31-32
(f) Prescription drug benefits
.....................................................................................................................................
33-35
(g) Special features
..........................................................................................................................................................
36
TDD Line: 850/ 383-3534
(h) Dental benefits
...........................................................................................................................................................
37
Summary of
benefits............................................................................................................................................................
55 11
11 Page 12
13
12 2002 Capital Health Plan
Section 5
(a). Medical services and supplies provided by physicians and other
health
care professionals
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 informa-tion
about how cost sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office $10 per visit
Office medical
consultations
Second surgical opinion
Professional services of physicians
In an urgent care center $15
per visit
Professional services of physicians
During a hospital stay
Nothing
In a skilled nursing facility
At home
Section 5( a)
I
M
P
O
R
T
A
N
T
I
M
P
O
R
T
A
N
T 12
12 Page 13 14
13 2002 Capital Health Plan Section 5( a)
Preventive Care-Adult continued on next page.
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests Nothing
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Preventive care, adult You pay
Routine screenings, such as $10 per
office visit
Blood pressure
Total Blood Cholesterol -once every
three years
Colorectal Cancer Screening, including
Fecal occult
blood test
Sigmoidoscopy, screening -every five years starting at age 50
$10 per office visit
Prostate Specific Antigen (PSA test) -one annually for men age 40 and
older $10 per office visit
Routine pap test $10 per office visit
Note: The office visit is covered
if pap test is received on the same day;
see Diagnosis and Treatment, above.
13
13 Page 14 15
14 2002 Capital Health Plan Section 5( a)
Preventive care, adult (Continued) You pay
Routine
mammogram-covered for women age 35 and older, as follows: Nothing
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
Not covered: Physical exams required for obtaining or continuing All
charges
employment or insurance, attending schools or camp, or travel.
Routine immunizations, limited to: $10 per office visit
Tetanus-diphtheria (Td) booster -once every 10 years, ages 19 and
over
(except as provided for under Childhood immunizations)
Influenza/
Pneumococcal vaccines, annually, age 65 and over
Preventive care, children You pay
Childhood immunizations
recommended by the American $10 per visit Academy of Pediatrics
Well-child care charges for routine examinations, immunizations
and
care (up to age 22)
Examinations, such as: $10 per visit
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) 14
14 Page 15 16
15 2002 Capital
Health Plan Section 5( a)
Maternity care You pay
Complete
maternity (obstetrical) care, such as: Copayments waived
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in
mind:
You do not need to precertify your normal delivery; see page 8 for
other circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular
delivery
and 96 hours after a cesarean delivery. We will extend
your inpatient stay
if medically necessary.
We cover routine nursery care of the newborn child during the
covered
portion of the mother's maternity stay. We will cover other
care of an
infant who requires non-routine treatment only if we
cover the infant under
a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as $100 per
hospital admission
for illness and injury. See Hospital benefits (Section
5c) and
Surgery benefits (Section 5b).
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning You pay
A broad range of voluntary family planning services, limited to: $10 per
office visit
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Injectable
contraceptive drugs (such as Depo provera)
Intrauterine devices
(IUDs)
Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
Not covered: reversal of voluntary surgical sterilization, genetic All
charges
counseling. 15
15 Page 16 17
16 2002 Capital
Health Plan Section 5( a)
You pay Nothing for the
radiation therapy.
Infertility services You pay
Diagnosis and treatment of
infertility, such as: $10 per visit
Artificial insemination:
intravaginal insemination (IVI)
Not covered: All charges
Fertility drugs
Assisted reproductive technology (ART) procedures, such
as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote
ZIFT
zygote transfer
Services and supplies related to excluded ART
procedures
Cost of donor sperm
Cost of donor egg
Allergy care You pay
Testing and treatment $10 per visit
Allergy injection
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy All charges
desensitization
Treatment therapies You pay
Chemotherapy and radiation therapy
$10 per visit to a physician
office
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under Organ/
Tissue
Transplants on page 24.
Respiratory and inhalation therapy
Dialysis -Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy -Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
We
will only cover GHT when we preauthorize the treatment.
Your primary care
physician will request preauthorization. Ask us to
authorize GHT before you
begin treatment; otherwise, we will only
cover GHT services from the date
you submit the information. If we
determine GHT is not medically necessary,
we will not cover the GHT
or related services and supplies. See Services
requiring our prior
approval in Section 3. 16
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17 2002 Capital Health Plan Section 5( a)
Physical and occupational therapies You pay
Up to two
consecutive months per condition for the services of each of the following:
-----qualified physical therapists and -----occupational therapists
Note: We only cover therapy to restore bodily function when there has been
a total or partial loss of bodily function due to illness or injury.
Not covered:
long-term rehabilitative therapy All charges
exercise programs
Cardiac rehabilitation following a
heart transplant, bypass surgery or a myocardial infarction
Speech therapy You pay
Up to two consecutive months per
condition
of speech therapists Nothing per visit during
covered hospital
admission
Not covered:
Speech therapy beyond two consecutive months per
condition.
