Group Health Cooperative of Eau Claire http:// www. group-health. com
2002
A Health Maintenance Organization
Serving: West Central Wisconsin
Enrollment in this Plan is
limited. You must live or work in this Geographic service area to enroll. See
page 6 for requirements.
Enrollment codes for this Plan:
WT1 Self Only WT2 Self and Family
RI 73-555
For changes in benefits
see pages 8, 50.
Cooperative of Eau Claire 1
1 Page 2 3
2002 Group Health
Cooperative of Eau Claire 2 Table of Contents
Table of
Contents
Introduction………………………………………………………………….........................................................................................
4
Plain
Language.......................................................................................................................................................................................
4
Inspector General
Advisory....................................................................................................................................................................
4
Section 1. Facts about this HMO
plan...................................................................................................................................................
6
How we pay
providers..........................................................................................................................................................
6
Who provides my health care?
.............................................................................................................................................
6
Your Rights
..........................................................................................................................................................................
6
Service Area
.........................................................................................................................................................................
6
Section 2. How we change for
2002......................................................................................................................................................
8
Program-wide changes
.........................................................................................................................................................
8
Changes to this Plan
.............................................................................................................................................................
8
Section 3. How you get care
.................................................................................................................................................................
9
Identification cards
...............................................................................................................................................................
9
Where you get covered care
.................................................................................................................................................
9
Plan providers
................................................................................................................................................................
9
Plan
facilities..................................................................................................................................................................
9
What you must do to get covered care
.................................................................................................................................
9
Primary care
...................................................................................................................................................................
9
Specialty care
.................................................................................................................................................................
9
Hospital care
................................................................................................................................................................
10
Circumstances beyond our control
.....................................................................................................................................
10
Services requiring our prior approval
.................................................................................................................................
11
Section 4. Your costs for covered
services..........................................................................................................................................
12
Co-payments
................................................................................................................................................................
12
Deductible
....................................................................................................................................................................
12
Section 5.
Benefits...............................................................................................................................................................................
13
Overview............................................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals.................................... 14
(b) Surgical and
anesthesia services provided by physicians and other health care professionals
................................ 21
(c) Services provided by a hospital or
other facility, and ambulance services
.............................................................. 24
(d)
Emergency services/ accidents
.................................................................................................................................
26
(e) Mental health and substance abuse benefits
............................................................................................................
29
(f) Prescription drug benefits
........................................................................................................................................
30
(g) Special features
.......................................................................................................................................................
32
Flexible benefit option
.........................................................................................................................................
32
24 hour
Nurseline.................................................................................................................................................
32
(h) Dental benefits
.........................................................................................................................................................
33 2
2 Page 3 4
2002 Group Health Cooperative of Eau Claire 3
Table of Contents
Section 6. General exclusions --things we don't
cover
.......................................................................................................................
34
Section 7. Filing a claim for covered
services.....................................................................................................................................
35
Section 8. The disputed claims process
...............................................................................................................................................
36
Section 9. Coordinating benefits with other coverage
........................................................................................................................
38
When you have…
Other health coverage
..................................................................................................................................................
38
Original Medicare
........................................................................................................................................................
38
Medicare managed care plan
.......................................................................................................................................
40
TRICARE/ Workers' Compensation/ Medicaid
..................................................................................................................
40
Other Government agencies
...............................................................................................................................................
41
When others are responsible for injuries
............................................................................................................................
41
Section 10. Definitions of terms we use in this brochure
.....................................................................................................................
42
Section 11. FEHB facts
.......................................................................................................................................................................
44
Coverage
information.......................................................................................................................................................
44
No pre-existing condition
limitation.........................................................................................................................
44
Where you get information about enrolling in the FEHB
Program..........................................................................
44
Types of coverage available for you and your family
..............................................................................................
44
When benefits and premiums start
...........................................................................................................................
44
Your medical and claims records are
confidential....................................................................................................
45
When you retire
.......................................................................................................................................................
45
When you lose
benefits.....................................................................................................................................................
45
When FEHB coverage
ends......................................................................................................................................
45
Spouse equity coverage
...........................................................................................................................................
45
Temporary Continuation of Coverage
(TCC)..........................................................................................................
45
Converting to individual coverage
..........................................................................................................................
45
Getting a Certificate of Group Health Plan Coverage
.............................................................................................
46
Long-term care insurance is coming later in 2002
...............................................................................................................................
47
Index.....................................................................................................................................................................................................
49
Summary of benefits
............................................................................................................................................................................
