For changes
in benefits
see page
6.
Serving: Greater Birmingham, Mobile, and Montgomery
Enrollment
in this Plan is limited. You must live or work in our geographic service area to
enroll. See page 5 for requirements.
Enrollment code: DF1 Self Only
DF2 Self and Family
RI73-349 1
1 Page
2 3
2002 The Oath 2 Table of
Contents
Table of Contents
Introduction………………………………………………………………….
............................................................... 4
Plain
Language………………………………………………………………...............................................................
4
Inspector General Advisory
...........................................................................................................................................
4
Section 1. Facts about this HMO plan
...........................................................................................................................
5
How we pay providers
.................................................................................................................................
5
Who provides my health
care?.....................................................................................................................
5
Your
Rights..................................................................................................................................................
5
Service
Area.................................................................................................................................................
5
Section 2. How we change for
2002………………………………………...................................................................
6
Program-wide
changes.................................................................................................................................
6
Changes to this
Plan.....................................................................................................................................
6
Section 3. How you get care …………...
......................................................................................................................
7
Identification
cards.......................................................................................................................................
7
Where you get covered
care.........................................................................................................................
7
Plan
providers........................................................................................................................................
7
Plan facilities
.........................................................................................................................................
7
What you must do to get covered care
.........................................................................................................
7
Primary
care...........................................................................................................................................
7
Specialty
care.........................................................................................................................................
7
Hospital care
..........................................................................................................................................
8
Circumstances beyond our
control...............................................................................................................
8
Services requiring our prior approval
..........................................................................................................
8
Section 4. Your costs for covered services
...................................................................................................................
9
Copayments
...........................................................................................................................................
9
Coinsurance
...........................................................................................................................................
9
Your out-of-pocket
maximum......................................................................................................................
9
Section 5.
Benefits…………………………………………………………................................................................
10
Overview....................................................................................................................................................
10
(a) Medical services and supplies provided by physicians and other health
care professionals ........... 11
(b) Surgical and anesthesia services
provided by physicians and other health care professionals........ 20
(c)
Services provided by a hospital or other facility, and ambulance services
..................................... 24
(d) Emergency services/ accidents
.........................................................................................................
27
(e) Mental health and substance abuse benefits
....................................................................................
29
(f) Prescription drug
benefits................................................................................................................
31
(g) Special features
...............................................................................................................................
34
Nutritional counseling
Breast cancer awareness 2
2 Page 3 4
2002 The Oath 3 Table of Contents
Discount subscriptions
Health journal
Immunization awareness
Preventive health guidelines
Preventive care reminder letters
(h)
Dental
benefits................................................................................................................................
35
(i) Non-FEHB benefits available to Plan members
............................................................................. 36
Section 6. General exclusions --things we don't
cover...............................................................................................
37
Section 7. Filing a claim for covered services
............................................................................................................
38
Section 8. The disputed claims
process.......................................................................................................................
39
Section 9. Coordinating benefits with other coverage
................................................................................................
41
When you have…
.....................................................................................................................................
41
Other health coverage
........................................................................................................................
41
Original Medicare
..............................................................................................................................
41
Medicare managed care
plan..............................................................................................................
43
TRICARE/ Workers' Compensation/ Medicaid
..........................................................................................
43
Other Government agencies
......................................................................................................................
44
When others are responsible for
injuries...................................................................................................
44
Section 10. Definitions of terms we use in this
brochure............................................................................................
45
Section 11. FEHB
facts...............................................................................................................................................
46
Coverage
information................................................................................................................................
46
No pre-existing condition limitation
.................................................................................................
46
Where you get information about enrolling in the FEHB
Program.................................................. 46
Types of
coverage available for you and your
family....................................................................... 46
When benefits and premiums
start....................................................................................................
46
Your medical and claims records are confidential
............................................................................ 47
When you retire
................................................................................................................................
47
When you lose benefits
.............................................................................................................................
47
When FEHB coverage ends
..............................................................................................................
47
Spouse equity
coverage.....................................................................................................................
47
Temporary Continuation of Coverage (TCC)
...................................................................................
47
Converting to individual
coverage....................................................................................................
48
Getting a Certificate of Group Health Plan
Coverage.......................................................................
48
Long term care insurance is coming later in 2002
......................................................................................................
49
Index
...............................................................................................................................................................
50
Summary of benefits
...................................................................................................................................................
52
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2002 The Oath 4 Introduction/ Plain Language/
Advisory
Introduction
The Oath – A Health Plan for Alabama,
Inc.
Two Perimeter Park South
Suite 200 West
Birmingham, Alabama
35243
This brochure describes the benefits of The Oath – A Health Plan for Alabama,
Inc. (The Oath) under our contract
(CS 2156) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. This brochure is the official statement of benefits. No oral statement
can modify or otherwise affect the benefits,
limitations, and exclusions of
this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and are
summarized on page 6. Rates are shown
at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we" means The Oath.
We Limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program, OPM is the Office of Personal Management. If we use others, we
tell you what they mean first.
Our brochure and other FEHB plans' brochures
have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www.
opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also
write to OPM at the Office of Personnel Management, Office of Insurance Planning
and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650.
Inspector General Advisory
Stop health care fraud! Fraud increases
the cost of health care for everyone. If you suspect that a physician, pharmacy,
or hospital has charged you for services you did not
receive, billed you
twice for the same service, or misrepresented any
information, do the
following:
o Call the provider and ask for an explanation. There
may be an error.
o If the provider does not resolve the matter,
call us at 205-968-1400 or
toll free at 1-800-947-5093 and explain the
situation.
o If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD LINE 202/ 418-3300
The United States of
Personnel Management Office of the Inspector General Fraud Hotline
1900 E.
Street, NW, Room 6400 Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate
anyone who uses an ID card if the person tries to obtain
services for someone who is not an eligible family member, or is no longer
enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 4
4 Page 5 6
2002 The Oath 5
Section 1
Section 1. Facts about this HMO plan
This Plan
is a health maintenance organization (HMO). We require you to see specific
physicians, hospitals, and other
providers that contract with us. These Plan
providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments or coinsurance
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.
