Serving: Cochise, Coconino, Gila, Maricopa, Pima, Pinal and Santa Cruz
counties
Enrollment in this Plan is limited; see page 7 for requirements.
Enrollment codes for this Plan:
A71 Self Only A72 Self and Family
RI 73-283
This Plan has commendable accreditation
from the NCQA. See the 2002
Guide for
more information on NCQA.
For
changes in
benefits
see page 8 1
1
Page 2 3
2002 Health Net 2 Table of Contents
Table of Contents
Introduction
..................................................................................................................................................................
4
Plain Language
..............................................................................................................................................................
4
Inspector General Advisory
..........................................................................................................................................
5
Section 1. Facts about this HMO plan
..........................................................................................................................
6
How we pay providers
.................................................................................................................................
6
Your
Rights.................................................................................................................................................
6
Who provides my
healthcare?......................................................................................................................
7
Service
Area.................................................................................................................................................
7
Section 2. How we changed for 2002
...........................................................................................................................
8
Program-wide
changes.................................................................................................................................
8
Changes to this
Plan.....................................................................................................................................
8
Section 3. How you get care
.........................................................................................................................................
9
Identification
cards.......................................................................................................................................
9
Where you get covered
care.........................................................................................................................
9
Plan
providers........................................................................................................................................
9
Plan facilities
.........................................................................................................................................
9
What you must do to get covered care
.........................................................................................................
9
Primary
care...........................................................................................................................................
9
Specialty
care.........................................................................................................................................
9
Hospital
care........................................................................................................................................
10
Circumstances beyond our
control.............................................................................................................
11
Services requiring our prior approval
........................................................................................................
11
Section 4. Your costs for covered services
.................................................................................................................
12
Copayments
.........................................................................................................................................
12
Deductible
...........................................................................................................................................
12
Coinsurance
.........................................................................................................................................
12
Your out-of-pocket
maximum....................................................................................................................
12
Section 5. Benefits
......................................................................................................................................................
13
Overview....................................................................................................................................................
13
(a) Medical services and supplies provided by
physicians and other health care professionals ........... 14
(b) Surgical and anesthesia services provided by physicians and
other health care professionals........ 24
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 28
(d) Emergency
services/
accidents.........................................................................................................
31
(e) Mental health and substance abuse
benefits....................................................................................
33
(f) Prescription drug
benefits................................................................................................................
35
(g) Special features
...............................................................................................................................
38
(h) Dental benefits
................................................................................................................................
39 2
2 Page 3 4
2002 Health Net 3 Table of Contents
(i)
Non-FEHB benefits available to Plan
members..............................................................................
40
Section 6. General exclusions
--things we don't cover
.............................................................................................
41
Section 7. Filing a claim for covered services
............................................................................................................
42
Section 8. The disputed claims process
......................................................................................................................
43
Section 9. Coordinating benefits with other
coverage
................................................................................................
45
When you have…
Other health coverage
.........................................................................................................................
45
Original
Medicare...............................................................................................................................
45
Medicare managed care plan
..............................................................................................................
47
TRICARE/ Workers' Compensation/
Medicaid...........................................................................................
48
Other Government
agencies.......................................................................................................................
48
When others are responsible for
injuries....................................................................................................
48
Section 10. Definitions of terms we use in this
brochure............................................................................................
49
Section 11. FEHB
facts...............................................................................................................................................
51
Coverage information
.............................................................................................................................
51
No pre-existing condition limitation
..................................................................................................
51
Where you get information about enrolling in the
FEHB Program................................................... 51
Types of coverage available for you and your
family........................................................................
51
When benefits and premiums
start.....................................................................................................
52
Your medical and claims records are confidential
.............................................................................
52
When you retire
................................................................................................................................
52
When you lose
benefits..............................................................................................................................
52
When FEHB coverage
ends...............................................................................................................
52
Spouse equity coverage
....................................................................................................................
52
Temporary Continuation of Coverage (TCC)
...................................................................................
52
Converting to individual
coverage....................................................................................................
53
Getting a Certificate of Group Health Plan
Coverage.......................................................................
53
Long term care insurance is coming later in 2002
......................................................................................................
54
Index
................................................................................................................................................................
55
Summary of
benefits....................................................................................................................................................
56
Rates
..................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Health Net 4
Introduction/ Plain Language
Introduction
Health Net of
Arizona, Inc., 930 North Finance Center Drive, Tucson, Arizona 85710-1362
This brochure describes the benefits of Health Net of Arizona, Inc. HMO
under our contract CS2121 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 are
summarized on page 8. Rates are shown
at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member, "we" means Health Net of Arizona,
Inc.
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 us know. Visit OPM's
"Rate Us" feedback area
at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. 4
4 Page 5 6
2002 Health Net 5 Inspector General Advisory
Inspector General Advisory
Stop health care fraud! Fraud
increases the cost of health care for everyone. If you suspect that a physician,
pharmacy, or hospital has charged you for services you did not
receive,
billed you twice for the same service, or misrepresented any
information, do
the following:
Call the provider and ask for an explanation. There may be an error. If
the provider does not resolve the matter, call us at 1-800-289-2818
and
explain the situation.
If we do not resolve the issue, call THE HEALTH
CARE FRAUD HOTLINE--202/ 418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud
Hotline, 1900
E Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Health Net
6 Section 1
Section 1. Facts about this HMO plan
This
Plan is a health maintenance organization (HMO). We require you to see specific
physicians, hospitals, and
other providers that contract with us. These Plan
providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or
coinsurance.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information
about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types
of information that we must make available to you.
Some of the required information is listed below.
Health Net has been in existence since 1981 Health Net is a for-profit
organization
You may review and obtain copies of your medical records on request. If you
want copies of your medical records,
ask your health care provider for them.
You may ask that a physician amend a record that is not accurate, not relevant
or incomplete. If the physician does not amend your record, you may add a
brief statement to it. If they do not
provide you your records, call us and
we will assist you.
If you want more information about us, call 1-800-289-2818, or write to
Health Net of Arizona, Inc., ATTN: Member
Inquiry, 930 North Finance Center
Drive, Tucson, Arizona 85710-1362. You may also contact us by fax at
1-520-
258-5176 or visit our website at www. health. net. 6
6 Page 7 8
2002 Health Net 7 Section 1
Who
provides my health care?
There are multiple locations throughout
Maricopa County, Pima County, Cochise County, Coconino County, Gila
County,
Pinal County and Santa Cruz County serving Health Net members. When you enroll,
you must select a
primary care physician (PCP) for yourself and eligible
family members. Each member may choose a different
primary care physician.
Health Net of Arizona sometimes contracts with Medical Groups to provide medical
care. In
these cases, the Medical Group determines the group of specialist(
s) and hospital( s) that are available.
The first and most important decision each member must make is the selection
of a primary care physician. The
decision is important since it is through
this doctor that all other health services, particularly those of specialists,
are
obtained. It is the responsibility of your primary care physician to
obtain any necessary authorizations from the plan
before referring you to a
specialist or making arrangements for hospitalization. Services of other
providers are
covered only when there has been a referral by the member's
primary care physician with the following exceptions: a
woman may see her
plan obstetrician/ gynecologist without a referral and a member who is diabetic
may see a plan
ophthalmologist for an annual eye examination to detect eye
disease without a referral
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:
Cochise, Coconino, Gila, Maricopa, Pima, Pinal and Santa Cruz counties.
