Enrollment codes for this Plan:
G21 Self Only
G22 Self and Family
Arnett HMO Health Plan
2002
R1 73-288
For
changes in
benefits see
. page 6
http: / / www. arnettplans. com
Authorization for distribution by the:
United States Office of
Personnel Management
Retirement and Insurance Service
http: / / www. opm. gov/ insure
This Plan has an excellent accreditation
from the NCQA. See the 2002
Guide
for more information on NCQA. 1
1
Page 2 3
2002
Arnett HMO 2
Table of Contents
Introduction . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 4
Plain language . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Inspector
General Advisory Stop Healthcare Fraud! . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Section 1. Facts about this HMO plan . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . 5
How we pay providers . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 5
Your Rights . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Service Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 5
Section 2. How we change for 2002 . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Program-wide
changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 6
Changes to this Plan . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 6
Section 3. How you get care . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 7
Where you get covered care . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 7
Plan providers . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Plan facilities
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
What you must do to get covered care . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 7
Primary care . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . 7
Specialty care . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 7
Hospital care . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Circumstances beyond
our control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Services
requiring our prior approval . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 4. Your costs for covered services . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 10
Copayments. . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . 10
Deductible . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Coinsurance . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Your out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . 10
Section 5. Benefits . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . 11
Overview. . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
( a) Medical services and supplies provided by physicians and other health
care professionals . . . . . . . . . . . . . . . . . . . 12
( b) Surgical
and anesthesia services provided by physicians and other health care
professionals . . . . . . . . . . . . . . . . . 18
( c) Services provided by
a hospital or other facility, and ambulance services . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . 21
( d) Emergency services/ accidents .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . 23
( e) Mental Health and
Substance Abuse benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 25
( f) Prescription
drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
(
g) Dental benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . 28
Table of Contents 2
2 Page 3 4
2002 Arnett HMO
3
Section 6. General Exclusions Things we don t cover . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 29
Section 7. Filing a claim for covered services . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 30
Section 8. The disputed
claims process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . 33
When you have
Other health coverage . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . 33
What is Medicare? . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
The Original
Medicare Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Medicare Managed Care Plan . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35
TRICARE/ Workers Compensation/ Medicaid . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Other Government Agencies . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 36
When others are responsible for injuries . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 36
Section 10. Definitions of terms we use in this brochure . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 37
Section 11. FEHB facts . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Coverage information
No pre-existing coverage limitation . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 38
Where you get information about enrolling in the
FEHB Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . 38
Types of coverage available to you and your family . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
When benefits and premiums start . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Your medical and claims records are confidential . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . 39
When you lose benefits
When FEHB coverage ends . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 39
Spouse equity coverage . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 39
Temporary
Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Enrolling in
TCC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40
Getting a Certificate of Group Health Plan Coverage . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Long term care insurance is coming later in 2002 . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. 41
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . 42
Summary of benefits. . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Inside back cover
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Back cover
Table of Contents 3
3 Page 4 5
2002 Arnett HMO
4 Introduction
Introduction
Arnett HMO
415 N. 26th
Street, Suite 101
Lafayette, IN 47903-6108
This brochure describes the benefits of Arnett HMO under our contract ( CS
2171) with the Office of Personnel Management ( OPM) ,
as authorized by the
Federal Employees Health Benefits law. This brochure is the official statement
of benefits. No oral statement can
modify or otherwise affect the benefits,
limitations, and exclusions
of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family
coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits that were available before
January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and changes are
summarized on page 11. Rates
are shown at the end of this brochure.
Plain Language
Terms 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 Arnett HMO
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 this brochure, let OPM know. Visit OPM s Rate
Us feedback area at
www. opm. gov/ insure or e-mail OPM at fehbwebcomments@
opm. gov. You may also write to OPM at The Office of Personnel
Management,
Office of Insurance Planning and Evaluation Division, 1900 E. Street NW,
Washington, DC 20415-3650
Inspectory General Advisory
Stop Healthcare 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 765-448-7440 and explain the
situation.
If we do
not resolve the issue, call or write
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the person tries to
obtain
services for someone who is not an eligible family member, or are no longer
enrolled in
the Plan and tries to obtain benefits. Your agency may also take
administrative action against
you.
THE HEALTH CARE FRAUD HOTLINE
202-418-3300
The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW, Room 6400
Washington, DC 20415 4
4 Page 5 6
2002 Arnett HMO 5
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.
Arnett HMO is a group model HMO. There are over 250 participating physicians.
Plan members may select their primary care
physicians among the
participating family practice physicians, internists, pediatricians, or
obstetrician/ gynecologists.
Your Rights
OPM requires that all FEHB Plans to 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.
If you want more information about us, call 888-448-7440, or write to Arnett
HMO P. O. Box 6108, Lafayette, IN 47903-6108. You
may also contact us by fax
at 765-448-7700, or visit our website at www. arnettplans. com.
Service Area
To enroll in this Plan, you must live in, or work in
our Service Area. This is where our providers practice. Our services area for
this
Plan are available in the following area: The Greater Lafayette,
Indiana area; including the counties of Benton, Boone, Carroll, Cass,
Clinton, Fountain, Fulton, Howard, Jasper, Montgomery, Newton, Pulaski,
Tippecanoe, Warren, and White counties.
Ordinarily you must get your care from our 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 out of our service area
unless the services have prior plan
approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the
area ( for
example, if your child goes to college in another state) , you should consider
enrolling in a fee-for-service plan or an HMO
that has agreements with
affiliates in other areas. If you or a family member move, you do not have to
wait until Open Season to
change plans. Contact your employing or retirement
office.
Section 1 5
5 Page
6 7
2002 Arnett HMO 6
Section 2. How we change for 2002
Do not rely on these change
descriptions, this page is not an official statement of benefits. For that go to
Section 5 Benefits. Also, we
edited and clarified language throughout the
brochure; any language change not shown here is a clarification that does not
change
benefits.
Program wide changes
We changed speech therapy benefits by
removing the requirement that services must be required to restore functional
speech.
(Section 5( a))
Changes to this Plan
Your share of the non-Postal premium will
decrease by -9.5% for Self Only or -14.3% for Self and Family.