Who provides my health care?
The Oath is an independent provider
association type Health Maintenance Organization, known in the FEHB Program
as an IPP or Individual Practice Plan, which means the HMO contracts with
more than one medical provider.
Your Rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You may get information
about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types
of information that we must make available to you.
If you want more information about us, call statewide, except Mobile, at
205-968-1400 locally or toll free at 1-800-
947-5093 (Mobile service area
call locally 334-470-8503 or toll free at 1-800-735-2439)., or write to The
Oath, Two
Perimeter Park South, Suite 200 West, Birmingham, Alabama 35243.
You may also contact us by fax at 205-968-
1668, or visit our website at
http:// www. TheOathofAlabama. com.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. This is where our Providers practice. Our service
area is:
The Alabama counties of: Autauga, Baldwin, Bibb, Blount, Bullock, Calhoun,
Cherokee, Chilton, Clarke, Coosa,
Cullman, Dallas, Dekalb, Elmore,
Jefferson, Lowndes, Macon, Marion, Mobile, Monroe, Montgomery, Russell,
Shelby, St. Clair, Talladega, Walker, Washington and Winston.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care benefits. We will not pay for any other health care services out of our
service
area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your
dependents live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family
member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 5
5 Page
6 7
2002 The Oath 6 Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5
Benefits. Also, we edited and clarified language throughout the
brochure; any language change not shown here is a
clarification that does
not change benefits.
Program-wide changes
We no longer limit total blood cholesterol
tests to certain age groups. (Section 5( a))
Changes to this Plan
Your share of the non-Postal premium will
decrease by 16. 1% for Self Only or 11. 9% for Self and Family.
We changed
our name to The Oath – A Health Plan for Alabama, Inc.
We increased speech
therapy benefits by removing the requirement that services must be required to
restore functional speech. (Section 5( a))
We now cover certain intestinal transplants. (Section 5( b)) 6
6 Page 7 8
2002 The Oath 7 Section 3
Section
3. How you get care
Identification cards We will send you an
identification (ID) card when you enroll. You should carry your ID card with you
at all times. You must show it
whenever you receive services from a Plan
provider, or fill a prescription
at a Plan pharmacy. Until you receive your
ID card, use your copy of the
Health Benefits Election Form, SF-2809, your
health benefits enrollment
confirmation (for annuitants), or your Employee
Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
205-968-
1400 or toll free at 1-800-947-5093.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments or coinsurance, 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. This 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.
What you must do to get covered care It depends on the type of care
you need. First, you and each family
member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for
most of your health care.
Primary care Your primary care physician can be an obstetrician/
gynecologist, family practitioner, internist or pediatrician. Your primary care
physician is
responsible for providing and arranging all your health care
services.
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 You are not required to obtain a referral from your
primary care physician in order to see a participating Specialist. You can make
an
appointment directly with a Plan Specialist.
Here are other things
you should know about specialty care:
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 have a chronic or disabling condition and lose access to your
specialist because we:
– terminate our contract with your specialist for other than cause; or
–
drop out of the Federal Employees Health Benefits (FEHB)
Program and you
enroll in another FEHB Plan; or 7
7 Page 8 9
2002 The Oath 8
Section 3
– 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 205-968-1400 or toll
free at 1-800-947-5093. If
you are new to the FEHB Program, we will
arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These provisions apply only to the hospital benefit of the hospitalized
person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In
that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our prior approval For certain services your
physician must obtain approval from us. Before
giving approval, we consider
if the service is covered, medically
necessary, and follows generally
accepted medical practice.
We call this review and approval process pre-certification. Your
physician must obtain our approval for certain services. Some of these
services include:
Pre-operative and post-operative care Diagnostic laboratory testing
Inpatient hospital services Skilled nursing care
Home health care
Rehabilitation services
Nutritional counseling Reconstructive surgery 8
8 Page 9 10
2002 The Oath 9 Section 4
Section
4. Your costs for covered services
You must share the cost of some
services. You are responsible for:
Copayments A copayment is a fixed
amount of money you pay to the provider, facility, pharmacy, etc., when you
receive services.
Example: When you see your primary care physician you pay a
copayment of
$15 per office visit and when you go in the hospital, you
pay a copayment of
$100 per admission.
Deductible We do not have a deductible.
Coinsurance
Coinsurance is the percentage of our negotiated fee that you must pay for
your care.
Example: In our Plan, you pay 20% of our allowance for the diagnosis
and
treatment of infertility and durable medical equipment.
Your catastrophic protection out-of-pocket maximum for
copayments and coinsurance After your copayments total $1000 per
person or $2000 per family enrollment in any calendar year, you do not have to
pay any more for
covered services. However, copayments for the following
services do
not count toward your out-of-pocket maximum, and you must
continue to
pay copayments for these services:
Prescription Drugs 9
9 Page
10 11
2002 The Oath 10 Section
5
Section 5. Benefits --OVERVIEW
(See page 6 for how
our benefits changed this year and page 52 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 205-968-
1400 or toll free
at 1-800-947-5093 or visit our website at http:// www. theoathofalabama. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .................................. 11-19
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family
planning
Infertility services Allergy care
Treatment therapies Physical
and Occupational therapies
Speech Therapy
Hearing services (testing, treatment, and supplies)
Vision services
(testing, treatment, and supplies)
Foot care Orthopedic and prosthetic
devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative Treatments
Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals............................... 20-23
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services ............................................................
24-26
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care Ambulance
(d) Emergency services/
accidents................................................................................................................................
27-28
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
...........................................................................................................
29-30
(f) Prescription drug benefits
.......................................................................................................................................
31-33
(g) Special features
...........................................................................................................................................................
34
Nutritional Counseling Breast Cancer Awareness
Discount Subscriptions Health Journal
Immunization Awareness Preventive
Health Guidelines
Preventive Care Reminder Letters (h) Dental benefits
............................................................................................................................................................