$10 per office visit
$10 per outpatient visit
$10 per office visit
Nothing per visit during
covered hospital
admission 17
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18 2002 Capital Health Plan
Section 5( a)
Hearing services (testing, treatment, and supplies) You
pay
Hearing testing for children through age 17 (see Preventive $10
per visit
care, children)
Not covered: All charges
all other hearing testing
hearing aids, testing and examinations for them
Vision services (testing, treatment, and supplies) You pay
One
pair of eyeglasses or contact lenses to correct an impairment $10 per office
visit
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts) The initial pair of eyeglasses is limited to
the
cost of the lens and up to $25 for the frame and obtained only
at CHP's Eye
Care Centers.
Eye exam to determine the need for vision correction for children
through age 17 (see Preventive care, children)
Annual eye refractions
Note: See Preventive care, children for eye
exams for children
Not covered: All charges
Eyeglasses, except initial pair
following cataract surgery or an
accidental injury which requires corrective
lenses
An examination and fitting for contact lenses. CHP Eye Care
offers
this service on a fee for service basis.
Contact lenses
Replacements for any lenses provided during the same calendar year
Eye exercises
Orthoptics
Radial
keratotomy and other refractive surgery 18
18
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2002 Capital Health Plan Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
$10 per visit
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe
inserts.
Not covered: All charges
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)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes to replace natural limbs and eyes lost Nothing
Braces and covered prosthetic devices (except cardiac pacemaker)
are
limited to the first such item prescribed for each specific
medical
condition.
Oxygen for home use including equipment is covered.
Cardiac pacemakers
Breast prostheses and surgical bras following
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.
Not covered: All charges
All other prosthetic devices, including
braces used during athletic
activities, are excluded.
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose,
and other
supportive devices 19
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Durable medical equipment (DME) You pay
Home health
services You pay
Home health care ordered by a Plan physician and
provided by a Nothing registered nurse (R. N.), licensed practical nurse (L. P.
N.), licensed
vocational nurse (L. V. N.), or home health aide. The Plan
physician
will periodically review the program for continuing
appropriateness
and need.
Services include oxygen therapy, intravenous therapy and medications.
Not covered: All charges
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.
Durable Medical Equipment which has been prescribed by your plan physician
and which has been authorized by CHP as a Covered Service. CHP reserves the
right to rent or purchase the most cost-effective DME which meets the
Member's needs. Maximum payment by CHP for durable medical equipment
will be up to $2,500 annually for a covered person.
This benefit covers a wide variety of durable medical equipment and
continu-ing
development of patient care equipment makes it impractical to
provide a
complete listing of covered durable medical equipment such as:
Crutches Canes
Manual wheelchairs Basic hospital beds
Walkers
Not covered:
Cost to repair or replace DME except when
authorized by CHP DME which has not been authorized by CHP.
Durable
Medical Equipment which is for patient convenience and/ or comfort
Water
therapy devices such as Jacuzzis, hot tubs, swimming pools or whirlpools
Exercise and massage equipment Electric scooters and motorized wheelchairs
Hearing aids Dental braces, air conditioners, humidifiers, water
purifiers,
hypo-allergenic pillows, mattresses or waterbeds, emergency alert
equipment.
This exclusion include but is not limited to:
Modifications to motor vehicles
Modifications to homes, such as wheelchair lifts or ramps
Escalators
or elevators, stair glides, handrails, heat appliances and dehumidifiers
Section 5( a)
All charges over $2500
per person per contract year
All charges 20
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21 2002 Capital Health Plan
Chiropractic You pay
Manipulation of the spine and
extremities $10 per office visit Adjunctive procedures such as ultrasound,
electrical muscle
stimulation, vibratory therapy, and cold pack application
Not covered:
Services that maintain rather than improve a
physical function,
Services that we determine will not result in
significant improvement of
the member's condition within a 62-day period.
Educational classes and programs You pay
Coverage is limited to:
Nothing
Smoking Cessation
Diabetes self-management
Newborn
care
Childhood Safety and CPR
CPR and Basic Life Support Training
Adult Asthma Management
Pediatric Asthma Management
All charges
Section 5( a)
Alternative Care You pay
No Benefit All
charges 21
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22 2002 Capital Health Plan
Section 5( b)
You pay nothing for physician
services at a hospital
or
outpatient surgery center.
Section 5 (b). Surgical and anesthesia services provided by physicians and
other
health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating
benefits
with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other
health
care professional for your surgical care. Look in Section 5 (c) for
charges associ-ated
with the facility (i. e., hospital, surgical center,
etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES.
Please refer to the precertification information shown in Section
3 to be
sure which services require precertification and identify which surgeries
require precertification.
Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
$10 per office visit
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.
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23 2002 Capital Health Plan Section 5( b)
Reconstructive surgery continued on next page.