We have a
new smoking cessation program where you receive 8 weeks of counseling and
prescriptions at no cost. (Section 5( f))
We now cover certain intestinal
transplants. (Section 5( b))
Section 2 6
6 Page
7 8
2002 Arnett HMO 7
Section 3. How you get care
Identification Cards We will send you
an identification ( ID) card when you enroll. You should carry your ID card with
you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your
ID card, use
your copy of the Health Benefits Election Form, SF-2809, your
health benefits
enrollment confirmation ( for annuitants) , or your Employee
Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of
your
enrollment, or if you need replacement cards, call us toll free at
888-448-7440 or 765-
448-7440.
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 member must choose
a primary care physician. This decision
is important since your primary care physician
provides or arranges for most
of your healthcare.
Primary Care Your primary care physician can be a family practitioner,
internist, pediatrician, or
obstetrician gynecologist. Your primary care
physician will provide most of your health
care, or give you a referral to
see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves
the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you
receive a referral from your primary
care physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain
number
of visits without additional referrals. The primary care physician must provide
or
authorize all follow-up care. Do not go to the specialist for return
visits unless your
primary care physician gives you a referral.
Section 3
to get covered care 7
7 Page 8 9
2002 Arnett HMO
8
Here are other things you should know about specialty care:
If you
need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will develop a treatment plan
that
allows you to see your specialist for a certain number of visits
without additional
referrals. Your primary care physician will use our
criteria when creating your
treatment plan.
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 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 765-448-7440 or 888-448-7440. If
you are new to the
FEHB Program, we will arrange for you to receive care.
Section 3 8
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2002 Arnett HMO 9
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 alternate care center; or
The
day your benefits from your former plan run out; or
The 92nd day after you
become a member of this Plan, whichever happens first.
These provisions apply only to the hospital benefit of the hospitalized
person; we cover
your other non-hospital care
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to
delay your services
or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most services. 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.
Your physician must obtain prior approval by the Plan for the following
service, but not
limited to:
All Inpatient Admissions
Same Day
Surgeries
Outpatient Mental Health and Substance Abuse visits
Home
Health Care
Skilled Nursing Facilities
Rehabilitation Therapies
Some
Durable Medical Equipment and Prosthetics
Out of Plan Network Referrals
Section 3
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Section 4. Your Costs for Covered Services
You must share
the cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. ,
when you receive services.
Example: When you see your primary care physician you pay a copayment of $ 10
per
office visit.
Deductible We do not have a deductible with this Plan.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care. In
our Plan, you pay 20% of our fees for durable
medical equipment and prosthetics. You
pay 50% of our allowance for
infertility services by a non-primary care physician in our
plan.
Your out-of-pocket maximum We do not have an out-of-pocket maximum for
coinsurance and copayments.
Section 4 10
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Section 5. Benefits OVERVIEW (See page 6 for how our benefits
changed this year and page 45 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 filing advice, or more information
about our benefits, contact us at 765-448-7440 or at our website at www.
arnettplans. com.
( a) Medical services and supplies provided by physicians and other health
care professionals . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-17
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
( b) Surgical and anesthesia services provided by physicians and other health
care professionals . . . . . . . . . . . . . . . . . . . . . . . . . 18-20
Surgical procedures
Reconstructive surgery
Oral and maxillofacial
surgery
( c) Services provided by a hospital or other facility, and ambulance
services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . 21-22
Inpatient hospital
Outpatient hospital or ambulatory
surgical center
Extended care benefits/ skilled
nursing facility
benefits
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . 23-24
Medical emergency
( e) Mental health and substance abuse benefits . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . 25-26
( f) Prescription drug benefits . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . 27-28
( g) Dental
benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . 29
Section 5
Speech therapy
Hearing services ( testing, treatment, and supplies)
Vision services ( testing, treatment, and supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment
Home
health services
Chiropractic
Alternative treatments
Educational
classes and programs
Ambulance
Hospice care
Ambulance
Organ/ tissue transplants
Anesthesia 11
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Section 5( a)
Preventive care, adult Continued on next page
Section 5 ( a) . Medical services and supplies provided by physicians and
other health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this
brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or
arrange your care.
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.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians $ 10 per office visit
In
physician s office
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood
tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
Ultrasound
Electrocardiogram and EEG
CAT scans and MRI $ 50 copay
Nothing
( Copays may apply to associated
visits)
Nothing
( Copays may apply to associated
visits) 12
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Routine screenings, such
as:
Total Blood Cholesterol once every three years
Colorectal Cancer
Screening, including
-Fecal occult blood test
-Sigmoidoscopy, screening
every five years starting at age 50
Prostate Specific Antigen ( PSA test)
one annually for men
age 40 and older.
Routine pap test
Routine
mammogram covered from age 35 and older as follows: :
-From age 35 through
39, one during this five year period
-From age 40 through 64, one every
calendar year
-At age 65 and older, one every two consecutive calendar years
Not covered: All charges
Physical exams required for obtaining or
continuing employment or
insurance, attending schools, camp, travel, or
sports are not covered
Routine immunizations
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics
Well-child care charges for routine
examinations, immunizations and
care
Examinations, such as:
-Eye exams through age 17 to determine the need
for vision correction.
-Ear exams through age 17 to determine hearing
correction.
-Examinations done on the day of immunizations
Maternity care
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 8 for
other circumstances, such as extended
stays for you or your baby.
You may remain in the hospital up to 48 hours
after a regular delivery
and 96 hours after a cesarean delivery. We will
extend your impatient
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 or injury. See pages 18 and 21 for more information.
Not covered: Routine sonograms to determine fetal age, size, or sex. All
charges
Section 5( a)
Preventive care, adult You Pay
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
$ 10 for the initial office visit and
nothing thereafter.
Nothing
( Copays may apply to
associated visits) 13
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Family planning You Pay
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives ( such as Norplant)
Injectable contraceptives drugs
( such as Depo provera)
Intrauterine devices ( IUD s)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.