35
(i) Non-FEHB benefits available to Plan members
..........................................................................................................
36
Summary of
benefits.........................................................................................................................................................
52 10
10 Page 11
12
2002 The Oath 11 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
$15 per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
Nothing
At home Nothing
Diagnostic and treatment services --Continued on next
page 11
11 Page
12 13
2002 The Oath 12 Section
5( a)
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing
Preventive care, adult
Routine screenings, such as:
Hearing
Screening – One annually
Total Blood Cholesterol – once every three years
Colorectal Cancer Screening, including
--Fecal occult blood test
$15 per office visit
--Sigmoidoscopy, screening – every five years starting at age 50 Nothing
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
Nothing
Routine pap test
Note: The office visit is covered if pap test
is received on the same day;
see Diagnostics and Treatment services,
above.
Nothing 12
12 Page
13 14
2002 The Oath 13 Section
5( a)
Preventive care, adult (Continued) You pay
Routine mammogram –covered for women age 35 and older, as
follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year At age 65 and older, one every two
consecutive calendar years
Nothing
Not covered: Physical exams and immunizations required for obtaining
or continuing employment or insurance, attending schools or camp, or
travel.
All charges.
Routine Immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages 19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics Nothing
Examinations, such as:
--Eye exams through age 17 to determine the need
for vision
correction.
--Ear exams through age 17 to determine the need for hearing
correction
--Examinations done on the day of immunizations ( under age 22)
Well-child care charges for routine examinations, immunizations and care
(under age 22)
$15 per office visit 13
13 Page 14 15
2002 The Oath
14 Section 5( a)
Maternity care You pay
Complete
maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery care
of the newborn child during the covered portion of the mother's maternity stay.
We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
$15 copayment for initial office
visit only
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Tubal ligations
______________________________________________________________
Vasectomy
______________________________________________________________
Surgically implanted contraceptives (such as Norplant)
Injectable
contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphrams
Note: we cover oral contraceptives under the prescription
drug benefit.
$250 copay
___________________________________
$100 copay
____________________________________
Nothing
Nothing
Nothing
Nothing
Not covered: reversal of voluntary surgical sterilization, genetic
counseling
All charges. 14
14 Page 15 16
2002 The Oath
15 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility
______________________________________________________________
Artificial insemination:
– intravaginal insemination (IVI)
–
intra-cervical insemination (ICI)
– intrauterine insemination
(IUI)
20% of charges
____________________________________
50% of charges
Not covered:
Assisted reproductive technology (ART) procedures,
such as:
– in vitro fertilization
– embryo transfer,
gamete GIFT and zygote ZIFT
– zygot transfer
Services and supplies related to excluded ART procedures
Fertility drugs
Cost of donor egg
Cost of donor
sperm
All charges.
Allergy care
Testing and treatment
__________________________________________________________________
Allergy injection
$15 per office visit
____________________________________
Nothing
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges.
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page xx.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: – We will only cover GHT when we
preauthorize the treatment.
GHT is covered under the plan's medical benefit.
Nothing 15
15 Page
16 17
2002 The Oath 16 Section
5( a)
Physical and Occupational therapies You pay
Two
consecutive months per condition for the services of each of the following:
– qualified physical therapists; and
– occupational therapists.
Note:
We only cover therapy to restore bodily function or speech
when there has
been a total or partial loss of bodily function due to
illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to 36 visits or 6 months.
Nothing
Not Covered:
long-term rehabilitatative therapy
exercise
programs
Speech Therapy
Two months per condition Nothing
Hearing services (testing, treatment, and supplies)
Routine
hearing screening annually $15 per office visit
Not covered:
hearing aids
implanted cochlear hearing devices
All charges. 16
16 Page 17 18
2002 The Oath
17 Section 5( a)
Vision services (testing, treatment, and
supplies) You pay
Routine annual eye exam for diabetics
Eye
refraction once every 24 months
Diagnosis and treatment of diseases of the
eye
$15 per office visit
Not covered:
Eyeglasses or contact lenses
Eye
exercises and orthoptics
Radial keratotomy and other refractive
surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic
or peripheral vascular disease, such as diabetes.
$15
per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges. 17
17 Page 18 19
2002 The Oath
18 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs (initial device only)
Externally worn breast
prostheses and surgical bras, including necessary replacements, following a
mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy. Note:
See 5( b)
for coverage of the surgery to insert the device.
Corrective orthopedic
appliances for non-dental treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome.
20% of the charges up to a plan
maximum payment of $5000 per
member
per year. Any
combination of orthopedic and
prosthetic devices or DME
can
apply to the $5000 maximum.
Not covered:
orthopedic and corrective shoes
arch
supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings,
support hose, and other supportive devices
All charges.
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, of durable medical equipment
(standard models only) prescribed by
your Plan physician, such as
oxygen and dialysis equipment. Under this
benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
insulin pumps
20% of the charges up to a plan
maximum payment of $5000 per
member
per year. Any
combination of orthopedic and
prosthetic devices or DME
can
apply to the $5000 maximum.
Not covered:
motorized wheel chairs
maintenance and repairs of durable medical equipment
specialty
beds
All charges. 18
18 Page 19 20
2002 The Oath
19 Section 5( a)
Home health services
Home health care
ordered by a Plan physician and provided by a registered nurse (R. N.), licensed
practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home
health aide.
Services include oxygen therapy, intravenous therapy and
medications.
Nothing
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family;
home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative
All charges.
Chiropractic
Manipulation of the spine and extremities
Coverage limited to twelve (12) visits per calendar year
$15 per office visit
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Six (6) month program. To enroll in "A Healthy Habit,"
call 1-888-467-3426.