Surgical procedures (Continued) You pay
Voluntary sterilization
Treatment of burns $10 per office visit
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.
Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care.
Reconstructive surgery You pay
Surgery to correct a functional
defect $10 per office visit
Surgery to correct a condition caused by
injury or illness if:
the condition produced a major effect on the
member's appearance
and
the condition can reasonably be expected to be corrected by
such
surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
All stages of
breast reconstruction surgery following a mastectomy,
such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure. 23
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24 2002 Capital
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Organ/ tissue transplants continued on next page.
Section 5(
b)
Reconstructive surgery ( Continued) You pay
Not covered: All
charges
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
Oral and maxillofacial surgery You pay
Oral surgical procedures,
limited to: $10 per visit
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.
Surgical treatment of TMJ (Related dental care for TMJ is excluded)
Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as
the periodontal membrane, gingiva, and alveolar bone)
Organ/ tissue transplants You pay
Limited to: Nothing
Cornea
Heart
Heart/ lung Kidney
Kidney/ Pancreas Liver
Lung:
Single-Double Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and
peripheral stem
cell support) for the following conditions: acute
lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced
non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple
myeloma; epithelial
ovarian cancer; and testicular, mediastinal,
retroperitoneal and
ovarian germ cell tumors
Intestinal transplants
(small intestine) and the small intestine with the liver or small intestine with
multiple organs such as the liver,
stomach, and pancreas 24
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25 2002 Capital
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Organ/ tissue transplants (Continued) You
pay
Nothing Limited Benefits -Treatment for breast cancer, multiple
myeloma, and
epithelial ovarian cancer must be 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.
Not covered: All charges
Implants of artificial organs
Transplants not listed as covered
Anesthesia You pay
Professional services provided in -Nothing
Hospital (inpatient)
Professional services provided in -Nothing
Hospital outpatient
department
Skilled nursing facility
Ambulatory surgical center
Professional services provided in -$10 per visit
Office 25
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26 2002 Capital Health Plan
Section 5
(c). Services provided by a hospital or other facility, and ambulance services
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 associ-ated
with the professional charge (i. e., physicians, etc.) are covered in
Sections
5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to the precertification information shown in Section 3 to
be sure which services require precertification.
Benefit Description You pay
Inpatient hospital
Room and board,
such as $100 per admission
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.
Other hospital services and supplies, such as: Nothing
Operating, recovery, maternity, and other treatment rooms
Prescribed
drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not
donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics,
including nurse anesthetist services
Take-home items
Medical
supplies, appliances, medical equipment,
and any covered items billed by a
hospital for use
at home
Section 5( c)
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Not covered: All
charges
Custodial care
Non-covered facilities, such as nursing
homes, schools
Personal comfort items, such as telephone, television,
barber
services, guest meals and beds
Private nursing care
Outpatient hospital or ambulatory surgical center You pay
Operating, recovery, and other treatment rooms Nothing
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.
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care/ Skilled nursing facility (SNF): The Plan provides a
comprehen-Nothing
sive range of benefits for up to 60 days per admission
with subsequent
admission available 180 days from discharge date of previous
admission 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.
Not covered: Custodial care All charges
Inpatient hospital (Continued) You pay
Section 5( c) 27
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28 2002 Capital
Health Plan
Hospice care You pay
Supportive and palliative
care for a terminally ill members is Nothing
covered in the home or hospice
facility. Services include inpatient
and outpatient care, and family
counseling; these services are
provided under the direction of a Plan doctor
who certifies that the
patient is in the terminal stages of illness, with a
life expectancy of
approximately six months or less.
Not covered: Independent nursing, homemaker services All charges
Ambulance You pay
Local professional ambulance service when
medically Nothing
appropriate
Section 5( c) 28
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Section 5( d)
Section 5 (d). Emergency services/ accidents
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.
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.
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. 29
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30 2002 Capital Health Plan Section 5( d)
Benefit Description You pay
Emergency within our service area:
Emergency care at a doctor's office $15 per visit
Emergency care
at an urgent care center $15 per visit
Emergency care as an outpatient or inpatient at a hospital, $50 per visit
including doctors' services
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area You pay
Emergency care
at a doctor's office $15 per visit
Emergency care at an urgent care center
$15 per visit
Emergency care as an outpatient or inpatient at a hospital, $50 per visit
including doctors' services
Not covered: All charges
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
Ambulance You pay
Professional ambulance service when medically appropriate. Nothing
See 5(
c) for non-emergency service.
Not covered: air ambulance unless medically necessary and All charges
approved by the Plan's Medical Director. 30
30
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31
2002 Capital Health Plan
Parity
When you get our approval
for services and follow a treatment plan we approve, cost-sharing
and
limitations for Plan mental health and substance abuse benefits will be no
greater than for similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this
bro-chure.
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.
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Your cost sharing responsibili-ties
are no
greater than for other
illnesses or conditions.
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Section 5 (e). Mental health and substance abuse benefits
Benefit Description You pay
Mental health and substance abuse benefits
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.