You may also enroll with us if you live or work in the following places: the
Tucson, Phoenix, Sierra Vista, Flagstaff,
Casa Grande and Nogales City
areas.
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. We will not pay for any other health care services unless the services
have prior
plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page
8 9
2002 Health Net 8 Section 2
Section 2. How we change for 2002
Program-wide changes
We removed the requirement that services must be needed to restore functional
speech from the speech therapy benefit
Changes to this Plan
Your share of the non-Postal premium will
increase by 21. 1 % for Self Only or 39. 5 % for Self and Family.
The out of pocket maximums will change to $2,000 for self only or $4,000
for family enrollment per year. Previously, the out of pocket maximums were
equal to 200% of your yearly premium.
You will pay $100 per admission for inpatient hospital visits to Plan
hospitals in 2002. Previously, you paid $0 for inpatient hospital admissions.
You will pay $50 per visit for outpatient hospital services to Plan
hospitals in 2002. Previously, you paid $0 for outpatient hospital services.
You will pay $10 for generic, $20 for preferred brand name and $40 for
non-preferred brand name medications in 2002. Previously, you paid $5 for
generic and $10 for brand name medications.
You will pay two times the
preferred brand name ($ 40) for self-injectable drugs (excluding insulin) with
prior approval from the Plan in 2002. Previously, you paid the brand name copay
with prior
approval from the Plan.
We will cover up to 60 visits per year for speech therapy in 2002.
Previously, we provided speech therapy as rehabilitative treatment up to two
months per condition.
We now cover certain intestinal transplants (section 5( b)). 8
8 Page 9 10
2002 Health Net 9 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it
whenever you receive services from a
Plan provider, or obtain a
prescription at a Plan pharmacy. Until you
receive your ID card, use your
copy of the Health Benefits Election Form,
SF-2809, your health benefits
enrollment confirmation (for annuitants), or
your Employee Express
confirmation letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
1-800-
289-2818.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our
members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities
in our service area that we contract with to provide covered services to our
members. We list these
in the provider directory, which we update
periodically. The list is also
on our website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for
most of your health care. You can find a primary
care physician by
looking in the provider directory, visiting our website,
or calling us at
1-800-289-2818
Primary care Your primary care physician can be a Family Practice,
General Practice, Internal Medicine, or Pediatrics physician. Your primary care
physician
will provide most of your health care, or give you a referral to see a
specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. However, you may see a plan obstetrician/
gynecologist and diabetic
members may see a plan opthamologist for an annual
eye examination to
detect eye disease without a referral.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician
will work with the
specialist and/ or the plan to develop a treatment
plan that allows you to
see your specialist for a certain number of
visits without additional
referrals. Your primary care physician will 9
9
Page 10 11
2002
Health Net 10 Section 3
use our criteria when creating your
treatment plan (the physician may
have to get an authorization or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide
what
treatment you need. If he or she decides to refer you to a
specialist, ask
if you can see your current specialist. If your current
specialist does not
participate with us, you must receive treatment
from a specialist who does.
Generally, we will not pay for you to see
a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until
we can make arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
-terminate our contract with your specialist for other than cause; or
-drop out of the Federal Employees Health Benefits (FEHB)
Program and
you enroll in another FEHB Plan; or
-reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days
after you receive
notice of the change. Contact us or, if we drop out of
the Program, contact
your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary hospital arrangements and supervise your care. This includes
admission
to a skilled nursing or other type of facility.
If you are in
the hospital when your enrollment in our Plan begins, call
our customer
service department immediately at 1-800-289-2818. If you
are new to the FEHB
Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. 10
10 Page 11 12
2002 Health Net
11 Section 3
In that case, we will make all reasonable efforts to
provide you with the
necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from
us. Before giving
approval, we consider if the service is covered,
medically necessary, and
follows generally accepted medical practice.
We call this review and approval process prior authorization. Your
physician must obtain prior authorization for services such as: hospital
stays, some surgeries, home health care and organ transplants.
When your primary care physician feels that you may need such a
service,
he or she will submit a request for an authorization.
Authorization Made Easy Program
Because we want your healthcare to
be easy and convenient, we have
developed an Authorization Made Easy
Program. Primary care
physician's who are part of this program can give you
a direct written
referral or authorization. This allows you to see certain
specialists or get
certain tests, without any prior approval.
This could include an initial
consultation or evaluation, diagnostic
tests and same day treatment.
If the specialist you need to see or the test or procedure you need done is
not eligible for an Authorization Made Easy referral or authorization, as
described above, the following process will occur:
Your primary care physician will submit the request to Health Net. Once we
receive the request, our medical staff will review it. They
review the
treatment plan, covered benefits, medical history and
national treatment
standards.
If a request is denied, it will automatically proceed to one of our doctors
for review. He or she will either support the decision for
denial or approve the care requested.
If the case or treatment is
complex, we may ask for an outside review from non-Health Net doctors who are
experts in the field of
care requested. If these doctors recommend the care, it will be
approved.
If a case involves new medical technology, our doctors may review current
medical literature and/ or consult with medical experts. Our
doctors will use this information to decide if the care requested is
appropriate.
Remember, your primary care physician must coordinate your
medical
care. If you need specialty care, your primary care
physician will determine
the most appropriate specialist, based on
your medical condition. If you go
to a specialist, or receive a service
without prior authorization (except
for emergencies, OB/ GYN visits,
and diabetic members may see a plan
opthamologist for an annual
eye exam), the services you receive will not be
covered by your
Health Net health plan. 11
11 Page 12 13
2002 Health Net 12 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider when you receive
services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit and when you go in the hospital, you pay
$100 per
admission.
Deductible We do not have a deductible
Coinsurance We do not have coinsurance.
Your out-of-pocket
maximum After your copayments total $2,000.00 per person or $4, 000.00 per
family for deductibles, coinsurance, enrollment in any calendar year, you
do not have to pay any more for
and copayments covered services. However, copayments for the following
services do not count toward your out-of-pocket maximum, and you must continue
to pay
copayments for these services:
prescription drugs infertility services
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 Health Net 13 Section 5
Section 5. Benefits – OVERVIEW
(See page 8 for how our
benefits changed this year and page 56 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 1-800-289-2818
or at our website at www. health. net.
(a) Medical services and supplies provided by physicians and other health
care professionals...................................... 14-23
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care
Family planning
Infertility services Allergy care
Treatment
therapies Physical and Occupational therapies
Speech therapy
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care Orthopedic and prosthetic
devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 24-27
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services..................................................... 28-30
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/ accidents
........................................................................................................................
31-32
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
...................................................................................................
33-34
(f) Prescription drug benefits
...............................................................................................................................
35-37
(g) Special
features.....................................................................................................................................................
38
Flexible benefits option Services for deaf and hearing impaired
Disease Management Services
(h) Dental
benefits......................................................................................................................................................
39
(i) Non-FEHB benefits available to Plan members
...................................................................................................