51
Rates.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Group Health Cooperative of Eau Claire 4 Introduction/ Plain
Language/ Inspector General Advisory
Introduction
Group
Health Cooperative of Eau Claire 2503 North Hillcrest Parkway
Altoona, WI
54720
This brochure describes the benefits of Group Health Cooperative of
Eau Claire under our contract (CS 2615) with the Office of Personnel Management
(OPM), as authorized by the Federal Employees Health Benefits law. This brochure
is the official statement
of benefits. No oral statement can modify or
otherwise affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits that were available before
January 1, 2002 unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002 and
changes are summarized on page 8. Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we"
means Group Health
Cooperative of Eau Claire, Group Health Cooperative, or Group Health.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel
Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure,
let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. 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:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 888/ 203-7770 and explain the
situation. If we do not resolve the issue, call:
THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States
Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400 Washington, DC 20415 4
4 Page 5 6
2002 Group Health Cooperative of Eau Claire 5
Introduction/ Plain Language/ Inspector General Advisory
Penalties
for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can
be prosecuted for fraud. Also, the Inspector General may investigate anyone who
uses an ID card if the person tries to
obtain services for someone who is
not an eligible family member, or is no longer enrolled in the Plan and tries to
obtain benefits. Your agency may also take administrative action against
you. 5
5 Page 6
7
2002 Group Health Cooperative of Eau Claire 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan
providers, you will not have to submit claim forms or pay bills. You only pay
the co-payments, coinsurance, and deductibles described in this brochure. When
you receive emergency services from non-Plan providers, you may
have to
submit claim forms.
You should join an HMO because you prefer the plan's
benefits, not because a particular provider is available. You cannot change
plans because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will
be available and/ or remain
under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your co-payments and deductible.
Who provides my health care?
Group Health Cooperative of Eau
Claire is a network model, non-profit, member directed health maintenance
organization. Group Health has been in operation since 1976 and provides
services through twenty-five clinics. Four clinics are located in Eau Claire;
three
in Chippewa Falls; two in Rice Lake, Thorp and Stanley; and one each
in Augusta, Baldwin, Bruce, Cadott, Chetek, Cornell, Cumberland, Ladysmith,
Osseo, Owen and Radisson. Group Health has over 120 primary care physicians to
choose from and over
600 referral specialists. Primary care is the
professional focus at Group Health, which includes specialists in family
practice, obstetrics/ gynecology, internal medicine, pediatrics, and sports
medicine. Also included in our team of professionals are the services
of our
physicians assistants, certified family and pediatric nurse practitioners and
nurse midwives.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get
information about us, our networks, providers, and facilities. OPM's FEHB
website (www. opm. gov/ insure) lists the specific types of information that
we must
make available to you. Some of the required information is listed
below.
We are a State licensed HMO that meets all Federal and State
requirements
Group Health has been a Cooperative for 27 years
Group
Health is a non-profit organization
If you want more information about us,
call 888/ 203-7770 or write to: Group Health Cooperative of Eau Claire; P. O.
Box 3217; Eau Claire, WI 54702. You may also contact us by fax at 715/ 552-3500
or visit our website at www. group-health. com.
Service Area
To enroll in this plan, you must live in or work in
our Service Area. This is where our providers practice. This plan considers its
service area to be a 25-mile radius around each primary care clinic. Please see
this Plan's Provider Directory for a list of those clinics.
You may also
enroll with us if you live or work in the following counties: Barron, Buffalo,
Chippewa, Clark, Dunn, Eau Claire, Jackson, Pepin, Rusk, Sawyer, Taylor,
Trempealeau, and Washburn.
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. 6
6 Page 7 8
2002 Group Health Cooperative of Eau Claire 7
Section 1
If you or a covered family member move outside of our
service area, you can enroll in another plan. If your dependents live out of the
area (for example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO
that has agreements
with affiliates in other areas. If you or a family member move, you do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page 8
9
2002 Group Health Cooperative of Eau Claire 8
Section 2
Section 2. How we change for 2002
Do not rely on
these change descriptions; this page is not an official statement of benefits.
For that, go to Section 5 Benefits. Also, we edited and clarified language
throughout the brochure; any language change not shown here is a clarification
that does not change
benefits.
Program-wide changes
We increased speech therapy benefits by removing the requirement that
services must be required to restore functional speech. (Section 5( a))
Changes to this Plan
Your share of the non-Postal premium will
increase by 59. 7% for Self Only or 49. 9% for Self and Family.
Prescription
Drugs now require a $10 co-payment per prescription.
Speech therapy is
covered for up to 2 months when medically necessary and subject to prior
authorization.
Intestinal transplants are covered.
Smoking cessation is
covered. You pay a $10 member copayment for the initial visit. The Zyban drug is
covered up to 3 months under the prescription drug benefit.
The TMJ appliances are now covered under the DME with a $50 deductible. 8
8 Page 9 10
2002 Group Health Cooperative of Eau Claire 9
Section 3
Section 3. How you get care
Identification cards
We will send you an identification (ID) card when you enroll. You should
carry your ID card with you at all times. You must show it whenever you receive
services from a Plan
provider, or 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 888/ 203-7770.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay co-payments and deductibles, and you will
not have to file claims.
Plan providers Plan providers are physicians
and other health care professionals in our service area that we contract with to
provide covered services to our members. We credential Plan
providers
according to national standards.
We list Plan providers in the provider
directory, which we update periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in the provider directory, which
we update
periodically. The list is also on our website.
It depends on the type of
care you need. First, you and each family member must choose a primary care
clinic. This decision is important since your primary care physician, at
your clinic, provides or arranges for most of your health care. Each member
of the family can choose a different clinic for their care. You may change
clinics twice a year by
calling Member Services at 888/ 203-7770.