Professional services, including individual or group therapy by $10 per
visit
providers such as psychiatrists, psychologists, or clinical
social
workers
Medication management
Diagnostic tests $10 per (visit or test)
Services provided by a hospital or other facility $100 per admission
Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, facility based intensive
outpatient treatment
Not covered: Services we have not approved. All charges
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. 31
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32 2002 Capital Health Plan
Preauthorization To be eligible to receive these benefits you
must obtain a treatment plan and follow all of the following authorization
processes. These include:
If you are referred to a specialist 1) We
process routine visits to specialists through an automated system. You can
confirm your referral and obtain your referral
number within 3 to 5 working
days by dialing 383-3530 and
following the instructions given.
2) Once you receive authorization, your primary care physician's staff
will schedule your appointment with the specialist. Many
times, however, your physician will ask you to schedule the
appointment
yourself. If you schedule your own appointment,
please allow five (5)
working days for the necessary records to
arrive at the specialist's office.
If your appointment is scheduled
within five (5) working days from the date
your primary care
physician refers you, you will want to make arrangement to
hand-carry
any required records or x-rays.
3) Your referral to the specialist will be for a specific number of
visits and is valid for sixty (60) days.
4) If the specialist recommends additional services, office visits,
diag-nostics tests, surgery, hospitalization, or other specialty care, you
MUST call your primary care physician for authorization before
such
services are scheduled.
5) However, routine lab tests do not require authorization from your
primary care physician. The physician ordering the lab tests will
give you appropriate lab orders and directions.
6) X-rays may be
done at Capital Health Plan's x-ray departments located at 2140 Centerville
Place in Tallahassee or 1491 Governors
Square Boulevard in Tallahassee, unless other arrangements have
been made
by your primary care physician.
7) If you have any questions regarding the referral system, please
call CHP's Member Services Department at 850/ 383-3311.
Limitation
Section 5( e)
We may limit your benefits if you do not obtain a
treatment plan. 32
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33 2002 Capital Health Plan
Section 5 (f). Prescription drug benefits
Here are some important
things to keep in mind about these benefits:
We cover prescribed drugs
and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits
with other coverage, including with Medicare.
There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or licensed
dentist must write the prescription.
Where you can obtain them. You
must fill the prescription at a Plan pharmacy.
We administer an open
formulary. If your physician believes a name brand product is necessary or there
is no generic available, your physician may prescribe a name brand drug from a
formulary list.
This list of name brand drugs is a preferred list of drugs that we selected
to meet patient needs at a
lower cost Brand name drugs not on the preferred
list are dispensed at a higher copay. To order a
prescription drug brochure,
call 850/ 383-3311.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor and
obtained at a Plan pharmacy will be
dispensed for up to a 30-day supply or one commercially
prepared unit (i. e.
one inhaler, one vial ophthalmic medication or insulin) you pay a $20 copay per
prescription unit or refill for any brand drug which appears on the plan's
Preferred Medication List
when generic substitution is not available and a
$7 copay per prescription unit or refill for generic
drugs. For brand drugs
not on the plan's Preferred Medication List you pay $35. If a generic drug is
available and at the request of the member or the prescribing physician a
brand name prescription is
dispensed, you pay the price difference between
the generic and name brand drug as well as the
copay for the preferred or
non-preferred brand name drug per prescription unit or refill. Prescription
refills will not be covered until at least 75 percent of the previous
prescription has been used by the
member (based on the dosage schedule
prescribed by the physician).
Prescription drug benefits begin on the next page.
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Benefit Description You pay
Section 5( f)
$20 per prescription for preferred brand
name drugs
$35 per prescription for non-preferred
brasnd prescription drugs
Note: If there is no generic equivalent
available, you will still have to
pay the
brand name copay.
Covered medications and supplies
We cover the following
medications and supplies prescribed by a $7 per prescription for generic drugs
Plan physician and obtained from a Plan Pharmacy:
Drugs and medicines that by Federal law of the United States
require a
physician prescription for their purchase
Oral and injectable contraceptive drugs
Insulin with a $7 copay charge applied to each vial
Disposable
needles and syringes needed to inject covered prescribed
medication
Diabetic supplies including test strips and glucometers at the CHP
Pharmacy
only
Drugs for sexual dysfunction
Prenatal Vitamins
Contraceptive devices
Note: We cover injectable contraceptive drugs under the Family Planning
Benefit.
Covered medications and supplies continued on next page. 34
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35 2002 Capital Health Plan
Covered
medications and supplies (Continued) You pay
Not covered: All Charges
Drugs and supplies for cosmetic purposes including appetite
suppressants
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy except for
out-of-area
emergencies
Medical supplies such as dressing and antiseptics
Nutrients and food supplements even if a physician
prescribes or
administers them
Nonprescription medicines
Smoking cessation drugs and medications, including nicotine patches
Vitamins, except prenatal vitamins
Section 5( f) 35
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36 2002 Capital
Health Plan Section 5( g)
Section 5 (g). Special features
Feature
Description
Flexible benefits 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
with draw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to
OPM review under the disputed claims process.