Other programs offered at discount rates:
American Red Cross Training
Courses
Fitness Center Memberships
Weight Watchers Enrollment
Charges based on negotiated
discounts 19
19
Page 20 21
2002
The Oath 20 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e. hospital,
surgical center, etc.). YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME
SURGICAL PROCEDURES.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures
Treatment
of fractures, including casting Normal pre-and post-operative care by the
surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy
procedures Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery) Surgical treatment of morbid obesity --a condition
in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members
must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
Nothing
Surgical procedures continued on next page. 20
20 Page 21 22
2002 The Oath 21 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization;
Tubal legation $250 copay
Vasectomy $100 copay
Treatment of burns
Note: Generally, we pay for
internal prostheses (devices) according to
where the procedure is done. For
example, we pay Hospital benefits for
a pacemaker and Surgery benefits for
insertion of the pacemaker.
Nothing
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
– the
condition produced a major effect on the member's
appearance and
– the condition can reasonably be expected to be corrected by such
surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
Nothing 21
21 Page
22 23
2002 The Oath 22 Section
5( b)
Reconstructive surgery (Continued) You pay
All stages of breast reconstruction surgery following a mastectomy, such
as:
– surgery to produce a symmetrical appearance on the other breast;
–
treatment of any physical complications, such as lymph edemas;
– breast
prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
See above.
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges.
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
Reduction of fractures of the jaws or facial bones; Surgical correction
of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or their supporting
structures.
Temporamandibular joint disorder (TMJ)– Note: Limited to
non-surgical and surgical management for TMJ disorders, including
office
visits, x-rays, orthopedic/ orthodontic appliances,
pharmacological therapy,
joint splints, physical therapy and all
hospital related services.
Nothing
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures
(such as the periodontal membrane, gingiva, and alveolar bone)
All charges. 22
22 Page 23 24
2002 The Oath
23 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Liver
Lung: Single –Double
Skin transplants/ grafting
Allogeneic (donor)
bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral stem
cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach and
pancreas
Limited Benefits -Treatment for breast cancer, multiple myeloma,
and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center
Office
Nothing 23
23 Page
24 25
2002 The Oath 24 Section
5( c)
Section 5 (c). Services provided by a hospital or other
facility, and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
Plan physicians must provide or arrange your care
and you must be hospitalized in a Plan facility.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The
amounts listed below are for the charges billed by the facility (i. e., hospital
or surgical center) or ambulance service for your surgery or care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in
Sections 5( a) or (b).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require pre-certification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general nursing
care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary,
you
pay the additional charge above the semiprivate room rate.
$100 per admission
Inpatient hospital continued on next page. 24
24 Page 25 26
2002 The Oath 25 Section 5( c)
Inpatient hospital (Continued) You pay
Other
hospital services and supplies, such as:
Operating, recovery, maternity, and
other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Take-home
items Medical supplies, appliances, medical equipment, and any covered
items
billed by a hospital for use at home
Nothing
Not covered:
Custodial care Non-covered facilities, such
as nursing homes, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals Blood and blood
plasma, if not donated or replaced
Pre-surgical testing Dressings, casts,
and sterile tray services
Medical supplies, including oxygen Anesthetics and
anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do
not cover the dental procedures.
$50 for outpatient procedures 25
25 Page 26 27
2002 The Oath
26 Section 5( c)
Extended care benefits/ skilled nursing care
facility benefits You pay
Extended care benefit:
90 days per calendar year
bed
board
general nursing care
meals
drugs
biologicals
supplies
$100 per admission
Not covered: custodial care All charges
Hospice care
Supportive and palliative care for a terminally ill member in a home or
hospice facility. Services include inpatient and outpatient care and
family counseling when plan doctor certifies that the patient is in the
terminal stages of illness, with a life expectancy of six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance
Emergency ambulance transport (air or ground) to a hospital when medically
appropriate. Nothing 26
26 Page
27 28
2002 The Oath 27 Section
5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe
endangers your life or could result in serious
injury or disability, and requires immediate medical or
surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more
serious; examples include deep cuts and broken bones. Others are
emergencies because they are
potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability
to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area.
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
local emergency system
(e. g., the 911 telephone system) or go to the
nearest hospital emergency room. Be sure to tell the emergency
room
personnel that you are a Plan member so they can notify the Plan. You or a
family member must notify
the Plan within 48 hours unless it was not
reasonably possible to do so. It is your responsibility to ensure that
the
Plan has been timely notified.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following
your admission, unless it was not
reasonably possible to notify the Plan within that time. If you are
hospitalized in non-Plan facilities and a Plan doctor believes care can he
better provided in a Plan hospital, you
will be transferred when medically
feasible with any ambulance charges covered in full.
Emergencies outside our service area. Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following
your admission, unless it was not
reasonably possible to notify the Plan within that time. If a Plan doctor
believes care can be better provided in a Plan hospital, you will be
transferred when medically feasible with
any ambulance charges covered in
full. 27
27 Page
28 29
2002 The Oath 28 Section
5( d)
Benefit Description You pay
Emergency within our service
area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient at a hospital, including doctors'
services
$15 per visit
$50 per visit
$50 per visit
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient at a hospital, including doctors' services
$15 per visit
$50 per visit
$50 per visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area
All charges.
Ambulance
Professional ambulance service (air or ground) when
medically
appropriate.
See 5( c) for non-emergency service.
No Charge 28
28 Page
29 30
2002 The Oath 29 Section
5( e)
Section 5 (e). Mental health and substance abuse benefits
I
M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost – sharing
and limitations for plan mental health and substance
abuse benefits will be no greater than for
similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered
services for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing
responsibilities are no
greater than for other
illness
or conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social
workers
Medication management
$15 per visit
Mental health and substance abuse benefits -Continued on next page 29
29 Page 30 31
2002 The Oath 30 Section 5( e)
Mental health and substance abuse benefits (Continued)
You pay
Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, half-way house,
residential treatment, full-day
hospitalization, facility based intensive
outpatient treatment
$100 per admission
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the
treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one
clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
Contact MHNET
at 1-800-272-2030 for referral and provider information. A
referral
authorization will be made for you to see an appropriate
participating
provider of your choice for mental health and substance abuse
treatment.