Primary care Your primary care physician can be a family practitioner,
internist, OB/ GYN, or pediatrician. Your primary care physician will provide
most of your health care, or give
you a referral to see a specialist.
If
you want to change primary care physicians or if your primary care physician
leaves the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain number of
visits without additional referrals. The primary care physician must provide or
authorize all follow-up care. Do not go to the specialist for return visits
unless your primary care physician gives you a referral. However, you may see
the Group Health
Cooperative contracted providers for Chiropractic and
Optometry (one annual exam) care without a referral
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits. Your
primary care physician will use our criteria when creating your treatment plan
(the physician may
have to get an authorization or approval beforehand).
What you must do to get covered care 9
9
Page 10 11
2002
Group Health Cooperative of Eau Claire 10 Section 3
If you are
seeing a specialist when you enroll in our Plan, talk to your primary care
physician. Your primary care physician will decide what treatment you need. If
he or
she decides to refer you to a specialist, ask if you can see your
current specialist. If your current specialist does not participate with us, you
must receive treatment from a
specialist who does. Generally, we will not
pay for you to see a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive
services from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other
than cause; or
drop out of the Federal Employees Health Benefits (FEHB)
Program and you enroll in another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
You may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact your
new
plan.
If you are in the second or third trimester of pregnancy and
you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until
the end of your postpartum care, even
if it is beyond the 90 days.
Hospital care Your Plan primary care
physician or specialist will make necessary hospital arrangements and supervise
your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan
begins, call our customer service department immediately at 715/ 552-4300. If
you are new to the FEHB Program,
we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable
efforts to provide you with the necessary care. 10
10
Page 11 12
2002
Group Health Cooperative of Eau Claire 11 Section 3
Group
Health's primary care physicians are supported by an extensive network of more
than 600 specialty and tertiary care physicians to ensure access to the complete
continuum of high-quality healthcare services.
If both you and your
primary care physician feel that you require additional treatment, together you
decide about the appropriate type of referral to a specialist. A written
referral is required for every visit with a specialist. Your primary care
physician will provide you with the referral. Every referral you receive will
have a limit of days and/ or a
specific number of visits for when you can
use that referral. Please make sure that you see that specialist within that
time allotted.
If you notice that your appointment falls after the referral end date, please
contact your primary care physician to receive a new referral.
If the
specialist believes it is necessary for you to seek additional treatment, you
should contact your primary care physician to discuss the additional referral.
The specialist
should not make a direct referral for you; it must come from
your primary care physician.
Services requiring our prior approval 11
11
Page 12 13
2002
Group Health Cooperative of Eau Claire 12 Section 4
Section 4. Your costs for covered services
You must share
the cost of some services. You are responsible for:
Copayments A
co-payment 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, a specialist, a
chiropractor, or home health services, you pay a co-payment of $10 per office
visit. You would also pay a
$25 co-payment for Emergency Room visits.
Deductible A deductible is a fixed expense you must incur for certain
covered services and supplies before we start paying benefits for them.
Co-payments do not count toward any
deductible The only deductible you have
is for Durable Medical Equipment, which is $50 per
person per calendar year.
We do not have an out-of-pocket maximum.
We may limit your benefits if you do not obtain a treatment plan.
Limitations
Your out-of-pocket maximum 12
12 Page 13 14
2002 Group Health Cooperative of Eau Claire 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 8 for how our
benefits changed this year and page 50 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
more information about how to obtain your benefits, contact us at
800/ 203-7770 or at our website at www. group-health. com.
(a) Medical services and supplies provided by physicians and other health
care professionals ....................................................... 14-20
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)
Vision services (one annual
routine exam) Foot care
Orthopedic and prosthetic devices Durable medical
equipment (DME)
Home health services Chiropractic
Educational classes
and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals................................................. 21-23
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..............................................................................
24-25
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits Ambulance
(d) Emergency services/
accidents..................................................................................................................................................
26-28 Medical emergency Ambulance
(e) Mental health and substance abuse
benefits
..................................................................................................................................
29
(f) Prescription drug benefits
........................................................................................................................................................
30-31
(g) Special Features
............................................................................................................................................................................
32
Flexible benefits
option..........................................................................................................................................................
32
24 hour Nurseline (FirstCare
Nurseline)................................................................................................................................
32
(h) Dental benefits
..............................................................................................................................................................................
33
Summary of benefits
............................................................................................................................................................................
50 13
13 Page 14
15
2002 Group Health Cooperative of Eau Claire
14 Section 5( a)
Section 5 (a). Medical services and supplies
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also, read Section 9 about coordinating benefits
with other coverage, including Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of
physicians
In physician's office
In specialist's office
In chiropractor's office
$10 per office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
Office medical consultations
Second surgical opinion
$10 per office visit
Nothing
$10 per office visit
$10 per office
visit
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 14
14 Page
15 16
2002 Group Health Cooperative of
Eau Claire 15 Section 5( a)
Preventive care, adult You pay
Routine physical
Routine screenings, such as:
Blood pressure
check
Total Blood Cholesterol
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening starting at age 50
Routine pap test
$10 per office visit and
Nothing for tests
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges
Tetanus-diphtheria (Td) booster
Influenza/ Pneumococcal vaccines,
annually, age 65 and over
Nothing
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics Nothing
Well-child care charges for routine examinations, immunizations and care
(under age 22)
Examinations, such as: Eye exams through age 17 to determine
the need for vision
correction. Ear exams through age 17 to determine the
need for hearing
correction Examinations done on the day of immunizations
(under age 22)
$10 per office visit
Nothing for one annual eye exam
Nothing
$10
per office visit 15
15 Page
16 17
2002 Group Health Cooperative of
Eau Claire 16 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to pre-certify your normal delivery; see page 24 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend
your inpatient stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
$10 co-payment for first office visit only.