Not covered: Reversal of voluntary surgical sterilization
Genetic counseling Voluntary abortion
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination:
-Intravaginal insemination ( IVI)
-Intracervical insemination ( ICI)
-Intrauterine insemination ( IUI)
Fertility drug Clomiphene citrate ( Clomid)
See Section 5( f)
Not covered:
Assisted reproductive technology (ART) procedures, such
as: -In vitro fertilization
-Embryo transfer, gameteGIFT and zygote ZIFT -Zygote transfer
Services and supplies related to excluded ART procedures Cost of donor sperm
Cost of donor egg
Allergy care
Testing and treatment
Allergy injection
Allergy serum
Not covered:
Provocative food testing and sublingual allergy
desensitization All charges
Treatment therapies
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 20.
Respiratory and inhalation therapy
Dialysis Hemodialysis and peritoneal
dialysis
Intravenous ( IV) Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
We will only cover GHT when we preauthorize the
treatment from
your physician s referral.
Nothing
( Copays may apply to
associated visits)
$ 10 per office visit with primary
care physician and 50%
coinsurance
for non primary
care physician and services.
Covered under the prescription
benefit.
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
All charges
All charges 14
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Physical and occupational therapies You Pay
60 visits per condition for the services of each of the following:
-qualified physical therapists and
-occupational therapists
Not covered: All charges
Long-term rehabilitative therapy
Exercise programs
Speech therapy
60 visits per condition for the services of speech
therapists
Hearing services ( testing, treatment, and supplies)
Hearing tests
are covered for diagnosis or treatment of disease or injury.
Hearing exams
are covered for diagnosis or treatment of disease
or injury. Children
through age 17. ( See Preventive care children )
Not covered: All charges
All other hearing testing
Hearing
aids, testing and examinations for them
Vision services ( testing, treatment, and supplies)
Annual eye
exam and refraction through age 17.
( See Preventive care, children )
Diagnosis and treatment of disease or injury of the eyes.
Refractions
following cataract surgery.
Not covered: All charges
Eyeglasses or contact lenses, and
examinations for them
Eye exercises and orthoptics
Radial keratotomy
and other refractive surgery
Foot care
Routine foot care when you are under active treatment
for a metabolic $ 10 per office visit
or peripheral vascular disease, such
as diabetes.
Podiatry care including bunions, spurs, ingrown toe nails, etc.
Not covered: All charges
Shoe inserts and orthotics
Cutting,
trimming of toenails, and similar routine treatment of
conditions of feet,
except as stated above
Treatment of weak, strained or flat feet and of
instability, imbalance
or subluxation of the foot
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits)
Nothing
( Copays may apply to
associated visits) 15
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Orthopedic and prosthetic devices You Pay
Artificial limbs
and eyes, stump hose 20% coinsurance
Externally worn breast prostheses and
surgical bras, including
necessary replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy
Note: We pay internal prosthetic devices as hospital benefits;
see
Section 5( c) for payment information. See 5( b) for coverage
of surgery to
insert the device.
Orthopedic braces
Corrective orthopedic aplliance for non-dental
treatment of
temporomandibular joint ( TMJ) pain dysfunction syndrome
Not covered: All charges
Orthopedic devices
Corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose,
and other
supportive devices
Durable Medical Equipment ( DME)
Rental or purchase at our option,
including repair and adjustment, of 20% coinsurance
durable medical
equipment prescribed by your Plan physician, such as
oxygen and dialysis
equipment. Under this benefit, we also cover:
Hospital beds
Standard wheelchairs
Crutches
Walkers
Blood
glucose monitors
Insulin pumps
Nebulizers
Note: Our provider for our durable medical equipment is Lincare. They
can
be contacted directly once the physician has prescribed the equipment
through them. You can reach them at 800-487-0001 to make arrangements
for pick up or delivery. If you would like to know more about this service,
please call us at 888-448-7440.
Not covered: All charges
Personal comfort or convenience items
Single patient use, self-administered dressings and
other disposable
supplies 16
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Section 5( a)
Home health services You Pay
Home health
care ordered by a Plan physician and provided by a Nothing
registered nurse
( R. N. ) , licensed practical nurse ( L. P. N. ) , licensed
vocational
nurse ( L. V. N. ) , or home health aid.
Services include oxygen therapy,
intravenous therapy, and medications.
Not covered: All charges
Nursing care requested by, or for the
convenience of, the patient or
the patient's family
Home care
primarily for personal assistance that does not include
a medical component
and is not diagnostic, therapeutic,
or rehabilitative
Chiropractic
No benefit All charges
Alternative treatments
Not covered: All charges
Acupuncture
Naturopathic services
Hypnotherapy
Biofeedback
Educational Classes and programs
Smoking Cessation Program (
there is an assessment for eligibility ) Nothing; 50% after 8 weeks
-8 weeks of Zyban or nicotine patches at no cost
( filled at Arnett
pharmacy only )
-smoking cessation counselors
-educational materials
If after 8 weeks there is need for more treatment, it is available. For more
information contact us at ( 765) 448-7453.
Note: Primary Care physicians can write prescriptions for the smoking aids
through the prescription drug benefit; see Prescription drugs. 17
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Section 5( b) .
Surgical and anesthesia services provided by physicians and other health
care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this
brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or
arrange your care.
Be sure to read Section 4. Your costs for covered
services, for valuable information about how cost
sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional
for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e., hospital,
surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF ALL
SURGICAL PROCEDURES.
Please refer to the precertification information shown
in Section 3.
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as: Nothing
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative
care by the surgeon
Correction of amblyopia and strabismus
Endoscopy
procedures
Biopsy procedures
Removal of tumors and cysts
Correction
of congenital anomalies ( see Reconstructive surgery )
Surgical
treatment of morbid obesity which is defined in our Plan as
-A weight of at
least two ( 2) times the ideal weight for frame, age,
height, and gender as
specified in the 1983 Metropolitan Life
Insurance tables;
-A body mass
index of at least thirty-five ( 35 kilograms per meter
squared with
comorbidity or coexisting medical conditions such as
hypertension,
cardiopulmonary conditions, sleep apnea, or diabetes;
-A body mass index of
at least forty ( 40) kilograms per meter
squared without comorbidity
-Morbid obesity that has persisted for at least five ( 5) years;
-For
which non-surgical treatment that is supervised by a physician
has been
unsuccessful for at least eighteen ( 18) consecutive months.