Limitation We may limit your benefits if you do not follow your treatment
plan. 30
30 Page
31 32
2002 The Oath 31 Section
5( f)
Section 5 (f). Prescription drug benefits
I
M P
O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I
M P
O
R
T
A N
T
There are important features you should be aware of. These
include:
Who can write your prescription. A plan or referral
physician must write the prescription.
Where you can obtain them. You
must fill the prescription at a plan pharmacy, or by mail for a maintenance
medication. Maintenance medications (only) are available through mail order.
We use a formulary. The Oath offers a "three tier" pharmacy copayment
benefit that provides quality pharmaceutical care for the lowest out-of-pocket
costs. The copayment amount is determined by the
medication prescribed.
Preferred brand name medications are selected by the The Oath Pharmacy and
Therapeutics Committee
and are considered the most appropriate for use based
upon safety standards, effectiveness and cost.
Non-preferred medications will have a higher copay than preferred brand name
medications. New
medications will be considered non-preferred until
evaluated by the Pharmacy and Therapeutics
Committee.
These are the dispensing limitations. Prescription drugs prescribed by
a plan referral physician and
obtained at a plan pharmacy will be dispensed
for up to a 31-day supply or (100 unit) supply,
whichever is less; 240
milliliters of liquid (8 oz.); 60 grams of ointment, creams or topical
preparation; or one commercially prepared unit (i. e. one inhaler, one vial
of ophthalmic medication or
insulin). The mail order program permits
dispensing of a 90-day supply of maintenance drugs at two
times the standard
copay. The mail order program is limited to certain maintenance medications. The
plan follows standard FDA dispensing guidelines.
A generic equivalent will be dispensed if it is available, unless your
physician specifically requires a
name brand. If you receive a name brand
drug when a Federally-approved generic drug is available,
and your physician
has not specified Dispense as Written for the name brand drug, you have to pay
the difference in cost between the name brand drug and the generic.
Why use generic drugs? To reduce your out-of-pocket expenses! A
generic drug is the chemical equivalent of a corresponding brand name drug.
Generic drugs are less expensive than brand name
drugs; therefore, you may
reduce your out-of-pocket costs by choosing to use a generic drug.
When
you have to file a claim. If you file a claim, please send all documents
and/ or receipts for your claim as soon as possible.
Prescription drug benefits begin on the next page. 31
31 Page 32 33
2002 The Oath 32 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:
Drugs for which a prescription is required by Federal law
Oral
contraceptive drugs and diaphragms
Insulin
Diabetic supplies limited to
insulin syringes, needles and blood glucose strips
Disposable needles and syringes needed to inject covered prescribed
medication
Intravenous fluids and medications for home use are provided
under home health services at no cost
Prenatal vitamins and oral infant
vitamin drops by prescription only
Drugs for sexual dysfunction
Limited Benefits:
Smoking cessation drugs and medication in
conjunction with a participating smoking cessation program. Nicotrol is limited
to six
(6) weeks and a $15 copay per seven (7) day supply. Zyban is limited
to
twelve (12) weeks. Pre-authorization is required
Toradol therapy limited to 28 tablets per month
Diflucan 150mg limited to
1 tablet per copay
Sedative hypnotics limited to 15 tablets or capsules per
copay
Zoloft limited to 100mg strength scored tablet
Migraine therapy is
limited to a quantity of dosage units as indicated per product package labeling
for treatment of one episode of care per
copay
31-day supply:
$5 generic copay
$15 preferred brand name
copay
$25 non-preferred brand name
90-day supply (mail order):
$10 generic copay
$30 preferred
brand name
copay
$50 non-preferred brand name
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay. 32
32 Page 33 34
2002 The Oath
33 Section 5( f)
Covered medications and supplies
(continued) You pay
Here are some things to keep in mind
about our prescription drug program:
A generic equivalent will be dispensed
if it is available. If you receive a name brand drug when a Federally approved
generic drug is
available, you have to pay the difference in cost between
the name
brand drug and the generic.
Not covered:
Drugs available without a prescription or for which
there is a nonprescription equivalent available
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Vitamins and nutritional substances that can be purchased without a
prescription
Medical supplies such as dressings and antiseptics Drugs for
cosmetic purposes
Drugs to enhance athletic performance Fertility drugs
Nicorette Implanted time-release medications, except Norplant
Contraceptive jellies, ointments or foams Injectable drugs, excluding
insulin and Imitrex
Anorexiants and other drugs FDA approved or utilized for
weight loss
All Charges 33
33 Page 34 35
2002 The Oath
34 Section 5( g)
Section 5 (g). Special Features
Feature
Description
Nutritional Counseling Coverage provided by a certified
diabetes educator associated with a plan provider, to assist in controlling
diabetes, high blood pressure
and high cholesterol.
Breast Cancer Awareness During the month of October, a packet of
information is sent to all female members age 20 and above. The packet includes
preventive
health care guidelines for women, a breast self-exam shower card
and
information on how to obtain a mammogram.
Discount Subscriptions Members can receive half off the regular yearly
subscription to Cooking Light and Weight Watchers magazines. Contact member
services for more information.
Health Journal A quarterly magazine published "exclusively" to help
communicate general wellness articles and information specific to the Plan.
Immunization Awareness An immunization schedule is included in Health
Journal annually. A reminder letter is sent to members with children under the
age of two
regarding the importance of childhood immunizations.
Preventive Health Guidelines Preventive care guidelines are included
in Health Journal annually. The guidelines are prepared using the most current
recommendations
from national health care organizations.
Preventive Care Reminder Letters Happy Birthday – mailed each month to
women age 20 and above regarding the importance of check-ups and scheduled
mammograms.
Diabetic Eye Exam – mailed annually to all diabetics
regarding the importance of an annual eye exam.
Flu Shot – mailed annually to members over the age of 65 regarding the
importance of an annual flu shot. 34
34 Page 35 36
2002 The Oath
35 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
We cover hospitalization for certain 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.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary
to promptly repair
(but not replace) sound natural
teeth. The need for these services must
result from
an accidental injury.