Services for deaf and TDD Line: 850/ 383-3534
hearing impaired
option 36
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37 2002 Capital Health Plan
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Section 5( h)
Accidental injury benefit You pay
We
cover restorative services and supplies necessary to promptly Nothing
repair
(but not replace) sound natural teeth. The need for these
services must
result from an accidental injury.
Dental benefits
We have no other dental benefits.
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Section 5 (h). Dental benefits
Here are some important things to keep
in mind about these benefits:
Please remember that all benefits are
subject to the definitions, limitations, and
exclusions in this brochure and
are payable only when we determine they are
medically necessary.
Plan dentists must provide or arrange your care.
We cover
hospitalization for dental procedures only when a nondental physical
impairment exists which makes hospitalization necessary to safeguard the
health of
the patient; we do not cover the dental procedure unless it is
described below.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits
with other coverage, including with Medicare. 37
37 Page 38 39
38 2002 Capital Health Plan Section 6
Section 6. General exclusions things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a
benefit, we will not cover it unless your Plan doctor
determines it is medically necessary to prevent,
diagnose, or treat your
illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while
you are not enrolled in this Plan;
Services, drugs, or supplies that are
not medically necessary;
Services, drugs, or supplies not required
according to accepted standards of medical, dental, or
psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be
endangered if the fetus were carried to term or when the
pregnancy is the result of an act of
rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred
from the FEHB Program. 38
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39 2002 Capital
Health Plan
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:
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 assis-tance,
call us
at 850/ 383-3311.
When you must file a claim such as for out-of-area care submit it
on
the HCFA-1500 or a claim form that includes the information shown
below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the
physician or facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of
each service or supply;
The charge for each service or supply;
A
copy of the explanation of benefits, payments, or denial from any primary payer
such as the Medicare Summary Notice (MSN);
and
Receipts, if you paid for your services.
Submit your claims to: Capital Health Plan
Post Office Box 15349
Tallahassee, FL 32317-5349
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.
Section 7
Medical, hospital and drug benefits 39
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2002 Capital Health Plan
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: Capital Health Plan, ATTN:
Grievance Coordinator, P. O. Box 15349,
Tallahassee, FL 32317-5349; and
(c) Include a statement about why you believe our initial decision was
wrong, based on specific benefit
provisions in this brochure; and
(d)
Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills,
medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our
request-go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30
days of the date the information
was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
if we did not answer that request in some way within 30 days; or
120 days
after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E
Street, NW, Washington, DC
20415-3630.
Section 8 40
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41 2002 Capital Health Plan
The Disputed Claims process (Continued)
Send OPM the
following information:
A statement about why you believe our decision was wrong, based on specific
benefit provisions in this brochure;
Copies of documents that support your
claim, such as physicians' letters, operative reports, bills, medical records,
and explanation of benefits (EOB) forms;
Copies of all letters you sent to
us about the claim;
Copies of all letters we sent to you about the claim;
and
Your daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which
claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your repre-sentative,
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
adminis-trative
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 850/
383-3311 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.
Section 8 41
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42 2002 Capital Health Plan
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 Commission-ers'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65
years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who was a Federal
employee on
January 1, 1983 or since automatically qualifies.)
Otherwise, if you are age
65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more
information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly
Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in
how you get
your health care. Medicare + Choice is the term used to describe
the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits
with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and
is the way most people get their Medicare Part A and Part B benefits
now. You may go to any doctor, specialist, or hospital that accepts
Medi-care.
The Original Medicare Plan pays its share and you pay your share.
Some things are not covered under Original Medicare, like prescription
drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your
care must continue to be authorized by your Plan primary care physician.
We will not waive any of our copayments.
(Primary payer chart
begins on next page.)
(Part A or Part B)
The Original Medicare Plan
Section 9 42
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43 2002 Capital Health Plan
A. When either you or your covered spouse are age 65 or over
and ...
Then the primary payer is...
Original Medicare This Plan
4
4
4
4
4
4 4
4
4
4
4
4
4
4
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.
Section 9
4
Primary Payer Chart
1) Are an active employee with the Federal
government (including when you
or a family member are eligible for Medicare
solely because of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when...
a) The position is excluded from FEHB,
or.....................
b) The position is not excluded from
FEHB..................
(Ask your employing office which of these applies to
you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services) (for other services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined (except for claims
that you are unable to return to duty, 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........................................................................
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. 43
43
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2002 Capital Health Plan
Claims process when you have the Original
Medicare Plan Yo u
probably will never have to file a claim form when
you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When
Original Medicare is the primary payer, Medicare processes your claim first. In
most cases, your claims will be coordinated
automatically and we will pay
the balance of covered charges. You
will not need to do anything. To find
out if you need to do some-thing
about filing your claims, call us at our
Coordination of
Benefits Office 850/ 383-3377.