Note: For purposes of this section, body mass index equals weight in
kilograms divided by height in meters squared.
Insertion of internal prosthetic devices. See 5( a) Orthopedic
and
prosthetic device coverage information.
Voluntary sterilization
Treatment of burns
Section 5( b)
Surgical procedures Continued on next page
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Note: Generally, we pay for internal prostheses ( devices)
according to
where the procedure is done. For example, we pay Hospital
benefits for
a pacemaker and Surgery benefits for insertion of the
pacemaker.
Not covered: All charges
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care
Reconstructive surgery
Surgery to correct a functional defect
Nothing
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 for the common form or norm. Examples of
congenital anomalies are: protruding ear deformities, cleft lip, cleft
palate, birth marks, webbed fingers, webbed toes.
All stages of breast reconstruction surgery following a mastectomy,
such
as:
-surgery to produce a symmetrical appearance on the other breast;
-treatment of any physical complications, such as lymphedemas;
-breast
prosthesis and surgical bras and replacements
( see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones;
Surgical
correction of cleft lip, cleft palate or severe
functional malocclusion;
Removal of stones from salivary ducts;
Excision of leukoplakia or
malignancies;
Excision of cysts and incision of abscesses when done as
independent
procedures; and
Other surgical procedures that do not
involve teeth or their
supporting structures.
Section 5( b)
Surgical procedures (Continued) You pay
Nothing
Oral and maxillofacial surgery Continued on next page 19
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Oral and
maxillofacial surgery (Continued) You pay
Not covered:
All charges
Oral implants and transplants
Procedures that involve the
teeth or their supporting structures (such as
periodontal membrane, gingiva,
and alveolar bone.
Any dental care involved in treatment of
temporomandibular
joint (TMJ) pain dysfunction syndrome.
Organ/ tissue transplants
Limited to: Nothing
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single
Double
Pancreas
Allogeneic ( donor) bone marrow transplants
Autologous bone marrow transplants ( autologous stem cell and
peripheral
stem cell support) for the following conditions: acute
lymphocytic leukemia;
advanced Hodgkin s lymphoma; advanced
non-Hodgkin s lymphoma; advanced
neurpblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer;
and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
Intestinal transplants ( small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas
National Transplant Program ( NTP)
Limited Benefits Treatment of 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 as
long
as the recipient is enrolled into our Plan.
Not covered: All charges
Donor screening tests and donor search
expenses, except those
performed for the actual donor
Implants of
artificial organs
Transplants not listed as covered
Anesthesia
Professional services provided in: Nothing
Hospital
inpatient
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Section 5( b) 20
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Section 5( c) . Services provided by a hospital or other facility,
and
ambulance services
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this
brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or
arrange your care and you must be hospitalized in a Plan facility.
Be sure
to read Section 4. Your costs for covered services, for valuable
information about how cost
sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with
Medicare.
The
amounts listed below are for the charges billed by the facility ( i. e.,
hospital or surgical center)
or ambulance service for your surgery or
care. Any costs associated with the professional charge
( i. e.,
physicians, etc. ) are covered in Sections 5( a) or 5( b) .
YOUR
PHYSICIAL MUST GET PRECERTIFICATION OF ALL SURGICAL
PROCEDURES. Please
refer to the precertification information shown in Section 3.
Benefit Description You pay
Inpatient hospital
Room and board,
such as Nothing
ward, semiprivate, or intensive care accommodations;
general nursing care; and
meals and special diets
Note: If you want a private room and it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines given
while admitted.
Diagnostic laboratory tests and X-rays
Administration of
blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies
and equipment, including oxygen
Anesthetics, including nurse anesthetist
services
Take-home supplies
Medical supplies, appliances, medical
equipment, and any covered
items billed by a hospital for use at home.
Not covered: All charges
Custodial care
Non-covered
facilities, such as nursing homes and schools
Personal comfort items, such
as telephone, television,
barber services, guest meals and beds
Private
nursing care
Take-home drugs 21
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22 Section 5( c)
Outpatient hospital or ambulatory surgical
center You Pay
Operating, recovery, and other treatment rooms Nothing
Drugs and medications given at the facility
Diagnostic laboratory tests,
X-rays, and pathology services
Administration of blood, blood plasma, and
other biologicals
Blood or 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.
CAT Scans and MRIs $ 50 copay
Not covered: All charges
Take home
drugs
Extended care benefits/ skilled nursing facility benefits
Extended
care/ skilled nursing benefit Nothing
Note: 90 day annual limit
Not covered: All charges
Custodial care
Hospice Care
Care for a terminally ill member is covered in the
home or skilled facility Nothing
as long as there are skilled components
medically necessary. Services are
provided under the direction of a Plan
doctor who certifies that the patient
is in the terminal stages of illness,
with a life expectancy of approximately
six months or less.
Ambulance
Local professional ambulance service when medically
appropriate Nothing 22
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Section 5( d)
Section 5( d). Emergency services/ accidents
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.
Be sure to read Section 4. Your
costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with
Medicare.
What is a medical emergency? A medical emergency is the sudden and
unexpected onset if 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, poisoning, 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: Benefits are provided for urgent and
emergency medical services whether rendered inside or outside of the Plan s
Service
Area.
Urgent Care: Medical direction and advice is
available through your primary care physician, seven ( 7) days a week, twenty
four ( 24) hours a day. All urgent care services whether inside or outside
of the service area must be referred in advance by
your
primary care physician.
Emergency Care: Benefits are not provided for the use of an
emergency room except for emergency care. In the event of an
Emergency, you
should go to a participating practitioner, unless the condition requires you to
go to the nearest emergency
room. If you are admitted, the applicable copay
would be waived. If admitted in an out of area facility, please notify the
Plan within 48 hours of admitting, unless it is not reasonably possible to
do so. If this is the case, notify the Plan as soon as
possible.