$100 copay per inpatient admission, $50 copay for
outpatient surgery, or
$15 copay for an office visit .
Dental benefits
We have no other dental benefits. 35
35 Page 36 37
2002 The Oath 36 Section 5( i)
Section 5
(i). Non-FEHB benefits available to Plan members
The benefits on this
page are not part of the FEHB contract or premium, and you cannot file an
FEHB
disputed claim about them. Fees you pay for these services do not
count toward FEHB out-of-pocket maximums.
Eyewear: 25% discount at Participating Providers
Discount
dental
services: Services are provided by participating dentists at a
discount to Health Partners members and therefore cannot be used in coordinating
benefits with any other
dental plan. For a list of participating providers, contact the United
Concordia
Customer Service Department at 1-800-UCC-DENT or 1-800-822-3368.
Please
identify yourself as a The Oath FEHB member.
Medicare prepaid plan enrollment -This Plan offers Medicare recipients the
opportunity to enroll in a
Medicare plan, Seniors First. Annuitants and
former spouses with FEHB coverage and Medicare Part B may
elect to drop
their FEHB coverage and enroll in a Medicare prepaid plan when one is available
in their area.
They may then later reenroll in the FEHB Program. Most
Federal annuitants have Medicare Part A. Those
without Medicare Part A may
join this Medicare prepaid plan, but will probably have to pay for hospital
coverage in addition to the Part B premium. Before you join the plan, ask
whether the plan covers hospital
benefits and, if so, what you will have to
pay. Contact your retirement system for information on dropping
your FEHB
enrollment and changing to a Medicare prepaid plan. Contact Seniors First at
1-800-888-7647
for information on Seniors First.
If you are Medicare eligible and are interested in enrolling in a Medicare
HMO sponsored by this Plan
without dropping your enrollment in this Plan's
FEHB Plan, please call 1-800-888-7647 for information on
the benefits
available under the Medicare HMO. 36
36 Page 37 38
2002 The Oath
37 Section 6
Section 6. General exclusions --things we don't
cover
The exclusions in this section apply to all benefits. Although
we may list a specific service as a benefit, we
will not cover it unless
your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term.
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. 37
37 Page
38 39
2002 The Oath 38 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 or
coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians
must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 205-968-1400 or toll free at
1-800-947-5093.
When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown
below.
Bills and receipts should be itemized and show:
Covered member's name and ID number;
Name and address of the physician or
facility that provided the service or supply;
Dates you received the services or supplies;
Diagnosis;
Type of each
service or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary payer --such as
the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your services.
Submit your claims to:
The Oath Two Perimeter Park South
Suite 200 West
Birmingham, Alabama
35243
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. 38
38 Page
39 40
2002 The Oath 39 Section
8
Section 8. The disputed claims process
Follow this Federal
Employees Health Benefits Program disputed claims process if you disagree with
our decision on
your claim or request for services, drugs, or supplies –
including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: The Oath, Two Perimeter Park South, Suite 200 West,
Birmingham,
Alabama 35243; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific
benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports,
bills, medical records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy
of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us --if we did
not answer that request in some way within 30 days; or
120 days after we
asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
1900 E Street, NW, Washington, D. C.
20415-3630. 39
39 Page
40 41
2002 The Oath 40 Section
8
Section 8. The disputed claims process (Continued)
Send OPM
the following information:
A statement about why you believe our decision
was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of
all letters we sent to you about the claim; and
Your daytime phone number
and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies, or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
205-968-1400 or toll free
at 1-800-947-5093 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m. eastern time. 40
40
Page 41 42
2002
The Oath 41 Section 9
Section 9. Coordinating benefits with
other coverage
When you have other health coverage You must tell us if
you are covered or a family member is covered under another group health plan or
have automobile insurance that pays health
care expenses without regard to
fault. This is called "double coverage."
When you have double coverage, one
plan normally pays its benefits in
full as the primary payer and the other
plan pays a reduced benefit as the
secondary payer. We, like other insurers,
determine which coverage is
primary according to the National Association of
Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with
disabilities, under 65 years of age.
People with End-Stage Renal
Disease (permanent kidney failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people
do not have to pay for Part A. If you or your spouse worked for at least 10
years in Medicare-covered
employment, you should be able to qualify for premium-free Part A insurance.
(Someone who was a Federal employee on January 1, 1983 or since
automatically qualifies.) Otherwise, if you are age 65 or older, you may be
able to buy it. Contact 1-800-MEDICARE for more information.
Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social Security check
or
your retirement check.
If you are eligible for Medicare, you may have
choices in how you get your health
care. Original Medicare 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 (Part A or Part B) The Original Medicare
Plan (Original Medicare) is available everywhere
in the United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B benefits
now. You may go to any doctor, specialist, or hospital that accepts
Medicare. The Original Medicare Plan pays its share and you pay your
share. Some things are not covered under Original Medicare, like
prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you
still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be authorized by your Plan PCP, or pre-certified
as required.
We will not waive any of our copayments or coinsurance.
(Primary payer
chart begins on next page.) 41
41 Page 42 43
2002 The Oath
42 Section 9
The following chart illustrates whether the
Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or
a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a familymember are eligible for
Medicare solelybecause of a disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB
b) Or, the position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, (for
Part B
services)
(for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare
based on end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision,
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an
active employee
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare. 42
42
Page 43 44
2002
The Oath 43 Section 9
Claims process when you have the Original
Medicare Plan --You probably will never have to file a claim form when
you
have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim
first. In most cases, your
claims will be coordinated automatically and we
will pay the balance of covered charges. You will not need
to do anything.
To find out if you need to do something about filing your claims, call us at
1-800-947-5093
or visit our website at http:// www. TheOathofAlabama. com.
When Original Medicare is the primary payer, we do not waive any
out-of-pocket costs.
Medicare managed care plan If you are eligible
for Medicare, you may choose to enroll in and get your Medicare benefits from
another type of Medicare + Choice Plan --a
Medicare managed care plan. These
are health care choices (like HMOs)
in some areas of the country. In most
Medicare managed care plans, you
can only go to doctors, specialists, or
hospitals that are part of the plan.