We do not waive any costs when you have Medicare.
Medicare managed
care plan If you are eligible for Medicare, you may choose to enroll in and
get your
Medicare benefits from another type of Medicare+Choice plan a
Medicare managed care plan. These are health care choices (like HMOs)
in
some areas of the country. In most Medicare managed care plans, you
can only
go to doctors, specialists, or hospitals that are part of the plan.
Medicare
managed care plans provide all the benefits that Original
Medicare covers.
Some cover extras, like prescription drugs. To learn
more about enrolling in
a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE
(1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments for your
FEHB
coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed care
plan's network and/ or service area (if you use our Plan providers), but we
will not waive any of our copayments.
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
Medi-
care.
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.
Section 9 44
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45 2002 Capital Health Plan
If you do not have one or both Parts of Medicare, you can still be
covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you cant 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
settlement or other similar
proceeding that is based on a claim you
filed under OWCP or similar laws.
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 with OWCP.
Once OWCP or similar agency pays its maximum benefits
for your
treatment, we will cover your care. You must use our providers.
When you receive money to compensate you for medical or hospital
care for
injuries or illness caused by another person, you must reimburse
us for any
expenses we paid. However, we will cover the cost of
treatment that exceeds
the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subroga-tion
procedures.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State,
are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are responsible
for injuries
Section 9
If you do not enroll in
Medicare Part A or Part B 45
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46 2002 Capital Health Plan
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 10.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Custodial care means care that serves to
assist an individual in the activities of daily living, such as assistance in
walking, getting in and out
of bed, bathing, dressing, feeding, and using
the toilet, preparation of
special diets, and supervision of medication that
usually can be self-administered.
Custodial care essentially is personal
care that does not
require the continuing attention of trained medical or
paramedical
personnel. In determining whether a person is receiving
custodial care,
consideration is given to the level of care and medical
supervision
required and furnished. A determination that care received is
custodial is
not based on the patient's diagnosis, type of Condition, degree
of
functional limitation, or rehabilitation potential.
Experimental or When CHP determines that an evaluation, treatment,
therapy or device is
experimental/ investigational, it will not be covered by the Plan. CHP
makes such determinations based in part on information obtained from
the
United States Food and Drug Administration, The Florida Depart-ment
of
Health and most recently published medical literature in the
United States,
Canada or Great Britain. A consensus of opinion among
experts is sought
showing that the evaluation, treatment, therapy or
device is considered safe
and effective as compared with the standard
means for treatment or diagnosis
of the condition in question.
Medical necessity Medical necessity means, for coverage and payment
purposes, that a medical service or supply is required for the identification,
treatment, or
management of a condition, and is, in the opinion of CHP: 1)
consistent
with the symptom, diagnosis, and treatment of the Members'
condition;
2) widely accepted by the practitioners' peer group as
efficacious and
reasonably safe based upon scientific evidence; 3)
universally accepted
in clinical use such that omission of the service or
supply in these
circumstances raises questions regarding the accuracy of
diagnosis or the
appropriateness of the treatment; 4) not experimental or
investigational;
5) not for cosmetic purposes; 6) not primarily for the
convenience of the
Member, the Member's family, the physician or other
provider; and, 7)
the most appropriate level of service, care or supply
which can safely be
provided to the Member. When applied to inpatient care,
medically
necessary further means that the services cannot be safely
provided to the
Member in an alternative setting.
Us/ We Us and we refer to Capital Health Plan.
You You
refers to the enrollee and each covered family member.
Investigational services
Section 10 46
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47 2002 Capital Health Plan
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had before you enrolled in
this Plan solely because you had the condition
before you enrolled.
Where you can get information See www.opm.gov/insure. Also, your
employing or retirement office can answer your questions, and give you a Guide
to Federal Employees
Health Benefits Plans, brochures for other plans, and
other materials you
need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, your spouse, and your unmarried dependent
children under age 22,
including any foster children or stepchildren your
employing or retire-ment
office authorizes coverage for. Under certain
circumstances, you
may also continue coverage for a disabled child 22 years
of age or older
who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from
your coverage for any reason, including divorce, or when your child
under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.
When benefits and
premiums start The benefits in this brochure are
effective on January 1. If you joined
this Plan during Open Season, your
coverage begins on the first day of
your first pay period 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.
limitation
about enrolling in the
FEHB Program
you and your family
Section 11 47
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48 2002 Capital Health Plan
Your medical and claims We will keep your medical and claims
information confidential. Only the following will have access to it:
OPM,
this Plan, and subcontractors when they administer this
contract;
This Plan and appropriate third parties, such as other insurance
plans
and the Office of Workers' Compensation Programs (OWCP),
when coordinating
benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that
does
not disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about
a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years
of your Federal service. If you do not meet this requirement, you may be
eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continua-tion
of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity
law.