Benefit Description You pay
Emergency within our service area
Emergency care at doctor s office $ 10 copay
Emergency care at an approved urgent care center $ 25 copay
Emergency
care at a hospital, and not admitted. $ 75 copay
Emergency care at a
hospital, and admitted. Nothing
Not covered: All charges
Elective
care or non-emergency care
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Arnett HMO 24 Section 5( d)
Emergency outside our service area
You pay
Emergency care at an urgent care center $ 25 copay
Emergency care at a hospital, and not admitted. $ 75 copay
Emergency care
at a hospital, and admitted. Nothing
Not covered: All charges
Elective care or non-emergency care
Emergency care provided outside the
service area is the need for care
could have been foreseen before leaving
the service area
Medical and hospital costs resulting from a normal
full-term delivery
of a baby outside the service area
Ambulance
Professional ambulance service when medically
appropriate. Nothing
See 5( c ) for non-emergency service. 24
24 Page 25 26
2002 Arnett HMO 25
Section 5 (e). Mental
health and substance abuse benefits
Here are some important things to
remember about these benefits:
All benefits are subject to the
definitions, limitations, and exclusions in this brochure.
Be sure to read
Section 4. Your costs for covered services, for valuable information
about how cost
sharing works. Also read Section 9 about coordinating
benefits with other coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions
after
the benefits description below.
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Section 5( e)
Your cost sharing responsi-
bilities are no
greater than for
other illness or conditions
$ 10 copay per office visit
Benefit Description You pay
Network 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.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
Diagnostic tests Nothing
Services provided by a hospital or other
facility Nothing
Services in approved alternative care settings such as
partial hospitalization,
full-day hospitalization, facility based intensive
outpatient treatment
Not covered: Services we have not approved All charges
Note: OPM s review of disputes about the network treatment plans will be
based on the treatment plan s clinical appropriateness. OPM will generally
not order one clinically appropriate treatment plan in favor of another.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all of our network authorization processes.
Note: You primary care physician will make the referral for the treatment
plan for you.
Please contact your physician if you have questions, or call
us at 765-448-7440 or toll
free at 888-448-7440.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 25
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Section 5( f). Prescription drug benefits
Here are some important
things to keep in mind about these benefits:
We cover prescribed drugs
and medications, as described in the chart beginning on the next page.
All
benefits are subject to definitions, limitations, and exclusions in this
brochure and are payable
only when we determine they are medically
necessary.
Be sure to read Section 4. Your costs for covered services,
for valuable information about how cost
sharing works. Also read Section
9 about coordinating benefits with other coverage, including with
Medicare.
There are important features you should be aware of. These include:
Who can write your prescription . A plan physician must write the
prescription.
Where can you obtain them. Prescriptions must be
dispensed by a participating pharmacy, in order to receive this
benefit you
must present your Arnett HMO membership card at the time the prescription is
filled. The participating
pharmacy will then charge you the applicable
copayment amount. There are some specific drugs that require prior
authorization by Arnett HMO. Your ordering physician or the participating
pharmacy will then charge you the
applicable copayment amount. Take-home
prescriptions dispensed from a hospital facility will not be covered.
We use a formulary. The Arnett Prescription Drug Formulary is based on
the recommendations of our Pharmacy
and Therapeutics ( P& T) Committee
and from the input we receive from our physicians. The P& T Committee is
made up of pharmacists and physicians who make decisions regarding the
formulary. They review medications on
an ongoing basis to decide which are
the safest and most effective. The Committee meets every four months to
develop and update the formulary. Many medications have the same chemical
structure but are packaged
differently. The formulary limits the number of
similar drugs from which providers may choose. This allows us to
purchase
drugs in volume at greater discounts. This cost savings is passed on to our
members in the form of
reduced premiums and increased benefits.
These are the dispensing limitations. All prescriptions are filled for
up to a one month supply.
We offer three levels of copayments for this
prescription:
-Generic Drugs . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . $ 5 copay ( up to a one month supply)
-Formulary Brand Name
Drugs . . . . . . . . . . . . . . . . . . $ 15 copay ( up to a one month supply)
-Non-Formulary Brand Name Drugs . . . . . . . . . . . . . . $ 30 copay ( up
to a one month supply)
Note: If a generic drug is available and the prescription is filled with a
brand name drug, ( formulary or non-
formulary) member pays the difference in
cost between the generic and brand name drug in addition to the
copayment.
Drugs that require prior authorization must be authorized prior to the
prescription being filled in order to
be considered for payment.
Why use generic drugs? Generic drugs contain the same active
ingredients and are equivalent in strength and
dosage to the original brand
name product. Generic drugs cost you and your plan less money than a name-brand
drug.
When you have to file a claim. Our network providers should bill us
directly, but if by chance you receive a bill of
charges, you may contact us
at 765-448-7440 or mail them to us:
Arnett Health Plans, Attn HMO Claims Department, P. O. Box 6108, Lafayette,
IN 47903
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Prescription drug benefits begin on next page 26
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2002 Arnett HMO 27 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:
Drugs for which a prescription is required by
Federal law
Insulin,
with a copay charge applied to each visit.
Diabetic supplies, including
insulin syringes, needles,
glucose test tablets and test tape, Benedict s
solution
or equivalent, and acetone test tablets
Disposable needles and
syringes needed for injecting
covered prescribed medication
Oral
contraceptive drugs; contraceptive devices
Not covered: All charges.
Drugs available without a prescription or
for which
there is a nonprescription equivalent available
Drugs
obtained at a non-Plan pharmacy except for
out-of-area emergencies where the
network does
not extend
Vitamins, nutrients, and food supplements even
if
a physician prescribes or administers them
Medical supplies such as
dressings and antiseptics
Drugs and supplies for cosmetic purposes
Drugs to enhance athlete performance
Fertility drugs except for Chomiphene
(Clomid)
$ 5 copay Generic Drugs
$ 15 copay Formulary Brand Name Drugs
$ 30
copay Non--Formulary Brand Name Drugs
Note: Copays cover for up to a
one-month supply.
If there is no generic available, you will still
have
to pay the brand name copay. 27
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28 Section 5( g)
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Section 5( g). Dental benefits
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
providers must arrange your care.