Medicare managed care plans provide all
the benefits that Original
Medicare covers. Some cover extras, like
prescription drugs. To learn
more about enrolling in a Medicare managed care
plan, contact Medicare
at 1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov. If
you enroll in a Medicare managed care plan, the following
options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In
this case, we do not waive any of our copayments or
coinsurance for your
FEHB coverage.
This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when
your Medicare managed
care plan is primary, even out of the managed
care plan's network and/ or
service area (if you use our Plan providers),
but we will not waive any of
our copayments or coinsurance. 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
and enroll in a Medicare managed care plan, eliminating
your FEHB premium.
(OPM does not contribute to your Medicare
managed care plan premium.) For
information on suspending your
FEHB enrollment, contact your retirement
office. If you later want to re-enroll
in the FEHB Program, generally you
may do so only at the next
open season unless you involuntarily lose
coverage or move out of the
Medicare managed care plan's service area.
( If you do not enroll in Note: If you choose not to enroll in
Medicare Part B, you can still be
Medicare Part A or Part B covered
under the FEHB Program. We cannot require you to enroll in Medicare.
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. 43
43 Page
44 45
2002 The Oath 44 Section
9
Workers' Compensation We do not cover services that:
you
need because of a workplace-related illness or injury that the Office of
Workers' Compensation Programs (OWCP) or a similar
Federal or State agency
determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or
other similar proceeding that is based on a claim you
filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for for injuries medical or hospital care for injuries or illness caused
by another person,
you must reimburse us for any expenses we paid. However,
we will
cover the cost of treatment that exceeds the amount you received in
the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 44
44 Page 45 46
2002 The Oath
45 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 11.
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Care that
does not require the skill of a licensed professional.
Experimental or
investigational services The Oath employs a proactive strategy for
determining new and
emerging technology. The strategy includes an ongoing
review of new
drugs, devices and treatments which are supported by evidence
based
criteria. The criteria is compiled from computerized literature
searches,
clinical trials review, professional associations, association
standards,
regulatory agency endorsements, and research based vendors.
Medical necessity Health care services and supplies which are
determined by the Plan to medically appropriate.
Us/ We Us and we
refer to The Oath – A Health Plan for Alabama
You You refers to the
enrollee and each covered family member. 45
45
Page 46 47
2002
The Oath 46 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had limitation before you enrolled in this Plan solely
because you had the condition before
you enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office about enrolling in the can answer your questions, and give you
a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot
change your enrollment status without information from your employing
or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement
office authorizes
coverage for. Under certain circumstances, you may also
continue coverage
for a disabled child 22 years of age or older who is
incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which
the child is born or becomes an eligible family member. When you change
to Self and Family because you marry, the change is effective on the first
day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child under age
22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.
When benefits and Plan premiums start The benefits in this brochure
are effective on January 1. If you joined this
Plan during Open Season, your coverage begins on the first day of your
first pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage. 46
46 Page 47 48
2002 The Oath 47 Section 11
Your
medical and claims We will keep your medical and claims information
confidential. Only records are confidential the following will have
access to it:
OPM, this Plan, and subcontractors when they administer this
contract;
This Plan and appropriate third parties, such as other insurance
plans and the Office of Workers' Compensation Programs (OWCP), when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal
service. If you do not meet this requirement, you
may be eligible for other forms of
coverage, such as temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation
of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity law.
If you are recently divorced or are anticipating a divorce, contact your
ex-spouse's
employing or retirement office to get RI 70-5, the Guide to
Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, or other information about your
coverage choices.
Temporary continuation of coverage (TCC) If you leave Federal service,
or if you lose coverage because you no longer
qualify as a family member,
you may be eligible for Temporary
Continuation of Coverage (TCC). For
example, you can receive TCC if
you are not able to continue your FEHB
enrollment after you retire, if you
lose your job, if you are a covered
dependent child and you turn 22 or
marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of
Coverage and Former Spouse Enrollees, from your
employing or
retirement office or from www. opm. gov/ insure. It explains
what you have
to do to enroll. 47
47 Page 48 49
2002 The Oath
48 Section 11
Converting to You may convert to a non-FEHB
individual policy if: individual coverage Your coverage under TCC or the
spouse equity law ends. If you
canceled your coverage or did not pay your
premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this notice. However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You
must
apply in writing to us within 31 days after you are no longer eligible
for
coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of Group Health Plan Coverage The Health
Insurance Portability and Accountability Act of 1996 (HIPAA) is a
federal
law that offers limited federal protections for health coverage availability and
continuity to people who use employer group coverage. If you leave the FEHB
Program, we will give you a Certificate of Group Health Plan Coverage that
indicates
how long you have been enrolled with us. You can use this
certificate when getting
health insurance or other health care coverage.
Your new plan must reduce or
eliminate waiting periods, limitations, or
exclusions for health related conditions based
on the information in the
certificate, as long as you enroll within 63 days of losing
coverage under
this Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a certificate
from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB Program. See also the
FEHB web site
(http:// www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA"
frequently asked question. These highlight HIPAA rules, such as
the
requirement that Federal employees must exhaust any TCC eligibility
as one
condition for guaranteed access to individual health coverage under
HIPAA,
and have information about Federal and State agencies you can
contact for
more information. 48
48 Page
49 50
2002 The Oath 49 Long
Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality
long term care insurance program effective in
October 2002. As part of its
educational effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related
disease such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice
care, and more. LTC insurance can supplement care provided by family
members, reducing the burden you place on them.
Welcome to the club!
76% of Americans believe they will never need long
term care, but the facts are that about half of them will. And it's not just the
old folks. About 40%
of people needing long term care are under age 65. They may need chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital
to their financial and retirement planning.
Yes, it can be very
expensive. A year in a nursing home can exceed $50,000. Home care for only three
8-hour shifts a week can exceed $20,000 a year.
And that's before inflation!