Not covered: Routine sonograms to determine fetal age, size or sex or
medial and hospital costs resulting from a normal full-term delivery of
a
baby outside of the Group Health Cooperative service area.
All charges
Family planning
A broad range of voluntary family planning
services, limited to:
Voluntary sterilization
Injectable contraceptive
drugs (such as Depo provera)
Note: We cover oral contraceptives under the
prescription drug benefit.
$10 per office visit
Not covered:
Reversal of voluntary surgical sterilization,
genetic counseling,
Surgically implanted contraceptives, such as
Norplant
Intrauterine devices (IUD's),
Elective abortions
All charges 16
16 Page 17 18
2002 Group
Health Cooperative of Eau Claire 17 Section 5( a)
Infertility
services You pay
Diagnosis and treatment of infertility, if provided by
a Group Health Primary Care Physician, such as:
Artificial insemination: intravaginal insemination (IVI)
intracervical insemination (ICI) intrauterine insemination
(IUI)
$10 per office visit
Not covered:
Assisted reproductive technology (ART) procedures,
such as: In vitro fertilization
Embryo transfer, gamete GIFT and zygote ZIFT Zygote transfer
Services and supplies related to excluded ART procedures
Cost
of donor sperm
Cost of donor egg
Fertility drugs
All charges
Allergy care
Testing and treatment
Allergy injection
$10
co-payment per office visit
Nothing
Allergy serum Nothing
Not covered: provocative food
testing and sublingual allergy desensitization All charges
Treatment therapies
Chemotherapy and radiation therapy
Note:
High dose chemotherapy in association with autologous bone marrow transplants
are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/
Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Notes: Growth Hormone therapy is covered
under the prescription drug benefit.
Notes: Growth hormone therapy (GHT) -This requires medical director approval.
Call 888/ 203-7770 for pre-authorization or have
your physician call our
office.
Nothing 17
17 Page
18 19
2002 Group Health Cooperative of
Eau Claire 18 Section 5( a)
Physical and occupational
therapies You pay
60 visits per condition for the services of each of
the following: qualified physical therapists and
occupational therapists.
Note: We only cover therapy to restore bodily
function when there has been a total or partial loss of bodily function due to
illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided with approved referral.
Nothing
Not covered:
long-term rehabilitative therapy
exercise programs
All charges
Speech therapy
Up to two months when medically necessary and
subject to prior authorization. Nothing
Hearing services (testing, treatment, and supplies)
Diagnostic
hearing testing only when necessitated by accidental injury.
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
$10 per office visit
Not
covered: all other hearing testing
hearing aids, testing and
examinations for them
All charges
Vision services (testing, treatment, and supplies)
Annual eye
refractions Nothing at participating providers.
Not covered:
Eyeglasses or contact lenses and, after age 17, examinations for them
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
All charges 18
18 Page 19 20
2002 Group
Health Cooperative of Eau Claire 19 Section 5( a)
Foot care
You pay
Routine foot care when you are under active treatment for a
metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat feet
or bunions or spurs; and of any instability, imbalance or subluxation of the
foot (unless the
treatment is by open cutting surgery)
All charges
Internal prosthetic devices Internal prosthetic devices, such as
artificial joints, pacemakers, and
surgically implanted breast implant
following mastectomy.
Note: We pay internal prosthetic devices as hospital
benefits; see Section 5 (c) for payment information. See 5 (b) for coverage of
the
surgery to insert the device.
Nothing
Durable medical equipment (DME)/ Prosthetic/ Orthopedic Devices
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen
and dialysis equipment. Under this benefit, we also cover:
Hospital beds;
Wheelchairs;
Crutches;
Walkers;
Blood glucose monitors;
Insulin pumps; ________________________________________________
Artificial limbs and eyes; stump hose;
Externally worn breast prostheses
and surgical bras, including necessary replacements, following mastectomy;
Prosthetics.
________________________________________________
Corrective orthopedic appliances for non-surgical treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Custom made foot orthotics and corrective shoes;
Corsets, trusses, and
other braces and devices; and
$50 deductible per person, per calendar year.
$5,000 lifetime maximum
Durable medical equipment (continued on next page) 19
19 Page 20 21
2002 Group Health Cooperative of Eau Claire 20
Section 5( a)
Durable medical equipment (DME)/ Prosthetic/
Orthopedic Devices (continued) You pay
Note: Call us at 888/ 203-7770 as
soon as your Plan physician prescribes this equipment. We will arrange with a
health care
provider to rent or sell you durable medical equipment at
discounted rates and will tell you more about this service when you call.