We cover hospitalization for dental
procedures only when a non-dental physical impairment exists
which makes
hospitalization necessary to safeguard the health
of the patient; we do not
cover the dental procedure.
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.
Accidental injury benefit
We cover restorative services and
supplies necessary to promptly repair ( but not replace) sound natural teeth.
The need for these services must result from an accidental injury. Services
must be received within 72 hours
of the injury.
Service You Pay
In physician s or referral specialist s office $
10 copay
In an urgent care center $ 25 copay
In a hospital emergency room $ 75
copay
We have no other dental benefits. 28
28
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2002
Arnett HMO 29 Section 6
Section 6. General exclusions things
we don't cover
The exclusions in this section apply to all benefits.
Although we list a specific service as a benefit, we will not cover it unless
your
Plan doctor determines it is medically necessary to prevent, diagnose,
or treat your illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric practice;
Experimental or investigational
procedures, treatments, drugs, or devices;
Services, drugs, or supplies
related to abortions, except when the life of the mother would be endangered if
the fetus were carried
to term or when the pregnancy is the result of an act
of rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program. 29
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Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and
facilities, or obtain your prescription drugs at Plan pharmacies,
you will
not have to file claims. Just present your identification card and pay your
copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers, such as emergency care services.
Check with the
provider. If you need to file the claim, here is the process:
Medical, hospital,
and drug 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 765-448-7440 or toll free at
888-448-7440.
When you must file a claim such as an out of area emergency
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: Arnett Health Plans
Attn: HMO Claims
Department
P. O. Box 6108
Lafayette, IN 47903
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. 30
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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: Arnett HMO, Member Services Department, P. O. Box 6108,
Lafayette, IN 47903
(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
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. 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.
1
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Section 8
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 year in which you were denied
precertification or prior approval. This is the only deadline that may not
be extended.
OPM may disclose 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 765-448-7440 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 they can give your claim expedited treatment
too, or
-You can call OPM s Health Benefits Contracts Division 3 at 202-606-0737
between 8 a. m. and 5 p. m. eastern time.
5
6
The Disputed Claims process (Continued) 32
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2002 Arnett HMO 33 Section 9
Section 9. Coordinating benefits with other coverage
When you
have You must tell us if you are covered or a family member is covered under
another
other health coverage group health plan or have automobile
insurance that pays medical 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 if our allowance up to
our regular benefit. We will not
pay more than our allowance.
What is Medicare? Medicare is a health insurance program for:
People 65 years of age and older.
Some people with disabilities under 65
years of age.
People with end-stage renal disease ( permanent kidney failure
requiring dialysis or
a transplant) .
Medicare has two parts:
Part A ( Hospital Insurance) . Most people do not
have to pay for Part A. If you or
your spouse worked for at least 10 years
in Medicare-covered employment, you
should be able to qualify for
premium-free Part A insurance. ( Someone who was a
Federal employee on
January 1, 1983 or since automatically qualifies. ) Otherwise,
if you are
age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE
for more
information.
Part B ( Medical Insurance) . Most people pay monthly for Part
B. Generally, Part B
premiums are withheld from your monthly Social Security
check or your retirement
check.
If you are eligible for Medicare, you may have choices in how you get your
health care.
Medicare managed care plan is the term used to describe the
various health plan choices
available to Medicare beneficiaries. The
information in the next few pages shows how we
coordinate benefits with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan The Original Medicare Plan ( Original
Medicare) is available everywhere in the United
States. It is the way
everyone used to get Medicare benefits and is the way most people
get their
Medicare Part A and Part B benefits now. You may go to any doctor, specialist,
or hospital that accepts Medicare. The Original Medicare Plan pays its share
and you pay
your share. Some things are not covered under Original Medicare,
like prescription drugs.
(Primary payer chart begins on next page)
( Part A or Part B) 33
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2002 Arnett HMO
34 Section 9
( except for claims
related to
Workers
Compensation)
The following chart illustrates whether the Original Medicare Plan or
this Plan should be the primary payer for you according to our
enrollment
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
A. When either you or a covered spouse are age 65
or over and Then the primary Payer is
Original Medicare This Plan
1)
Are an active employee with the Federal government ( including when
you or
a family member are eligible for Medicare solely because of
a disability) .
2) Are an annuitant
3) Are a re-employed annuitant with the Federal
government when
a) The position is excluded from FEHB, or . . . . . . . . .
. . . . . . . . . . . .
b) The position is not excluded from FEHB . . . .
. . . . . . . . . . . . . . . . .
( Ask your employing office which of
these applies to you. )
4) Are a Federal judge who retired under title 28. U. S. C. , or a Tax Court
Judge who retired under Section 7447 of title 26, U. S. C. ( or if your
covered spouse is this type of judge) .
5) Are enrolled in Part B only, regardless of your employment status.
( for Part B ( for other
services) 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.
B. When you or a covered family member have Medicare based
on end
stage renal disease ( ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD.
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD.
3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision.
C. When you or a covered family member have FEHB and
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant
b)
Are an active employee
c) Are a former spouse of an annuitant, or
d)
Are a former spouse of an active employee 34
34
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2002
Arnett HMO 35
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
765-448-7440 or toll free at 888-448-7440.
We do not waive any out-of-pocket cost when you have the Original Medicare
Plan.
Medicare Managed Care Plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare
benefits from another type of
Medicare+ Choice plan a Medicare managed care plan. .
These are health care
choices ( like HMOs) in some areas of the country. In most
Medicare managed
care plans, you can only go to doctors, specialists, or hospitals that
are
part of the plan. Medicare managed care plans provide all the benefits that
original
Medicare covers. Some cover extras, like prescription drugs. To
learn more about
enrolling in a Medicare managed care plan, contact Medicare
at 1-800-MEDICARE ( 1-
800-633-4227) or at www. medicare. gov. If you
enroll in a Medicare managed care plan,
the following options are available
to you.
This plan and another plan's Medicare managed care plan: You may
enroll in another
plan s Medicare managed care plan and also remain 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 or coinsurance and you must remain in our
network. 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 premiums. ) For
information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB
program, generally you
may do so only at the next open season unless you involuntarily
lose
coverage or move out of the Medicare managed care plan s service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered under the
Medicare Part A or Part B
FEHB Program. We will not require you to enroll in Medicare Part B and, if
you can t get
premium-free Part A, we will not ask you to enroll in it.