Long term care can easily exhaust your
savings. Long term care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5( c) of
your FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted living facility or a continuing need for a home health aide to help
you get in and out of bed and with other activities of daily living. Limited
stays in
skilled nursing facilities can be covered in some circumstances.
Medicare only covers skilled nursing home care (the highest level of nursing
care) after a hospitalization for those who are blind, age 65 or older or fully
disabled. It also has a 100 day limit.
Medicaid covers long term care for
those who meet their state's poverty guidelines, but has restrictions on covered
services and where they can be
received. Long term care insurance can provide choices of care and preserve
your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will begin in
mid-2002. In the meantime, you can learn more about the program on our web site
at
www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are YOU
planning to pay for the future custodial or chronic care you may need? You
should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy. I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan, Medicare or
Medicaid cover
my long term care?
When will I get more information on how to apply for
this new
insurance coverage?
How can I find out more
about the program NOW? 49
49 Page 50 51
2002 The Oath 50 Index
Index
Do not rely on this page; it is for your convenience and may not show
all pages where the terms appear.
Accidental injury....................... 35
Allergy tests
.............................. 15
Allogenetic (donor) bone marrow
transplants………………… 23
Ambulance................................ 28
Anesthesia................................. 23
Autologous bone marrow
transplant ........................... 23
Biopsies..................................... 20
Blood and blood
plasma............ 25
Changes for 2002........................ 6
Chemotherapy........................... 15
Childbirth.................................. 14
Chiropractic
.............................. 19
Claims
....................................... 39
Coinsurance
................................ 9
Colorectal cancer screening ...... 12
Congenital anomalies................ 20
Contraceptive devices and
drugs....... 14
Coordination of benefits ........... 41
Covered
charges.......................... 9
Covered providers.......................
7
Definitions ................................ 45
Dental care
................................ 35
Diagnostic services ...................
11
Disputed claims review............. 39
Donor expenses (transplants)
.... 23
Durable medical equipment
(DME)................................
18
Educational classes and programs .. 19
Effective date of
enrollment...... 46
Emergency ................................ 27
Experimental or investigational 45
Family
planning........................ 14
Fecal occult blood test
.............. 12
General Exclusions ................... 37
Hearing services........................ 16
Home health services
................ 19
Hospice care............................ 26
Home
nursing care .................. 19
Hospital
................................... 24
Immunizations
........................ 13
Infertility
................................. 15
In-hospital physician care ....... 25
Inpatient Hospital Benefits...... 25
Insulin
..................................... 32
Laboratory and pathological
services............................. 12
Magnetic Resonance
Imaging
(MRIs).............................. 12
Mail Order Prescription
Drugs 32
Mammograms ......................... 13
Maternity
Benefits................... 14
Medicaid ................................. 44
Medically necessary................ 45
Medicare
................................. 41
Members
................................. 45
Mental Conditions/ Substance
Abuse
Benefits ................. 29
Neurological testing ................
12
Newborn care .......................... 14
Non-FEHB Benefits
................ 36
Nursery charges....................... 14
Obstetrical care ....................... 14
Occupational therapy
.............. 16
Office visits ............................. 11
Oral
and maxillofacial surgery ...... 22
Orthopedic devices.................. 18
Ostomy and catheter supplies........ 18
Out-of-pocket
expenses............. 9
Outpatient facility care ............ 25
Oxygen.................................... 25
Pap test .................................... 12
Physical
examination............... 12
Physical therapy ................. 16
Physician ............................ 11
Pre-certification.................... 8
Preventive care, adult .........
12
Preventive care, children .... 13
Prescription drugs...............
31
Preventive services............. 12
Prior approval
...................... 8
Prostate cancer screening.......... 12
Prosthetic devices............... 18
Radiation
therapy............... 15
Renal dialysis ..................... 15
Room and board ................. 24
Skilled nursing facility
care....... 26
Smoking cessation.............. 19
Speech therapy
................... 16
Sterilization procedures...... 21
Subrogation
........................ 44
Substance abuse ................. 29
Surgery............................... 20
Anesthesia ................... 23
Oral ............................. 22
Outpatient.................... 25
Reconstructive............. 21
Syringes.............................. 32
Temporary continuation
of
coverage ...................... 47
Transplants
......................... 23
Treatment Therapies........... 15
Vision
services ................... 17
Well child care
................... 13
Wheelchairs........................ 18
X-rays................................. 12 50
50 Page 51 52
2002 The Oath 51
NOTES: 51
51 Page 52 53
2002 The Oath 52
Summary of benefits for
The Oath -2002
Do not rely on this chart alone. All benefits are
provided in full unless indicated and are subject to the
definitions,
limitations, and exclusions in this brochure. On this page we summarize specific
expenses we
cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the
cover on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $15 primary care; $15 specialist 11
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
$100 per admission copay
$50 copay
24
25
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$50 per visit
$50 per visit
27
27
Mental health and substance abuse
treatment..................................... Regular cost sharing 29
Prescription drugs
................................................................................
$5 generic, $15 preferred brand
name, $25 non-preferred brand
name
31
Dental Care – accidental injury
benefit............................................. $100 per admission; or $50
outpatient surgery copay 35
Vision Care – eye refraction once every 24 months .........................
$15 copay 17
Special features: nutritional counseling, breast cancer
awareness, discount subscriptions, health journal,
immunization awareness,
preventive health guidelines, preventive care reminder letters
34
Protection against catastrophic costs
(your out-of-pocket
maximum).........................................................
Nothing after $1,000/ Self only or
$2,000/ Family enrollment per year
Some costs do not count toward
this protection
9 52
52 Page 53
2002 Rate Information for
The Oath
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply
and special FEHB guides are published for
Postal Service Nurses and Tool & Die employees
(see RI 70-2B); and for
Postal Service Inspectors and Office of Inspector General (OIG)
employees
(see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of
any postal employee organization. Refer to the
applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only DF1 97.86 34.25 212.03 74.21 115.52 16.59
Self and Family
DF2 223.41 114.78 484.06 248.69 263.75 74.44 53