Benefits are limited to a lifetime maximum of $5,000.
Not covered:
Motorized wheelchairs
Replacement of lost or stolen equipment.
All charges
Home health services
Home health care ordered by a Plan physician
and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.),
licensed
vocational nurse (L. V. N.), or home health aide. Services include oxygen
therapy, intravenous therapy and medications.
$10 per home visit
Not covered: Nursing care requested by, or for the convenience of,
the patient or
the patient's family; Home care primary for personal
assistance that does not include a
medical component and is not diagnostic,
therapeutic, or rehabilitative.
All charges
Chiropractic You pay Manipulation of the spine and extremities.
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application. $10 per office visit.
Alternative treatments
Not covered: naturopathic
services
hypnotherapy biofeedback
acupuncture
All charges
Educational classes and programs
Coverage is limited to:
Smoking Cessation – covered for initial consultation.
$10 for initial
office visit. 20
20 Page
21 22
2002 Group Health Cooperative of
Eau Claire 21 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 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 PRE-CERTIFICATION OF SOME SURGICAL PROCEDURES.
Please refer to the pre-certification information shown in Section 3 to be sure
which services require pre-certification and identify which surgeries require
pre-certification.
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. Voluntary
sterilization
Treatment of burns
Note: Generally, we pay for internal
prostheses (devices) according to where the procedure is done. For example, we
pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per office visit
Not covered: Reversal of voluntary sterilization
Routine
treatment of conditions of the foot; see Foot care.
All charges 21
21 Page 22 23
2002 Group Health Cooperative of Eau Claire 22
Section 5( b)
Reconstructive surgery You pay 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
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours
after the procedure.
Nothing
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;
Other surgical procedures that do not involve the
teeth or their supporting structures; and
TMJ surgery and other non-dental
services
$10 per office visit
Not covered: Oral implants and transplants
Procedures
that involve the teeth or their supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
All charges 22
22 Page 23 24
2002 Group Health Cooperative of Eau Claire 23
Section 5( b)
Organ/ tissue transplants You pay
Limited
to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single-Double
Pancreas
Allogeneic (donor) bone
marrow transplants Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute lymphocytic
or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple myeloma;
epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver, stomach,
and pancreas. We do transplants on a referral basis with Medical Director
approval.
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
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 Group Health Cooperative of
Eau Claire 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).
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as ward, semiprivate, or intensive care accommodations;
general nursing care; and meals and special diets.
Note: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as: Operating, recovery,
maternity, and other treatment rooms
Prescribed 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
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 24
24 Page 25 26
2002 Group
Health Cooperative of Eau Claire 25 Section 5( c)
Outpatient
hospital or ambulatory surgical center You pay
Operating, recovery, and
other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
Note: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
Extended Care/ Skilled nursing facility (SNF); if medically
necessary. Nothing
Not covered: custodial care All charges
Hospice care Not covered:
Independent nursing, homemaker services
Hospice care
All charges
Ambulance
Local professional ambulance service when medically
appropriate Nothing 25
25 Page
26 27
2002 Group Health Cooperative of
Eau Claire 26 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:
A medical emergency is a sudden, potentially life-threatening situation
where immediate medical treatment is needed. The following are some examples of
a medical emergency.
Heart Attack Major Trauma
Sudden Unconsciousness
When such a situation arises, no authorization is necessary and you should
proceed directly to the emergency department.
The enclosed Provider
Directory has a list of hospitals that will provide quality coverage for such
emergency care. You should also look at your Benefit Summary or your Group
Health contract policy and rider that will show if you have a co-payment
or
emergency services.
Emergencies outside our service area: If a true
emergency occurs while you are away from the Group Health service area,
treatment for the emergency will be covered at any facility. Follow-up care,
however, whether it is inpatient or
outpatient, must be provided by a contracted provider. To save yourself some
confusion and worry when out of the area, you can call our Member Service
Representatives at 888/ 203-7770 to review your coverage in case of an
emergency.
FirstCare Nurseline: You must call our FirstCare Nurseline before
obtaining urgent care services at any of our facilities.
Urgent Care within our service area: Conditions may arise that require
urgent medical attention but may not be serious enough to go to the ER. Examples
include the following:
Minor Injuries Ear Infections
Fevers Unless the
condition is a life-threatening emergency, you must call the FirstCare Nurseline
or your primary care clinic to
discuss the situation with a physician or
triage nurse. They will direct you to the proper setting to receive care. In
some situations, a physician may even be able to provide the appropriate
treatment over the phone. In other cases, you may be
instructed to go to the
emergency room or to an urgent care facility. In order to assure payment of
coverage, you must make the call and receive the authorization before going to
the emergency room for urgent care services. 26
26
Page 27 28
2002
Group Health Cooperative of Eau Claire 27 Section 5( d)
Urgent
Care outside our service area: Urgent care means that the member cannot
safely return to the Group Health Cooperative service area before needing
treatment. In such cases, the FirstCare Nurseline or physician may advise
you to seek care at the nearest appropriate facility. If it is not possible
to contact your primary care clinic for advice or authorization, you should seek
treatment at a physician's office, urgent care facility, or Emergency Department
depending on
the problem. A coverage decision will be made based on the
medical records from you visit. 27
27 Page 28 29
2002 Group
Health Cooperative of Eau Claire 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
or inpatient at a hospital, including doctors' services
$10 per office visit
$10 per office visit
$25 per office 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 or inpatient at a hospital, including
doctors' services
$10 per office visit
$10 per office visit
$25 per
office visit
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full-term delivery of a
baby outside the service area.