Section 9 35
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2002 Arnett HMO 36
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you
have questions about TRICARE
coverage.
Workers' Compensation We do not cover services that:
You need
because of a workplace-related illness or injury that the Office of Workers
Compensation Programs ( OWCP) or a similar Federal or State agency
determines
they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or
other
similar proceeding that is based on a claim you filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will
cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, or Federal Government
are responsible for your care
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or hospital care for injuries
for injuries and 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.
Section 9 36
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2002 Arnett HMO 37
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For enrollees, the
calendar year begins on the effective date of their enrollment and ends in
December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 10.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 10.
Covered Services Care we
provide benefits for, as described in this brochure.
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 10.
Experimental or Drugs, devices, services, supplies, medical treatments
or procedures which are
Investigational services experimental or
investigational in nature. The Plan will apply the following criteria in
determining whether services or supplies are experimental or investigational:
a. Any medical device, drug or biological product must have received final
approval to
market by the United States Food and Drug Administration ( FDA)
for the particular
diagnosis or condition.
b. Conclusive evidence from the published peer-review medical literature must
exist that
over time the technology has a definite positive effect on health
outcomes; such evidence
must include well-designed investigations that have
been reproduced by nonaffiliated
authoritative sources, with measurable
results, backed up by the positive endorsements of
national medical bodies
or panels regarding the efficacy and rationale.
c. Demonstrated evidence as reflected in the published peer-review literature
must exist
that over time the technology leads to improvements in health
outcomes, i. e., the
beneficial effects outweigh the harmful effects.
d. Proof as reflected in the published peer-reviewed literature must exist
that the
technology is at least as effective in improving health outcomes as
established
technology, or is usable in appropriate clinical contexts in
which established technology
is not employable.
e. Proof as reflected in the published peer-reviewed medical literature must
exist that
improvements in health outcomes, as defined in paragraph c, is
possible in standard
conditions of medical practice, outside clinical
investigatory settings.
Us/ We Us and we refer to Arnett HMO.
You You refers to the
enrollee and each covered family member.
Section 10 37
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2002 Arnett HMO 38
Section 11
Section 11. FEHB facts
We will not refuse to
cover the treatment of a condition that you had before you enrolled
in this
Plan solely because you had the condition before you enrolled.
See www. opm. gov/ insure. Also, your employing or retirement office can
answer your
questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures
for other plans, and other materials you need
to make an informed decision about:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to
another Federal agency, go on leave without pay,
enter military service, or
retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don t determine who is eligible for coverage and, in most cases, cannot
change your
enrollment status without information from your employing or
retirement office.
Self Only coverage is for you alone. Self and Family coverage is for you,
your spouse,
and your unmarried dependent children under age 22, including
any foster children or
stepchildren your employing or 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 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.
The benefits in this brochure are effective January 1. If you joined this
Plan during Open Season, your coverage begins 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.
No pre-existing condition
limitation
Where you can get information
about enrolling in the FEHB
Program
Types of coverage available
for you and your family
When benefits and
premiums start 38
38
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2002
Arnett HMO 39
We will keep your medical and claims information
confidential. Only the following will
have access to it:
OPM, this Plan,
and subcontractors when they administer this contract;
This Plan and
appropriate third parties, such as other insurance plans and the Office
of
Workers Compensation Programs ( OWCP) , when coordinating benefit payments
and subrogating claims;
Law enforcement officials when investigating
and/ or prosecuting alleged civil or
criminal actions;
OPM and the
General Accounting Office when conducting audits;
Individuals involved in
bona fide medical research or education that does not disclose
your
identity; or
OPM, when reviewing a disputed claim or defending litigation
about a claim.
When you retire When you retire, you can usually stay in the FEHB
program. Generally, you must have been enrolled in the FEHB program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as
Temporary Continuation
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 coverage If you are divorced from a Federal employee or
annuitant, you may not continue to get
benefits under your former spouse s
enrollment. But, you may be eligible for your own
FEHB coverage under the
spouse equity law. If you are recently divorced or are
anticipating a
divorce, contact your ex-spouse s employing or retirement office to get RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation
of Coverage and Former Spouse Enrollees, or other
information about your coverage
choices.
Temporary If you leave Federal service, or if you lose coverage
because you no longer qualify as a
family member, you may be eligible for
Temporary Continuation of Coverage ( TCC) .
For example, you can receive TCC
if you are not able to continue your FEHB enrollment
after you retire, if
you lose your job, if you are a covered dependent child and you turn
22 or
marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
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.
Section 11
Your medical and claims
records are confidential
Continuation
Coverage
( TCC) 39
39
Page 40 41
2002
Arnett HMO 40
You may convert to a non-FEHB policy if:
Your coverage
under TCC or the spouse equity law ends ( If you canceled your coverage
or
did not pay your premium, you cannot convert) ;
You decided not to receive
coverage under TCC or the spouse
equity law; or
You are not eligible for
coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert.
You must apply in writing to us within 31 days after you
receive this notice. However, if you
are a family member who is losing
coverage, the employing office will not notify you. You
must apply in
writing to us within 31 days after you are no longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will
not have to answer questions about your health, and we
will not impose a waiting period or
limit your coverage due to pre-existing conditions.
The Health Insurance Portability and Accountability Act of 1996 ( HIPAA) .
This
Federal law ( HIAA) is a Federal law that offers limited Federal
protections for health
coverage availability and continuity to people who
lose employer group coverage. If you
leave the FEHB program, we will give
you a Certificate of Group Health Plan Coverage that
indicates how long you
have been enrolled with us. You can use this certificate when getting
health
insurance or other health care coverage. Your new plan must reduce or eliminate
waiting periods, limitations, or exclusions for health related conditions
based on the
information in the certificate, as long as you enroll within 63
days of losing coverage under
this Plan. If you have been enrolled with us
for less than 12 months, but were previously
enrolled in other FEHB plans,
you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage ( TCC) under the FEHB Program. See also the FEHB website ( www.
opm. gov/
insure/ health) ; refer tot he 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 have
information about Federal and State agencies you can contact
for more
information.