40
Summary of
benefits....................................................................................................................................................
56 13
13 Page 14
15
2002 Health Net 14 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with
other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
Office medical consultations
Second
surgical opinions
$10 per visit
In an urgent care center $25 per visit
During a hospital stay
In a skilled nursing facility
Nothing
At home $10 per visit
Diagnostic and treatment services --Continued on next page 14
14 Page 15 16
2002 Health Net 15 Section 5( a)
Diagnostic and treatment services (Continued) You pay
Not covered: hearing exams to determine extent of hearing loss, if
you
are over age 18
All charges
Lab, X-ray and other diagnostic tests
Laboratory tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
If you receive these services
during your office visit, only your
$10
office visit copay will apply.
If you receive these services at an
outpatient hospital setting, a $50
copay per visit will apply.
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – periodic depending on risk factors
Colorectal Cancer
Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening
– every three to five years starting at age 50
Prostate Specific Antigen
(PSA test) – testing as determined by physician
Routine pap test
Note:
The office visit is covered if pap test is received on the same day;
see
Diagnosis and Treatment, above.
$10 per visit 15
15 Page
16 17
2002 Health Net 16
Section 5( a)
Preventive care, adult (Continued) You
pay
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 49, one every one or two years
At age 50 and older, one every year
Other screenings as requested by the Primary Care Physician
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges
Routine Immunizations, limited to:
Tetanus-diphtheria (Td) booster –
once every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
$10 per visit
Influenza/ Pneumococcal vaccines, annually, age 65 and over Nothing when
performed by non-physician personnel or an affiliated
flu shot clinic
sponsored by your
primary care physician or Health
Net
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics $10 per visit
Examinations, such as:
-Eye exams through age 17 to determine the need
for vision
correction.
-Ear exams through age 17 to determine the need for hearing
correction
-Examinations done on the day of immunizations ( through age 22)
Well-child care charges for routine examinations, immunizations and care
(up to age 22)
$10 per visit 16
16 Page
17 18
2002 Health Net 17
Section 5( a)
Maternity care You pay
Complete maternity
(obstetrical) care, such as:
Prenatal care
Delivery
Postnatal
care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 10 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 for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$10 per visit, nothing for prenatal
and postnatal care after the initial
diagnosis of pregnancy
Not covered: Sonograms, amniocenteses, ultrasound or any other
procedure to determine fetal age, size or sex; non-medically necessary
circumcision after the newborn period.
All charges
Family planning
Voluntary sterilization $10 per visit in a
physician's office; nothing in inpatient or
outpatient hospital
Surgically implanted contraceptives 50% of all services, limited to one
implant in any 3 consecutive year
period
Elective removal of surgically implanted contraceptives Nothing, limited to
one non-medically necessary removal in
any 3 consecutive year period
Injectable contraceptive drugs $10 per visit
Intrauterine devices
(IUDs)
Diaphragms
Elective removal of Intrauterine devices (IUDs)
$10 per visit, limited to one non-medically necessary removal in
any 3
consecutive year period
Not covered: reversal of voluntary surgical sterilization, genetic
counseling , diagnostic testing to establish paternity of a child, and
genetic testing
All charges 17
17 Page 18 19
2002 Health Net
18 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
-intravaginal insemination (IVI)
-intracervical
insemination (ICI)
-intrauterine insemination (IUI)
50% of all covered services
Not covered:
Assisted reproductive technology (ART)
procedures, such as:
-in vitro fertilization
-embryo transfer and GIFT
Services and supplies related to excluded ART procedures
Cost of donor sperm or sperm banking
Fertility drugs
All charges
Allergy care
Testing and treatment $10 per visit
Allergy injection $10 per visit; nothing if performed
by non-physician
personnel
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization, skin titration (Rinkel Method),
cytotoxicity testing
(Bryans Test), RAST testing, MAST testing, urine
autoinjection
All charges
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 27.
Respiratory and inhalation therapy
Intravenous (IV)/ Infusion Therapy
– Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we
preauthorize the treatment.
Call 1-800-863-7847 for preauthorization
information. We will ask you
or your doctor to submit information that
establishes that the GHT is
medically necessary. You or your doctor must ask
us to authorize
GHT before you begin treatment; otherwise, we will only
cover GHT
services from the date you submit the information. If you or your
doctor does not ask or if we determine GHT is not medically necessary,
we will not cover the GHT or related services and supplies. See
Services requiring our prior approval in Section 3.
$10 per visit in provider office or
$50 per visit if provided in
outpatient hospital setting. 18
18 Page 19 20
2002 Health Net
19 Section 5( a)
Dialysis – Hemodialysis and peritoneal
dialysis $10 per visit
Not covered: Experimental, investigational or
alternative therapies. All charges
Physical and occupational
therapies
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.
We provide cardiac rehabilitation following a heart transplant, bypass
surgery or a myocardial infarction, for two consecutive
months per condition.
$10 per visit in provider's office
or $50 per visit in outpatient
hospital setting.
Not covered:
Long-term rehabilitative therapy
Exercise programs
Therapies provided for the purpose of
maintaining physical condition
All charges 19
19 Page 20 21
2002 Health Net
20 Section 5( a)
Speech therapy You pay
60 visits
per year $10 per visit in provider's office or $50 per visit in outpatient
hospital setting.
Hearing services (testing, treatment, and supplies)
Hearing
screening to determine hearing loss and/ or to treat a suspected disease or
injury to the ear
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per visit
Not covered:
All other hearing testing, including hearing
exams to determine the extent of hearing loss if you are over age 18
Hearing aids, testing and examinations for them
All charges
Vision services (testing, treatment, and supplies)
The first
pair of contact lenses or corrective lenses following cataract surgery,
treatment of keratoconus, aphakia, or corneal
transplantation, including a
frame allowance of up to $75
$10 per visit
Eye exam to determine the need for vision correction for children through
age 17 (see preventive care)
Lenses and/ or frames once every 24 months
$10 per visit
Annual eye examination for refraction Nothing
Elective contact lenses
once every 24 months
Note: annual eye examination for refraction, lenses
and/ or frames and
elective contact lenses benefits are administered by IVS.
Call 800-443-
4994 x410
You pay any amount over the
$100 allowance we provide
toward the cost
of contact lenses,
evaluation and fitting
Not covered:
Eye exercises, orthoptics and any other vision
training
Radial keratotomy, lasik and any other refractive surgery
All charges
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat
feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot (unless the
treatment is by open cutting surgery)
All charge 20
20 Page
21 22
2002 Health Net 21
Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes, including the initial purchase and subsequent
purchases due to physical growth. Coverage is limited
to limbs that are
necessary because of an illness, injury or surgery
causing anatomical
functional impairment, or from a congenital
defect.
Prosthetic devices when determined to be medically necessary and result
from an illness, injury or surgery causing anatomical
functional impairment, or from a congenital defect. Coverage
includes the
fitting and purchase of a standard model. Replacement
is covered only if
determined to be medically necessary and results
from a change in your
physical condition.
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy.