All charges
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Nothing 28
28 Page 29 30
2002 Group Health Cooperative of Eau Claire 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 ARE REQUIRED TO USE THE GROUP HEALTH COOPERATIVE MENTAL
HEALTH PROVIDERS. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is clinically
appropriate to treat your condition and only when you receive
the care as
part of a treatment plan that we approve.
Your cost sharing responsibilities are no greater than for other illness or
conditions.
Professional services, including individual or group therapy by
providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit
Diagnostic tests Nothing
Services provided by a hospital or other
facility Nothing
Not covered: Services received outside our network.
Note: OPM will base its review of disputes about treatment plans on the
treatment plans 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
follow your treatment plan and all the following authorization processes:
You are required to use the Group Health Mental Health providers listed in
your provider directory. You can
obtain a directory or information from our website at
www. group-health. com
or from our Member Service Representatives at 715/ 552-4300 or 888/
203-7770.
Limitations We may limit your benefits if you do not obtain a
treatment plan! 29
29 Page
30 31
2002 Group Health Cooperative of
Eau Claire 30 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 we are payable only when we
determine they are medically necessary.
You have a $10 co-payment per prescription.
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
Medicare.
I M
P O
R T
A N
T
There are important features you
should be aware of. These include:
Who can write your prescription.
A licensed physician must write the prescription – or – A plan physician or
licensed dentist must write the prescription.
Where you can obtain them. You may fill the prescription at a any
contracted pharmacy,
We use a formulary. Drugs are prescribed by plan
doctors and dispensed in accordance with the plan's drug formulary.
Non-formulary drugs will be covered when prescribed by Plan doctor. A list of
prescription
products that are covered by Group Health Cooperative is available to you.
Products are chosen by a Pharmacy & Therapeutics (P& T) Committee
consisting of physicians, pharmacists and non-physician
clinicians.
Inclusion in the formulary is based on medical efficacy and cost effectiveness.
New products are automatically reviewed by the P& T Committee, while older
products are received at the request of a clinician
or when a substantial
number of prior authorizations have been requested for its use. Members who wish
to have a product added to the formulary should discuss the reasoning with their
primary care physician who
may then initiate the process with the P& T
Committee.
A generic equivalent will be dispensed if it is available.
These are the dispensing limitations. Prescription drugs prescribed
by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed
for up to a 31-day supply, or up to 100-day supply for drugs
on the Group Health Extended Supply List.
Why use generic drugs?
Generic drugs are lower-priced drugs that are the therapeutic equivalent to
more expensive brand-name drugs. They must contain the same active ingredients
and must be equivalent in
strength and dosage to the original brand-name product. Generics cost less
than the equivalent brand-name product. The U. S. Food and Drug Administration
sets quality standards for generic drugs to ensure that these
drugs meet the
same standards of quality and strength as brand-name drugs.
When you have
to file a claim. Prescription drugs are automatically paid electronically
because the pharmacist's computer bills Group Health directly. You do not have
to file any prescription claims. Group
Health has pharmacy contracts with all local pharmacies and most national
chains. If you are in an area without a provider pharmacy you may have the
pharmacy call our pharmacy department at 888-298-7770
(available 24 hours a
day, 7 days a week) or you may pay for the prescription and mail in the receipt
for reimbursement to: Attn: Claims Department; Group Health Cooperative; P. O.
Box 3217; Eau Claire, WI
54702. 30
30 Page 31 32
2002 Group
Health Cooperative of Eau Claire 31 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 and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those
listed as Not
covered. Insulin
Disposable needles and syringes for the administration
of covered medications
Drugs for sexual dysfunction (up to dosage
limitation) Contraceptive drugs
Zyban (limited to one time, 3 month
prescription).
$10 co-payment per prescription.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription medicines
Drugs used to
control or reduce weight
Nicotine patches
All charges 31
31 Page 32 33
2002 Group
Health Cooperative of Eau Claire 32 Section 5( g)
Section 5
(g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour Nurseline For urgent care or any of your health concerns, 24
hours a day, 7 days a week, you must call the FirstCare Nurseline and talk with
a registered nurse who will discuss treatment options and answer your health
questions. The phone number will be on
your ID Card when you join Group
Health. 32
32 Page
33 34
2002 Group Health Cooperative of
Eau Claire 33 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians or dentists must provide or arrange your care.
We cover
hospitalization for dental procedures only when a non-dental physical impairment
exists which makes hospitalization necessary to safeguard the health of the
patient; we do not cover the dental
procedure unless it is described below.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including
Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover the initial emergency
visit necessary to promptly repair (but not replace) sound natural teeth. The
need for these services must result
from an accidental injury. (Excludes restorations).