If you are recently divorced or are anticipating a divorce, contact
your
ex-spouse's employing or retirement office to get RI 70-5, the
Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, or other
information about your
coverage choices.
Temporary Continuation of
Coverage (TCC) If you leave Federal
service, or if you lose coverage because you no
longer qualify as a family
member, you may be eligible for Temporary
Continuation of Coverage (TCC).
For example, you can receive TCC if
you are not able to continue your FEHB
enrollment after you retire, if
you lose your job, if you are a covered
dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct.
Enrolling in TCC Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, from your
employing or
retirement office or from www.opm.gov/insure. It explains what
you
have to do to enroll.
records are confidential
Section 11 48
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49 2002 Capital Health Plan
Converting to You may convert to a non-FEHB individual policy
if:
Your coverage under TCC or the spouse equity law ends. If you canceled
your coverage or did not pay your premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not
notify
you. You must apply in writing to us within 31 days after you are
no
longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and
we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
The Health Insurance Portability and Accountability Act of 1996
(HIPAA)
is a Federal law that offers limited Federal protections for
health coverage
availability and continuity to people who lose employer
group coverage. If
you leave the FEHB Program, we will give you a
Certificate of Group Health
Plan Coverage that indicates how long you
have been enrolled with us. You
can use this certificate when getting
health insurance or other health care
coverage. Your new plan must
reduce or eliminate waiting periods,
limitations, or exclusions for health
related conditions based on the
information in the certificate, as long as
you enroll within 63 days of
losing coverage under this Plan. If you have
been enrolled with us for less
than 12 months, but were previously
enrolled in other FEHB plans, you may
also request a certificate from
those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB Program. See also the
FEHB web site
(www.opm.gov/insure/health); refer to the TCC and
HIPAA frequently asked
question. These highlight HIPAA rules, such
as the requirement that Federal
employees must exhaust any TCC
eligibility as one condition for guaranteed
access to individual health
coverage under HIPAA, and have information about
Federal and State
agencies you can contact for more information.
individual coverage
Section 11
Getting a Certificate of
Group Health Plan
Coverage 49
49 Page
50 51
50 2002 Capital Health Plan
Long Term Care Insurance Is Coming Later in 2002!
The Office
of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in
October 2002. As part of its educational
effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance?
Its insurance to help
pay for long term care services you may need if you cant take care of yourself
because of an extended illness or injury, or an age-related disease such as
Alzheimers.
LTC insurance can provide broad, flexible benefits for care in a nursing
home care, in an assisted living facility, in your home, adult day care, hospice
care, and more. LTC insurance can supplement care provided by family
members, reducing the burden you place on them.
Im healthy. I wont
need long-term care. Or, will I?
76% of Americans believe they will
never need long term care, but the facts are that about half them will. And its
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 you should have a plan
just in case. LTC insurance may be vital to your financial and retirement
planning.
Is long term care expensive?
Yes, it can be very expensive. A
year in a nursing home can exceed $50,000 and only three 8-hour shifts a week
can exceed $20,000 a year; thats before inflation!
LTC can easily exhaust your savings, but LTC insurance can protect it.
But wont my FEHB plan, Medicare or Medicaid cover my long term care?
Not FEHB. Look at the Not covered blocks in sections 5(a) and
5(c) of your FEHB brochure. Custodial care, assisted living, or continuing home
health care for activities of daily living are not covered. Limited stays in
skilled
nursing facilities can be covered in some circumstances.
Medicare only
covers skilled nursing home care after a hospitalization with a 100-day limit.
Medicaid covers LTC for those who meet their states guidelines, but restricts
covered services and where they can be
received. LTC insurance can provide choices of care and preserve your
independence.
When will I get more information?
Employees will
get more information from their agencies during the late summer/early fall of
2002. Retirees will receive information at home.
How can I find out more about the program NOW?
A toll-free
telephone number will begin in mid-2002. You can learn more about the program
now 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?
Consider buying long term care insurance.
Long Term Care Insurance 50
50 Page 51 52
51 2002 Capital
Health Plan
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:
Its insurance to help pay for long term care services you may need if you
cant take care of yourself because of an extended illness or injury,
or an
age-related disease such as Alzheimers.
LTC insurance can provide broad,
flexible benefits for nursing home care, care in an assisted living facility,
care in your home, adult day care,
hospice care, and more. LTC insurance can supplement care provided by
family members, reducing the burden you place on them.
Welcome to the club! 76% of Americans believe they will never need long
term care, but the
facts are that about half of them will. And its not just
the old folks.
About 40% of people needing long term care are under age 65.
They may
need chronic care due to a serious accident, a stroke, or
developing
multiple sclerosis, etc.
We hope you will never need long
term care, but everyone should have a plan just in case. Many people now
consider long term care insurance to
be vital to their financial and retirement planing.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed
$20,000 a year. And
thats before inflation!
Long term care can easily exhaust your savings.
Long term care insur-ance 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 dont 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
circum-
stances.