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following
mastectomy. Note: See 5( b) for coverage of the surgery
to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing
Not covered:
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
Repairs and/ or replacement of parts or
devices worn out due to misuse or abuse
Model upgrades, deluxe, or specialized equipment
Over-the-counter items
All charges 21
21 Page 22 23
2002 Health Net
22 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, of durable medical equipment
prescribed by your Plan physician, such as oxygen and dialysis
equipment. Under this benefit, we also cover:
Manual hospital beds
Standard size manual wheelchairs
Crutches,
canes
Walkers
Plan approved standard blood glucose monitors
Insulin pumps
Plan approved peak flow meters
Medical supplies
determined by Health Net to be medically necessary to operate and/ or maintain a
covered prosthesis or item of
Durable Medical Equipment, subject to the following exclusions and
limitations
Nothing
Not covered:
Motorized, electric or specialized wheel chairs
Scooters or other power operated vehicles
More than one device to provide essentially the same functional
assistance
Deluxe, specialized or customized equipment, model
upgrades Transcutaneous Electrical Nerve Stimulation (TENS) units
Repair or replacement of equipment or parts due to misuse and/ or
abuse
Over-the-counter braces and other DME devices, except as
listed above
Prophylactic braces Braces used primarily for
sports activities
Foot orthotics which are not an integral part of
a leg brace
All charges
Home health services
Home health care ordered by a Plan
physician and provided by a registered nurse (R. N.), licensed practical nurse
(L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide who is
part of a
Health Net contracted Home Health Care Agency.
Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
Nursing care requested by, or for the
convenience of, the patient or the patient's family;
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative;
Housekeeping services; Services of a person who resides in
the patient's home
Custodial care, rest cures, respite care Services performed by
the patient's family member
All charges 22
22 Page 23 24
2002 Health Net
23 Section 5( a)
Chiropractic You pay
Up to 12
visits per year for manipulation of the spine and extremities
Note: We cover
adjunctive procedures such as ultrasound, electrical muscle
stimulation,
vibratory therapy, and cold pack application.
$10 per visit
Alternative treatments
No benefit for services such as:
Naturopathic services Hypnotherapy
Acupuncture services Acupressure services
Behavior
training Educational, recreational, art, dance, sex, sleep or music
therapies
Other forms of holistic treatment or alternative
therapies
All charges
Educational classes and programs
Coverage is limited to classes
offered by or through Health Net's Health
Education department. Recent
classes and seminars include:
Smoking Cessation
Diabetes self-management
Stress management
Parenting
Health nutrition
Congestive heart failure counseling
Lamaze
Weight management
Nothing
A nominal fee may be required for
classroom materials 23
23 Page 24 25
2002 Health Net 24 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with
other
coverage, including with Medicare.
The amounts listed below are for the
charges billed by a physician or other health care professional for your
surgical care. Look in Section 5( c) for charges associated with the
facility charge (i. e. hospital, surgical center, etc.).
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
Treatment of
fractures, including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedure
Biopsy
procedure 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 braces and
prosthetic devices for device coverage information.
$10 per office visit, $50 per
outpatient hospital visit, or $100
per
hospital admission.
Surgical procedures continued on next page. 24
24 Page 25 26
2002 Health Net 25 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization
Treatment of burns
$10 per office visit, $50 per
outpatient hospital visit, or $100
per
hospital admission.
Not covered:
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care All charges
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the
condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes.
$10 per office visit, $50 per
outpatient hospital visit, or $100
per
hospital admission.
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 this procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
Not covered:
Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges 25
25 Page 26 27
2002 Health Net
26 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction or manipulation of
fractures of the jaws or facial bones and supporting tissues;
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts;
Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses
when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures.
$10 per office visit, $50 per
outpatient hospital visit, or $100
per
hospital admission.
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
Routine or general care of teeth or dental structures
Extraction of impacted or abscessed teeth
Dental splints, dental
implants, dental prostheses or dentures
Accidental injury to the
teeth or gums caused by chewing
All charges 26
26 Page 27 28
2002 Health Net
27 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogenic (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.
Donor searches limited to $5,000 per organ per
lifetime
Limited Benefits – Treatment for breast cancer, multiple myeloma,
and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor
when we
cover the recipient.
$10 per office visit, $50 per
outpatient hospital visit, or $100
per
hospital admission.
Not covered:
Donor screening tests and donor search expenses
which exceed the maximum lifetime benefit
Implants of artificial or non-human organs Transplants not
listed as covered
All charges
Anesthesia
Professional services provided in –
Hospital
(inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Nothing
Office Nothing 27
27 Page
28 29
2002 Health Net 28
Section 5( c)
Section 5 (c). Services provided by a hospital or
other facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e.,
hospital or surgical center) or ambulance service for your surgery or care. Any
costs
associated with the professional charge (i. e., physicians, etc.) are covered
in
Section 5( a) or (b).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general
nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
$100 per admission
Inpatient hospital continued on next page. 28
28 Page 29 30
2002 Health Net 29 Section 5( c)
Inpatient hospital (Continued) You pay
Other
hospital services and supplies, such as:
Operating, recovery, maternity,
and other treatment rooms
Prescribed drugs and medicines
Diagnostic
laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen
Anesthetics, including nurse anesthetist services
$100 per admission
Not covered:
Custodial care
Non-covered facilities
Personal comfort or convenience
items, such as telephone, television, barber services, guest meals and beds,
travel expenses
and take-home supplies
Private nursing care
Collection and/ or storage of blood
products for any unscheduled or non-covered medical procedure
All charges
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration
of blood, blood plasma, and other biologicals
Blood and blood plasma, if
not donated or replaced
Pre-surgical testing
Dressings, casts, and
sterile tray services
Medical supplies, including oxygen
Anesthetics
and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do
not cover the dental procedures.
$50 per visit
Not covered: collection and/ or storage of blood products for any
unscheduled or non-covered medical procedure
All charges 29
29 Page 30 31
2002 Health Net 30 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You
pay
Skilled nursing facility (SNF):
Coverage is provided when
full-time skilled nursing care is medically
necessary and confinement in a
SNF is medically appropriate as
determined by a plan doctor and approved by
Health Net. Covered
services include:
Bed, board and general nursing care
Drugs, biologicals, supplies and
equipment ordinarily provided or arranged by the SNF when prescribed by a plan
doctor.
Nothing
Not covered: custodial care, domiciliary care or convalescent care All
charges
Hospice care
Members who are diagnosed as having an
illness giving them a life
expectancy of 6 months or less may request
Hospice care. All Hospice
care must be provided by a licensed participating
Hospice and include
inpatient and outpatient care related to the condition
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when
medically appropriate
Air ambulance when prior authorized or if the
member's condition is an emergency and the location of the accidental injury
and/ or
illness is inaccessible by ground vehicles or transport by ground
ambulance would be detrimental to the member's health
Nothing 30
30 Page
31 32
2002 Health Net 31
Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits
with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe
endangers your
life or could result in serious injury or disability, and requires immediate
medical or
surgical care. Some problems are emergencies because, if not
treated promptly, they might become more
serious; examples include deep cuts
and broken bones. Others are emergencies because they are
potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability
to breathe. There are many other acute conditions that we
may determine are medical emergencies – what
they all have in common is the
need for quick action.
What to do in case of emergency:
If you are faced with a medical
emergency, call 911 or go to the nearest emergency room.