Nothing
Dental benefits
We have no other dental benefits. 33
33 Page 34 35
2002 Group Health Cooperative of Eau Claire 34
Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may
list a specific service as a benefit, we will not cover it unless your Plan
doctor determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury,
or condition.
We do not cover the
following:
Care by non-Plan providers except for authorized referrals or
emergencies (see Emergency Benefits);
Services, drugs, or supplies you
receive while you are not enrolled in this Plan;
Services, drugs, or
supplies that are not medically necessary;
Services, drugs, or supplies not
required according to accepted standards of medical, dental, or psychiatric
practice;
Experimental or investigational procedures, treatments, drugs or
devices;
Services, drugs, or supplies related to abortions, except when the
life of the mother would be endangered if the fetus were carried to term or when
the pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program. 34
34 Page
35 36
2002 Group Health Cooperative of
Eau Claire 35 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 co-payment or deductible.
Group Health Cooperative members should not receive a bill for medical
services provided, except when an applicable co-payment or deductible applies.
Routine office visits, hospitalizations, and specialist services will be covered
according to your contract if you stay
within the Group Health network and
obtain a written referral when required. 35
35
Page 36 37
2002
Group Health Cooperative of Eau Claire 36 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: P. O. Box 3217; Eau Claire, WI
54702; and
(c) Include a statement about why you believe our initial
decision was wrong, based on specific benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request -go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in
some way within 30 days; or
120 days after we asked for additional
information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630.
The Disputed Claims process
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. 36
36 Page 37 38
2002 Group
Health Cooperative of Eau Claire 37 Section 8
Note: You are the
only person who has a right to file a disputed claim with OPM. Parties acting as
your representative, such as medical providers, must include a copy of your
specific written consent with the review request.
Note: The above deadlines
may be extended if you show that you were unable to meet the deadline because of
reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision,
your only recourse is to sue. If you decide to sue, you must file the suit
against OPM in Federal court by December 31 of the third year after the year in
which you received the disputed services, drugs, or supplies or from the year in
which you were denied pre-certification 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 888/ 203-7770 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. 37
37
Page 38 39
2002
Group Health Cooperative of Eau Claire 38 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. Medicare + Choice is the term used to describe
the various health plan choices available
to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits with
Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in
the United States. It is the way everyone used to get Medicare benefits and is
the way most people
get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts 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.
The Original Medicare Plan (Part A or Part B) 38
38 Page 39 40
2002 Group Health Cooperative of Eau Claire 39
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 anactiveemployeewith
theFederalgovernment(including whenyouora familymemberare
eligibleforMedicaresolely becauseofadisability),
2) Are an annuitant,
3) Are a reemployed annuitant with the
Federal government when…
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only,
regardless of your employment status, (for Part B services) (for other
services)
6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined 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 39
39 Page 40 41
2002 Group Health Cooperative of Eau Claire 40 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 888/ 203-7770.
We waive some costs when you have the Original Medicare Plan --When Original
Medicare is the primary payer, we will waive some out-of-pocket costs, as
follows:
We will waive your office visit co-payments if you have both Part A and Part
B
of Medicare.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare benefits from another type of
Medicare+ Choice plan --a Medicare managed care plan.
These are health care
choices (like HMOs) in some areas of the country. In most Medicare managed care
plans, you can only go to doctors, specialists, or hospitals that
are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care
plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www.
medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You
may enroll in our Medicare managed care plan and also remain enrolled in our
FEHB plan. In this case, we do/ do not
waive any of our co-payments,
coinsurance, or deductibles 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 co-payments, coinsurance, or
deductibles. If you enroll in a Medicare managed care plan, tell us. We will
need to know whether you
are in the Original Medicare Plan or in a Medicare
managed care plan so we can correctly coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your Medicare managed care plan premium.) For information
on suspending your FEHB
enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next open season unless you involuntarily
lose coverage or move out of the
Medicare managed care plan's service area.
If you do not have one or both
Parts of Medicare, you can still be covered under the FEHB Program. We will not
require you to enroll in Medicare Part B and, if you can't
get premium-free
Part A, we will not ask you to enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.
If you do not enroll in Medicare Part A or Part B 40
40 Page 41 42
2002 Group Health Cooperative of Eau Claire 41
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.
We do
not cover services and supplies when a local, State, or Federal Government
agency directly or indirectly pays for them.
When you receive money to compensate you for medical or hospital care for
injuries or illness caused by another person, you must reimburse us for any
expenses we
paid. However, we will cover the cost of treatment that exceeds
the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures.
When other Government agencies are responsible for your care
When
others are responsible for injuries 41
41
Page 42 43
2002
Group Health Cooperative of Eau Claire 42 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.
Co-payment A co-payment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Provision of room and board, nursing care,
or personal care designed to assist an individual who, in the opinion of a plan
physician, has reached the maximum level of
recovery. In the case of
confinement in a Hospital or nursing facility, Custodial Care also includes room
and board, nursing care, or such other care which is provided to an
individual for whom it cannot reasonably be expected, in the opinion of the
plan physician, that the medical or surgical treatment will enable that person
to live outside an
institution. Custodial Care also includes rest cures,
respite care, and home care provided by family members.