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 states 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 information on
how to apply for this new
insurance coverage?
How can I find out more
about the program NOW?
Long Term Care Insurance 51
51 Page 52 53
52 2002 Capital
Health Plan
Index
Do not rely on this page; it is for your
convenience and may not show all pages where the terms appear.
Accidental injury 37
Allergy tests 16
Ambulance 28, 30
Anesthesia 25
Allogenetic (donor) bone marrow
transplant
24
Biopsies 22
Blood and blood plasma 13, 26
Breast cancer
screening 13
Casts 26
Catastrophic protection 10
Changes for
2002 6
Chemotherapy 16
Chiropractic 21
Cholesterol tests 13
Claims 39
Coinsurance 10
Colorectal cancer screening 13
Congenital anomalies 22
Contraceptive devices and drugs 15, 34
Coordination of benefits 42-45
Covered charges 12-37
Covered
providers 7
Crutches 20
Deductible 10
Definitions 46
Dental care 37
Diagnostic services 12
Disputed claims review 40-41
Donor expenses (transplants) 25
Dressings 26
Durable medical
equipment
(DME) 20
Educational classes and programs 21
Effective date of enrollment 47
Emergency 29-30
Experimental or
investigational 46
Eyeglasses 18
Family planning 15
Fecal occult blood test 13
General Exclusions 38
Hearing services 18, 36
Home
health services 20
Hospice care 28
Home nursing care 20
Hospital 9
Immunizations 5, 14
Infertility 16
Inpatient Hospital
Benefits 26-28
Insulin 34
Laboratory and pathological
services 5,13
Magnetic Resonance Imagings
(MRIs) 13
Mammograms 13-14
Maternity Benefits 15
Medicaid 45
Medically
necessary 46
Medicare 42-45
Members 7
Mental Conditions/ Substance
Abuse Benefits 31-32
Newborn care 15
Nurse
Licensed
Practical Nurse 20
Registered Nurse 20
Nursery charges 15
Obstetrical care 15
Occupational therapy 17
Ocular injury 18
Office visits 5
Oral and maxillofacial surgery 24
Orthopedic devices
19
Out-of-pocket expenses 10
Outpatient facility care 27
Oxygen 26
Pap test 13
Physical examination 5, 14
Physical
therapy 17
Physician 7
Precertification 10, 15, 25, 30-38
Preventive
care, adult 13-14
Preventive care, children 14
Prescription drugs 33-35
Prior approval 8-9, 10
Prostate cancer screening 13
Prosthetic
devices 19
Psychologist 31
Radiation therapy 16
Renal
dialysis 16
Room and board 26
Second surgical opinion 12
Skilled nursing facility care 27
Smoking cessation 21
Speech therapy
17
Splints 26
Sterilization procedures 23
Subrogation 45
Substance abuse 31-32
Surgery 22-23
Anesthesia 25
Oral 24
Reconstructive 23-24 Syringes 34
Temporary continuation of
coverage 48
Transplants 24-25
Treatment therapies 16
Vision services 18
Well child
care 5, 14
Wheelchairs 20
Workers' compensation 45
X-rays 5,
13
Index 52
52 Page
53 54
53 2002 Capital Health Plan
Notes
Notes 53
53 Page 54 55
54 2002 Capital
Health Plan
Notes
Notes 54
54 Page 55 56
55 2002 Capital Health Plan
Summary of
benefits for Capital Health Plan -2002
Do not rely on this chart
alone. All benefits are provided in full unless indicated and are subject to
the defini-tions,
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 12
Services provided by a hospital:
Inpatient $100 per admission copay
26-27
Outpatient Nothing 27
Emergency benefits:
In-area $50 per emergency room visit 30
Out-of-area $50 per emergency room visit 30
Mental health and substance abuse treatment Regular cost sharing 31
Prescription drugs $7 generic
$20 preferred brand
$35 non-preferred
brand 33-35
Dental Care No benefit 37
Vision Care Limited benefit 18
Special
features: Services for deaf and hearing impaired TDD Line: 850/ 383-3534 36
Protection against catastrophic costs 10
(your out-of-pocket maximum)
Office visit copay: $10
primary care; $10 specialist
Nothing after $1,500/ self only
or $3,000/ family enrollment
per
year.
(Except Accidental Injury)
Summary 55
55 Page
56
56 2002 Capital Health Plan
2002 Rate
Information for
Capital Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the
FEHB Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for
United States Postal Service Employees,
RI 70-2. Different postal rates apply and special FEHB guides are
published
for Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and
Office of Inspector
General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal
employee organization who are not career
postal employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Tallahassee, Florida area
Self Only EA1 $85.39 $28.46 $185.01 $61.67
$101.04 $12.81
Self and Family EA2 $223.41 $80.55 $484.06 $174.52 $263.75 $40.21
Type of Gov't Your Gov't Your USPS Your
Enrollment Code Share Share
Share Share Share Share
Rate Information 56