Please notify your primary care physician within 48 hours following emergency
services, or as soon as
reasonably possible.
Emergency services do not include the use of a hospital emergency room or
other emergency medical
facility for routine medical care, or follow-up or
continuing care unless prior authorization has been given
by your primary
care physician or Health Net.
Emergencies within our service area: : call 911 or go to the nearest
emergency room
Emergencies outside our service area: : call 911 or go
to the nearest emergency room 31
31 Page 32 33
2002 Health Net
32 Section 5( d)
Benefit Description You pay
Emergency
within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at
an urgent care center $25 per visit
Emergency care as an outpatient or
inpatient at a hospital, including doctors' services $50 per visit (waived if
admitted; $100 inpatient
hospital copayment will
apply).
Not covered: Elective care or non-emergency care, continuing, routine
or follow-up care without prior authorization
All charges
Emergency outside our service area
Emergency care at a doctor's
office $10 per visit
Emergency care at an urgent care center $25 per visit
Emergency care
as an outpatient or inpatient at a hospital, including doctors' services $50 per
visit (waived if admitted; $100 inpatient
hospital copayment will
apply).
Not covered:
Elective care or non-emergency care,
Continuing, routine or follow-up care without prior authorization
Emergency care provided outside the service area if the need for
care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of
a baby outside the service area
All charges
Ambulance
Professional ambulance service when medically
appropriate and in an
emergency situation. Air ambulance when prior
authorized or if the
member's condition is an emergency and the location of
the accidental
injury and/ or illness is inaccessible by ground vehicles or
transport by
ground ambulance would be detrimental to the member's health
See 5( c) for non-emergency service.
Nothing 32
32 Page
33 34
2002 Health Net 33
Section 5( e)
Section 5 (e). Mental health and substance abuse
benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve,
cost-sharing and limitations for Plan mental health and substance
abuse benefits will
be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION FOR INPATIENT SERVICES. See the
instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended
by a Plan provider and
contained in a treatment plan
that we approve. The treatment plan may
include
services, drugs, and supplies described elsewhere in
this
brochure.
Note: Plan benefits are payable only when we
determine the care is
clinically appropriate to treat
your condition and only when you receive the
care
as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists,
psychologists, or clinical social workers
Medication management
$10 per visit
Diagnostic tests Nothing
Services provided by a hospital or other
facility
Services in approved alternative care settings such as a half-way
house, residential treatment, or full-day
hospitalization.
$100 per admission
Services in approved alternative care settings such as partial
hospitalization or facility based intensive
outpatient treatment
$50 per admission 33
33 Page
34 35
2002 Health Net 34
Section 5( e)
Mental health and substance abuse benefits You pay
Not covered: Services we have not approved.
Note: OPM will base
its review of disputes about
treatment plans on the treatment plan's
clinical
appropriateness. OPM will generally not order us
to pay or
provide one clinically appropriate
treatment plan in favor of another.
All charges
Preauthorization To be eligible to receive these mental health and
substance abuse benefits you must obtain a treatment plan and follow all of the
following
authorization processes. These include:
To access Mental
Health and/ or Substance Abuse benefits, you must contact
Catalina
Behavioral Health Services at 1-800-977-0281. Services are
covered as
necessary for the diagnosis and treatment of acute conditions
and as
outlined above. 34
34 Page
35 36
2002 Health Net 35
Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
M P
O
R
T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write
the prescription
Where you can obtain them. You must fill the
prescription at a Plan pharmacy, or by mail for a maintenance medication
We use a Formulary (Preferred Drug List). Drugs are prescribed by
Plan doctors in accordance with the Plan's Preferred Drug List. Generic drugs
are available at the lowest copayment level.
Preferred brand name drugs are
available for a slightly higher copayment. Unless otherwise
excluded, other
FDA-approved brand name drugs are available at the highest copayment level.
To order a Preferred Drug List call 1-800-289-2818 or visit our website at
www. health. net.
These are the dispensing limitations. Prescription drugs obtained at
a plan pharmacy will be dispensed for up to a 31-day supply. Mail order
prescriptions are limited to Health Net's mail order
provider and will be dispensed for up to a 93-day supply. Some medications
may be dispensed in
quantities less than those stated due to prepackaging by
the pharmaceutical manufacturer. Insulin,
diabetic supplies and inhalers
have quantity per copayment limitations, as stated below. Refills are
only
covered when authorized by a plan physician. You will be financially liable for
the cost of
medications obtained after you are no longer eligible for
coverage under this plan.
Why use generic drugs. Generic drugs offer a safe and economic way
to meet your prescription drug needs. The generic name of a drug is its chemical
name; the name brand is the name under
which the manufacturer advertises and sells a drug. Under federal law,
generic and name brand
drugs must meet the same standards for safety,
purity, strength, and effectiveness. A generic
prescription costs you – and
us – less than a name brand prescription.
When you have to file a claim. If you are required to pay for a
prescription in an out-of-area emergency situation, you must submit an itemized
statement to Health Net for the charges you paid,
along with a completed claim form. Claims forms can be obtained by calling
Health Net at 1-800-
289-2818. Proof of payment must accompany the request
for reimbursement.
Claims should be addressed to:
Health Net of Arizona, Inc.
Attn:
Pharmacy Department
930 N. Finance Center Drive
Tucson, Arizona
85710-1362
Prescription drug benefits begin on the next page. 35
35 Page 36 37
2002 Health Net 36 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
Drugs for which a prescription is required by Federal law
Drugs for
sexual dysfunction require prior authorization and have dispensing limitations.
Contact plan for details.
Oral contraceptive drugs and contraceptive diaphragms
Insulin –
limited to 2 vials per copayment
Disposable needles and syringes for the
administration of covered medications – limited to 100 per copayment
Diabetic supplies, including lancets, glucose test strips, visual reading
testing strips, and urine testing strips – limited to 100 per
copayment
Insulin cartridges for the legally blind – limited to the equivalent of 2
vials of insulin per copayment
Automatic lancing devices – limited to one every six months per copayment
Insulin aids (insulin pen) – limited to one every six months per copayment
Glucogon (requires prior authorization) – limited to one per copayment
Spacers and holding chambers for inhaled medications – limited to one per
six months per copayment
Inhalers – up to 2 (nasal or oral), or up to a
31-day supply, whichever is less, per copayment
$10 per generic prescription or
refill obtained from a plan
pharmacy
$20 per preferred brand name
prescription or refill obtained from
a
plan pharmacy
$40 per non-preferred brand name
prescription or refill obtained from
a plan pharmacy
$30 per generic prescription or
refill obtained through our mail
order program
$60 per preferred brand name
prescription or refill obtained
through
our mail order program
$120 per non-preferred brand name
prescription or refill obtained from
a plan pharmacy 36
36 Page
37 38
2002 Health Net 37
Section 5( f)
Covered medications and supplies (continued)
You pay
Self-injectable drugs require prior authorization.
(brand name copayment applies to insulin) $40 per prescription or refill, up to
a 31-day supply. Quantity
limitations may apply to specific
drugs.