Section 11
Converting to
individual coverage
Getting a Certificate of
Group Health Plan Coverage 40
40 Page 41 42
2002 Arnett HMO 41
Section 12. Long Term
Care Insurance Is Coming Later in 2002!
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.
The office of
Personnel Management ( OPM) will sponsor a high-quality long term care insurance
program effective in October 2002.
As part of its educational effort, OPM
asks you to consider these questions.
What is long term care It s insurance to help pay for long term care
services you may need if you (LTC) insurance? can t take of yourself
because of an extended illness or injury. or an age-related
disease such as
Alzheimer s.
LTC insurance can provide broad, flexible benefits for nursing
home care, care in an
assisted living facility, care in your home, adult day
care, hospice care, and more.
LTC insurance can supplement care provided by
family members, reducing the
burden you place on them.
I'm healthy. I won't need Welcome to the club! long term care. Or,
will I? 76% of Americans believe they will never need long term care, but
the facts are that
about half them will. And 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 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 planning.
Is long term care expensive? 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.
But won't my FEHB plan, Not FEHB. Look at the Not covered blocks in
sections 5( ( a) and 5( c) of Medicare or Medicaid cover your FEHB
brochure. Health plans don t cover custodial care or a stay in an
my long
term care? 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 hospitalization for those who are blind, age 65
or older or fully disabled. It 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.
Long Term Care Insurance
When will I get more information
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.
How can I find out more about 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.
on how to apply for this new insurance coverage?
the program NOW? 41
41 Page 42 43
2002 Arnett HMO
42
A ccidental injury 29
Allergy tests 14
Alternative
treatment 17
Allogenetic ( donor) bone marrow
transplant
Ambulance 24
Anesthesia 20
Autologous bone marrow
transplant 20
B iopsies 18
Blood and blood plasma 21
Breast cancer screening
13
C asts 18
Catastrophic protection 11
Changes for 2002 6
Chemotherapy 14
Childbirth 13
Chiropractic 17
Cholesterol tests
12
Circumcision 13
Claims 5
Coinsurance 10
Colorectal cancer
screening 12
Congenital anomalies 19
Contraceptive devices and drugs 27
Coordination of benefits 34
Covered charges 10
Covered providers 7
Crutches 16
D eductible 10
Definitions 38
Dental care 29
Diagnostic
services 12
Disputed claims review 32
Donor expenses ( transplants) 20
Dressings 16
Durable medical
equipment ( DME) 16
E ffective date of enrollment 39
Emergency 23
Experimental or investigational 38
Eyeglasses 15
F amily planning 14
Fecal occult blood test 12
G eneral Exclusions 30
H earing services 15
Home health
services 17
Hospice care 22
Home nursing care 17
Hospital 21
I mmunizations 13
Infertility 14
In-hospital physician care 18
Inpatient Hospital benefits 21
Insulin 28
L aboratory and
pathological services 12
M achine diagnostic tests 12
Magnetic Resonance
Imaging (
MRIs) 22
Mammograms 13
Maternity benefits 13
Medicaid 36
Medicare 34
Members 38
Mental conditions/ Substance abuse
benefits 25
N ewborn care 12
O bstetrical care 13
Occupational
therapy 15
Ocular injury 15
Office visits 12
Oral and maxillofacial
surgery 19
Orthopedic devices 16
Out-of-pocket expenses 10
Outpatient facility care 22
Oxygen 16
P ap test 12
Physical examination 12-13
Physical therapy 12
Physician 12
Precertification 9
Preventive care, adult 12
Preventive care,
children 13
Prescription drugs 27
Preventive services 12
Prior
approval 9
Prostate cancer screening 12
Prosthetic devices 16
Psychologist 25
Psychotherapy 25
R adiation therapy 14
Renal dialysis 14
Room and board 21
S econd surgical opinion 12
Skilled nursing facility care 22
Smoking cessation 17
Speech therapy 15
Splints 16
Subrogation 37
Surgery 18
Anesthesia 20
Oral 19
Outpatient 22
Reconstructive 19
Syringes 16
T emporary Continuation
of Coverage 40
Transplants 20
Treatment therapies 17
V ision services 15
W ell child care 13
Wheelchairs 16
X -rays 12
Index
Index
Do not rely on this page; it is for your convenience and may
not show all pages where the terms appear. 42
42
Page 43 44
2002
Arnett HMO 43
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 . . . . . . . . 12
Services provided by a hospital:
Inpatient . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 21
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . Nothing 22
CAT scans and MRI tests ( Outpatient) . . . . . . . . . . . . . . . . . . . .
. . . . . $ 50 copay 12
Emergency benefits:
In-and Out-of-area
Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . $ 25 copay 23
Hospital . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . $ 75 copay 23, 24
Mental health and substance abuse treatment . . . . . . . . . . . . . . . . .
. . Regular cost sharing 25
Prescription drugs:
Generic drugs . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 5
copay 26
Formulary brand name drugs . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . $ 15 copay 26
Non-formulary brand name drugs . . . . . .
. . . . . . . . . . . . . . . . . . . . $ 30 copay 26
Dental care: Accidental injury only . . . . . . . . . . . . . . . . . . . . .
. . . . . . Nothing 28
Vision care . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . Nothing 15
Summary
Office visit copay: $ 10 primary
care; $ 10 specialist
Summary of Benefits for Arnett HMO Health Plan 2002 43
43 Page 44
2002
Arnett HMO 44 28
2002 Rate Information for
Arnett HMO Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB
Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to most career U. S. 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 70-21N).
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.
The Lafayette, Indiana Area
Self Only G21 $93.94 $31.31 $203.54 $67.84
$111.16 $14.09
Self and Family G22 $223.41 $102.26 $484.06 $221.56 $263.75
$61.92
Type of Gov't Your Gov't Your USPS Your Enrollment Code Share Share Share
Share Share Share
Non-Postal Premium
Monthly Biweekly
Postal Premium
A
Biweekly 44