Not covered:
Drugs and supplies for cosmetic purposes
Nonprescription medicine
Drugs obtained at a non-plan
pharmacy, except for out-of-area emergencies
Anorexiants, appetite suppressants, diet aids, weight loss medication,
and drugs used to treat obesity
Fertility drugs
Vitamins (except prenatal)
Drugs to enhance athletic performance
Any drug consumed at the place where it is dispensed or that is
dispensed or administered by the physician
Drugs prescribed for non-covered services
Take home drugs;
drugs prescribed for use after discharge from a hospital, nursing home, skilled
nursing facility or other inpatient
facility must be obtained from a plan pharmacy
Replacement
prescriptions
All Charges 37
37 Page 38 39
2002 Health Net
38 Section 5( g)
Section 5 (g). Special Features
Feature
Description
Flexible benefits option Under the flexible benefits option,
we determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
Alternative benefits
are subject to our ongoing review.
By approving an alternative benefit, we
cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Services for deaf and hearing impaired We provide a TTY line for the
deaf and hearing impaired 1-800-977-6757.
Disease Management Services
We help our members and the community learn how to stay healthy and how to
manage chronic conditions. Health Net offers AsthmaWise
Education and
Management, Senior Outreach Programs, Diabetes
Management, Depression
Management, Maternity Care, Congestive Heart
Failure Management, Migraine
Management, Secondary Prevention
Following A Heart Attack, and Smoking
Cessation Programs. 38
38 Page
39 40
2002 Health Net 39
Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental
physical impairment exists which makes hospitalization necessary to safeguard
the health of
the patient; we do not cover the dental procedure unless it is described
below.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with
other coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You Pay
We cover restorative services
and supplies necessary to promptly repair
(but not replace) sound natural
teeth, the jawbone and supporting tissues
(does not include injury caused by
the act of chewing). The need for
these services must result from an
accidental injury.
Nothing
Dental benefits
We have no other dental benefits. 39
39 Page 40 41
2002 Health Net 40 Section 6
Section 5 (j). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed
claim about them. Fees you pay
for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Health Net has added the WellRewards Program – a discount program offered to
all Health Net members.
Health Net has been able to negotiate reduced prices
and excellent values on a number of products and services,
including:
Acupuncture Chiropractic Cosmetic surgery Eye exams/ eyewear
Health club discounts Hearing aids Home care management Home medical
equipment/ supplies
Lasik & PRK surgery Massage therapy Podiatry
Pregnancy & childbirth
Safety Sleep improvement (mattresses)
Vitamins, herbs and supplements Weight Watchers
If you would like more information regarding WellRewards, please contact our
Customer Service department at
1-800-289-2818, or TTY 1-800-977-6757 for the
hearing impaired, Monday through Friday from 7 a. m. to 6
p. m., excluding
holidays.
Direct Information Automated Line (D. I. A. L.) is available 24 hours a day,
7 days a week for you to access
information about your account. If you do
not have a personal identification number (P. I. N.), please contact
Customer Service.
Personal Health Advisor is available to members 24 hours a day, 7 days a week
to speak directly with a registered
nurse or obtain recorded health
information whenever you have a question.
An Indemnity dental plan is now available to all eligible members. This
insurance plan helps you cover the costs of
dental care. Covered dental
services include exams, cleanings, fillings and extractions as well as crowns,
bridges,
and dentures. This plan reimburses you for covered dental expenses
based upon a percentage of the reasonable and
customary (R & C) fee for
those covered expenses. This plan allows you to select your own dentist and it
is
affordable for you and your family. Premiums may be paid monthly
(automatic deduction from your checking
account) or on either a quarterly or
semi-annual basis.
Medicare Prepaid Plan Enrollment This Plan offers Medicare recipients
the opportunity to enroll in the plan through Medicare. As indicated on page
44, annuitants and former spouses with FEHB coverage and Medicare Part B may
elect to drop their FEHB coverage
and enroll in a Medicare prepaid plan when
one is available in their area. They may then later re-enroll in the FEHB
Program. Contact your retirement system for information on dropping your
FEHB enrollment and changing to a
Medicare prepaid plan. Contact us at
1-800-289-2818 for information on the Medicare prepaid plan and the cost of
that enrollment.
If you are Medicare eligible and are interested in enrolling in a Medicare
HMO sponsored in this Plan without
dropping your enrollment in this Plan's
FEHB plan, call the numbers above for information on the benefits available
under the Medicare HMO. 40
40 Page 41 42
2002 Health Net
41 Section 6
Section 6. General exclusions --things we don't
cover
The exclusions in this section apply to all benefits. Although
we may list a specific service as a benefit, we
will not cover it unless
your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury or condition and we agree, as discussed
under What Services Require Our
Prior Approval on page 11.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest ;
Services, drugs, or supplies related to sex transformations;
or
Services, drugs, or supplies you receive from a provider or facility
barred from the FEHB Program. 41
41 Page 42 43
2002 Health Net
42 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at
Plan pharmacies, you will
not have to file claims. Just present your identification card and pay your
copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 1-800-289-2818.
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: Health Net of Arizona, Inc. Attn: Claims
Department
930 N. Finance Center Drive
Tucson, Arizona 85710-1362
Prescription drugs Follow the process as stated above, but send your
request for reimbursement to the following address.
Submit your claims
to: Health Net of Arizona, Inc. Attn: Pharmacy Department
930 N. Finance
Center Drive
Tucson, Arizona 85710-1362
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative
operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 42
42 Page
43 44
2002 Health Net 43
Section 8
Section 8. The disputed claims process
Follow
this Federal Employees Health Benefits Program disputed claims process if you
disagree with our decision on
your claim or request for services, drugs, or
supplies – including a request for preauthorization:
Step Description
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: Health Net of Arizona, Inc.
Attn: Member
Inquiry Department
930 N. Finance Center Drive
Tucson, Arizona
85710-1362; 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.
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.
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.
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. 43
43 Page
44 45
2002 Health Net 44
Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you
believe our decision was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies
of all letters we sent to you about the claim; and
Your daytime phone
number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
OPM will review your disputed claim request and will use the information it
collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no
other administrative
appeals.
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 third year in which you were
denied precertification or
prior approval. This is the only deadline that
may not be extended.
OPM may disclose the information it collects during the review process to
support their disputed claim
decision. This information will become part of
the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
1-800-289-2818 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. 44
44
Page 45 46
2002
Health Net 45 Section 9
Section 9. Coordinating benefits with
other coverage
When you have other health coverage You must tell us if
you are covered or a family member is covered under another group health plan or
have automobile insurance that pays health
care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one
plan normally pays its benefits in
full as the primary payer and the other
plan pays a reduced benefit as the
secondary payer. We, like other insurers,
determine which coverage is
primary according to the National Association of
Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age. People with
End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a
transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most
people do not have to pay for Part A. If you or your spouse worked for at least
10 years in Medicare-covered
employment, you should be able to qualify for premium-free Part A
insurance. (Someone who was a Federal employee on January 1, 1983, or
since January 1, 1983, automatically qualifies) Otherwise, if you are age
65 or older, you may be able to buy it. Contact 1-800-MEDICARE for
information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for
Medicare, you may have choices in how you get
your health care. Medicare +
Choice is the term used to describe the
various health plan choices
available to Medicare beneficiaries. The
information in the next few pages
shows how we coordinate benefits
with Medicare, depending on the type of
Medicare managed care plan
you have.
The Original Medicare Plan The Original Medicare Plan is available
everywhere in the United States. It is the way everyone used to get Medicare
benefits and is the way most
people get their Medicare Part A and Part B
benefits now. You may go
to any doctor, specialist, or hospital that accepts
Medicare. The Original
Medicare Plan pays its share and you pay your share.
Some things are
not covered under Original Medicare, like prescription
drugs.
When you are enrolled in the Original Medicare Plan 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 and prior authorized as required.
We will not waive any of our copayments, coinsurance, or deductibles.
(Primary payer chart begins on next page.) 45
45 Page 46 47
2002 Health Net 46 Section 9
The
following chart illustrates whether Original Medicare or this Plan should be the
primary payer for you according
to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements
correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including
when you or a family member are eligible for
Medicare solely
because of a disability),
9
2) Are an annuitant, 9
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB 9
b) Or, the position is not excluded from FEHB
Ask your employing office
which of these applies to you.
9
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),
9
5) Are enrolled in Part B only, regardless of your employment status, 9 (for
Part B
services)
9
(for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
9
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare
based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits
solely because of ESRD, 9
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD, 9
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision, 9
C. When you or a covered family member have FEHB and…
a) Are
eligible for Medicare based on disability, and are an annuitant
9
b) Are
an active employee 9
c) Are a former spouse of an annuitant 9
d) Are a former spouse of an
active employee 9
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare 46
46
Page 47 48
2002
Health Net 47 Section 9
Claims process when you have the
Original Medicare Plan – You probably will never have to file a claim form
when you have both
our Plan and the Original Medicare Plan.
When we
are the primary payer, we process the claim first.
When Original Medicare
is the primary payer, Medicare processes
your claim first. In most cases,
your claims will be coordinated
automatically and we will pay the balance of
covered charges. You
will not need to do anything. To find out if you need
to do something
about filing your claims, call us at 1-800-289-2818.
When Medicare is the primary payer, we do not waive any out-of-pocket
costs.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from 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, coinsurance, or
deductibles. If you enroll in a Medicare
managed care plan, tell us. We
will need to know whether you are in the
Original Medicare Plan or in a
Medicare managed care plan so we can
correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your
FEHB coverage to
enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM
does not contribute to your Medicare
managed care plan premium.) For
information on suspending your
FEHB enrollment, contact your retirement
office. If you later want to re-enroll
in the FEHB Program, generally you
may do so only at the next
open season unless you involuntarily lose
coverage or move out of the
Medicare+ Choice service area.
Enrollment in Note: If you choose not to enroll in Medicare Part B,
you can still be
Medicare Part B covered under the FEHB Program. We
cannot require you to enroll in Medicare. 47
47
Page 48 49
2002
Health Net 48 Section 9
TRICARE TRICARE is the health care
program for eligible dependents of military persons and retirees of the
military. TRICARE includes the CHAMPUS
program. If both TRICARE and this
Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if
you have questions about
TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your eligible care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for for injuries medical or hospital care for injuries or illness caused
by another person,
you must reimburse us for any expenses we paid. However,
we will
cover the cost of treatment that exceeds the amount you received in
the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 48
48 Page 49 50
2002 Health Net
49 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Room and board, nursing care (except for
skilled nursing care), and personal care designed to assist a member who has
reached the maximum
level of recovery
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for
those services. See page 12.
Experimental or investigational services Our parent company, Health
Net, Inc. (HNI), has a technology assessment policy committee whose sole
function is to evaluate if a drug,
device, medical treatment or procedure is
experimental or
investigational. HNI bases its determination on one or more
of the
following:
Is it broadly accepted in the medical community as standard, safe and
effective for the illness or injury being treated;
Is it approved for use by the appropriate governmental regulatory bodies,
including the FDA:
It is attainable in the U. S. outside of a research
institution, program or protocol;
Does it clearly improve the net health
outcome as evaluated against non-experimental or non-investigational health care
services using
credible and accepted medical evidence.
Group Health Coverage Health care coverage that a member is eligible
for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies. 49
49
Page 50 51
2002
Health Net 50 Section 10
Medical necessity Services
required to identify or treat an illness that is either diagnosed or reasonably
suspected. Medically Necessary services must, in the
judgement of Health
Net:
1. be required to treat an illness or injury; and
2. be consistent
and appropriate for the diagnosis and treatment of the
Member's conditions;
and
3. be in accordance with the standards of accepted principles of
medical practice in the United States; and
4. be performed at the most
appropriate level of care for the Member as
determined by the Member's
medical condition and not the
Member's financial or family situations, or
the distance the Member
lives from the Hospital, or any other non-medical
factor; and
5. not be for the convenience of the Member, nor the Member's
family,
support network, Physician or another Health Professional; and
6. not be Experimental, Unproved or Investigational or furnished in
connection with medical or other research.
Us/ We Us and we refer to Health Net of Arizona, Inc.
You
You refers to the enrollee and each covered family member. 50
50 Page 51 52
2002 Health Net 51 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office about enrolling in the can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot change your
enrollment status without information from
your employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22, including any
foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a
disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if
you marry, give birth, or add a child to your family. You may
change your enrollment 31
days before to 60 days after that event. The Self
and Family enrollment begins on the
first day of the pay period in which the
child is born or becomes an eligible family
member. When you change to Self
and Family because you marry, the change is effective
on the first day of
the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no
longer eligible to receive health benefits, nor will we. Please
tell us immediately when
you add or remove family members from your coverage
for any reason, including
divorce, or when your child under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not
be enrolled in or covered as a family member by another FEHB
plan. 51
51 Page
52 53
2002 Health Net 52
Section 11
When benefits and The benefits in this brochure are
effective on January 1. If you joined premiums start this Plan during
Open Season, your coverage begins on the first day of your first pay
period
that starts on or after January 1. Annuitants' coverage and premiums begin on
January 1. If you joined at any other time during the year, your employing
office will tell
you the effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
Law enforcement officials when investigating and/
or prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as
temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are
a family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you may be eligible
for your own FEHB coverage under the spouse equity law. If you are recently
divorced
or are anticipating a divorce, contact your ex-spouse's employing
or retirement office to
get RI 70-5, the Guide to Federal Employees
Health Benefits Plans for Temporary
Continuation of Coverage and Former
Spouse Enrollees, or other information about your
coverage choices.
TCC If you leave Federal service, or if you lose coverage because
you no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC).
For example, you can receive TCC if you are
not able to continue your FEHB enrollment
after you retire.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
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. 52
52 Page 53 54
2002 Health Net 53 Section 11
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity law
ends. If you canceled your
coverage or did not pay your premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse
equity law.
If you leave Federal service, your employing office will notify
you of your right to
convert. You must apply in writing to us within 31 days
after you receive this notice.
However, if you are a family member who is
losing coverage, the employing or
retirement office will not notify
you. You must apply in writing to us within 31 days
after you are no longer
eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you
will not have to answer questions about your health, and we
will not impose a waiting
period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 offers limited Federal Group Health Plan
protections for health coverage availability and continuity to people who
lose employer
Coverage group coverage. If you leave the FEHB Program, we will give
you a Certificate of Group Health Plan Coverage 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
questions. These highlight HIPAA rules, such as the requirement that Federal
employees
must exhaust any TCC eligibility as one condition for guaranteed
access to individual
health coverage under HIPAA, and information about
Federal and State agencies you can
contact for more information. 53
53 Page 54 55
2002 Health Net 54 Long Term Care
Long Term Care Insurance Is Coming Later in 2002!
The Office
of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in October
2002. As part of its educational
effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease
such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice care, and more. It
can supplement care provided by family members, reducing the burden you place
on
them.
Welcome to the club! 76% of Americans believe they will never need long
term care, but the facts are that
about half them will. And it's not just
the old folks. About 40% of people needing
long term care are under age 65.
They may need chronic care due to a serious
accident, a stroke, or
developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their
financial and retirement planing.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's
before inflation!
Long term care can easily exhaust your
savings. Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a stay in
an assisted
living facility or a continuing need for a home health aide to
help you get in and out
of bed and with other activities of daily living.
Limited stays in skilled nursing
facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or older
or fully disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
{RV:
7-26}
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin
in mid-2002. In the meantime, you can learn more about the program on our web
site at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs. Unfortunately, they are WRONG!
How are YOU planning to pay for the future custodial or chronic care you may
need? You should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information
on how to apply for this new
insurance coverage?
How can I find out more about the
program NOW? 54
54 Page 55 56
2002 Health Net 55 Index
Index
Do not rely on this page; it is for your convenience and does not
explain your benefit coverage.
Accidental injury 25, 26, 29, 30, 32 ,39
Allergy tests 18 Alternative treatment 19, 23, 33
Ambulance 30, 32
Anesthesia 27, 29
Autologous bone marrow transplant 19, 27
Biopsies 24
Blood and blood plasma 29
Casts 29 Catastrophic protection 57
Changes
for 2002 8 Chemotherapy 19
Childbirth 17, 51 Cholesterol tests 15
Circumcision 17 Claims 35, 42, 47, 52
Coinsurance 12, 49 Colorectal
cancer screening 15
Congenital anomalies 24, 25 Contraceptive devices and
drugs
17, 36 Coordination of benefits 45
Covered charges 49
Crutches
22
Deductible 12, 49 Definitions 49
Dental care 26, 39 Diagnostic services 14, 15, 29, 33
Disputed claims
review 43 Donor expenses (transplants) 27
Dressings 29 Durable medical
equipment
(DME) 22 Educational classes and programs
23 Effective date of
enrollment 52
Emergency 7, 32 Experimental or investigational 49
Eyeglasses 20
Family planning 17 Fecal occult blood test 15
General Exclusions 41
Hearing services 16, 20
Home health services 22 Hospice care 30
Hospital
28 Immunizations 16
Infertility 18 In hospital physician care 28
Inpatient Hospital Benefits 28 Insulin 22, 35, 36
Laboratory and
pathological services 15, 29
Magnetic Resonance Imagings (MRIs) 15
Mail
Order Prescription Drugs 36 Mammograms 15, 16
Maternity Benefits 17 Medicaid
48
Medically necessary 50 Medicare 45, 46, 47
Members 4 Mental
Conditions/ Substance
Abuse Benefits 33 Newborn care 17
Non-FEHB
Benefits 40 Nurse
Licensed Practical Nurse 22 Nurse Anesthetist 29
Registered Nurse 22 Nursery charges 17
Obstetrical care 9, 17
Occupational therapy 19
Office visits 12, 14, 15, 17, 56 Oral and
maxillofacial surgery 26
Orthopedic devices 20, 21 Out-of-pocket expenses 12
Outpatient facility care 29, 32 Oxygen 29
Pap test 15
Physical examination 15 Physical therapy 19
Physician 9, 24, 28 56
Preventive care, adult 15
Preventive care, children 16 Preventive services
15, 16
Prescription drugs 35 Prior approval 11, 43
Prostate cancer
screening 15 Prosthetic devices 21, 22
Psychologist 33 Radiation therapy 19
Rehabilitation therapies 19 Renal dialysis 19, 22
Room and board 28, 49
Second surgical opinion 14
Skilled nursing facility care 14, 30, 49
Smoking cessation 23, 38 Speech therapy 20
Splints 26, 29 Sterilization
procedures 17, 25
Subrogation 48 Substance abuse 33
Surgery 24
Anesthesia 27 Oral 26
Outpatient 29 Reconstructive 25
Syringes 36 Temporary continuation of
coverage 52 Transplants 27
Treatment therapies 19 Vision services 16, 20
Well child care 16 Wheelchairs 22
Workers' compensation 48 X-rays 15, 29
55
55 Page 56 57
2002 Health Net 56 Summary
Summary of Benefits – for Health Net of Arizona HMO -2002
Do not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the definitions, limitations, and exclusions in
this brochure. On this page we summarize specific expenses we cover;
for
more detail, look inside.
If you want to enroll or change your enrollment
in this Plan, be sure to put the correct enrollment code from the cover on your
enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office Office visit
copay: $10 primary care; $10 specialist 14
Services provided by a hospital:
Inpatient
Outpatient
$100 per admission
$50 per visit
28
29
Emergency benefits:
In-area
Out-of-area
$50 per visit
$50 per visit
31
32
Mental health and substance abuse treatment Regular cost sharing. 33
Prescription drugs Drugs prescribed by a Plan doctor
and obtained at a
Plan pharmacy.
You pay a $10 copay per generic
prescription unit or
refill; $20
copay per preferred brand name
prescription unit or refill;
$40
copay per non-preferred brand
name prescription unit or refill;
$40 copay per self-injectable
(except for insulin) prescription
unit
or refill.
35
Dental Care Accidental injury benefit. You pay
nothing. 39 56
56 Page 57 58
2002 Health Net 57 Summary
Vision
Care Comprehensive examination once every 12 months – you pay nothing
Lenses
and/ or frames once every
24 months – you pay $10 copay for
materials
Elective contact lenses once every
24 months -$100 allowance
provided
toward cost of contacts,
evaluation and fitting
20
Special features: Flexible benefits option, services for deaf and hearing
impaired, Disease Management
Services
38
Protection against catastrophic costs
(your out-of-pocket maximum)
Nothing after $2,000.00/ Self Only
or $4, 000. 00/ Family enrollment
per year
Some costs do not count toward
this protection
12 57
57 Page
58 59
2002 Health Net 58
Summary
Notes 58
58 Page 59 60
2002 Health Net
59 Summary
Notes 59
59
Page 60
2002 Health Net 60
Rates
2002 Rate Information for
Health Net of Arizona,
Inc.
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and
special FEHB guides are published for
Postal Service Nurses, RI 70-2B; and for Postal Service
Inspectors and
Office of Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of
any postal employee organization who are not career
postal employees. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only A71 $87.21 $29.07 $188.96 $62.98 $103. 20 $13.08
Self and
Family A72 $223.41 $90.35 $484.06 $195.75 $263. 75 $50.01 60