Deductible A deductible is a fixed amount of covered expenses you must
incur for certain covered services and supplies before we start paying benefits
for those services. See page 12.
Is a health service, treatment, or supply
used for an illness or injury which, at the time it is used, meets one or more
of the following criteria:
Is subject to approval by an appropriate
governmental agency for the purpose it is being used for such as, but not
limited to the Food and Drug Administration
(FDA), which has not granted
that approval; Is not a commonly accepted medical practice in the American
medical
community; Is the subject of a written investigational or research
protocol;
Requires a written investigational or research protocol; Requires
a written informed consent by a treating facility that makes reference
to it
being experimental, investigative, educational, for a research study, or posing
an uncertain outcome, or having an unusual risk;
Is the subject of an
outgoing FDA Phase I, II, III clinical trial; Is undergoing review by an
institutional review board;
Lacks recognition and endorsement of supporting
medical literature published in an established, peer reviewed scientific
journal;
Has unacceptable failure rates and side effects or poses uncertain
risks and outcomes;
Is being used in place of other more conventional and
proven methods of treatment;
Has been disapproved by the GHC Technology
Assessment Committee.
Experimental or investigative services 42
42
Page 43 44
2002
Group Health Cooperative of Eau Claire 43 Section 10
Medical
necessity A service, treatment, procedure, equipment, drug, device or supply
provided by a hospital, physician or other health care provider that is required
to identify or treat a participant's
illness or injury and which is, as
determined by the plan: 1. consistent with symptoms or diagnosis and treatment
of the participants; 2. appropriate under the standards of
acceptable
medical practice to treat that illness or injury; 3. not solely for the
convenience of the participant, physician, hospital or other health care
provider; 4. the most appropriate
service, treatment, procedure, equipment,
drug, device or supply which can be safely provided to the participant and
accomplishes the desired end result in the most economical
manner.
Us/ We Us and we refer to Group Health, Group Health Cooperative, and
Group Health Cooperative of Eau Claire.
You You refers to the enrollee and each covered family member. 43
43 Page 44 45
2002 Group Health Cooperative of Eau Claire 44
Section 11
Section 11. FEHB facts
We will not refuse to
cover the treatment of a condition that you had before you enrolled in this Plan
solely because you had the condition before you enrolled.
See -www. opm. gov/ insure. Also, your employing or retirement office can
answer your questions, and give you a Guide to Federal Employees Health
Benefits Plans, brochures
for other plans, and other materials you need
to make an informed decision about:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to
another Federal agency, go on leave without pay, enter military service, or
retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your employing or
retirement office.
Self Only coverage is for you alone. Self and Family coverage is for you,
your spouse, and your unmarried dependent children under age 22, including any
foster children or
stepchildren your employing or retirement office
authorizes coverage for. Under certain circumstances, you may also continue
coverage for a disabled child 22 years of age or
older who is incapable of
self-support.
If you have a Self-Only enrollment, you may change to a Self
and Family enrollment if you marry, give birth, or add a child to your family.
You may change your enrollment 31
days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period in
which the child is born or becomes an eligible family
member. When you
change to Self and Family because you marry, the change is effective on the
first day of the pay period that begins after your employing office receives
your
enrollment form; benefits will not be available to your spouse until
you marry.
Your employing or retirement office will not notify you
when a family member is no longer eligible to receive health benefits, nor will
we. Please tell us immediately when
you add or remove family members from
your coverage for any reason, including divorce, or when your child under 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.
The benefits in this brochure are effective on January 1. If you
joined this Plan during Open Season, you coverage begins on the first day of
your first pay period that
starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any other time during
the year, your employing office will tell you the
effective date of
coverage.
No pre-existing condition limitation
Where you can get information
about enrolling in the
FEHB Program
Types of coverage available to you and your family
When benefits and premiums start 44
44
Page 45 46
2002
Group Health Cooperative of Eau Claire 45 Section 11
We will keep
your medical and claims information confidential. Only the following will have
access to it:
OPM, this Plan, and subcontractors when they administer this
contract;
This Plan and appropriate third parties, such as other insurance
plans and the Office of Workers' Compensation Programs (OWCP), when coordinating
benefit payments and
subrogating claims;
Law enforcement officials when investigating and/ or
prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary 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 If you leave Federal service, or if you
lose coverage because you no longer qualify as a Coverage (TCC) 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.
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.
Your medical and claims records are confidential 45
45 Page 46 47
2002 Group Health Cooperative of Eau Claire 46 Section 11
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days after you
receive this notice.
However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You
must apply in writing to us within 31 days
after you are no longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB
Program; however, you will not have to answer questions about your health, and
we will not impose a waiting
period or limit your coverage due to
pre-existing conditions.
The Health Insurance Portability and Accountability
Act of 1996 (HIPAA) is a federal law that offers limited Federal protections for
health coverage availability and
continuity to people who lose employer
group coverage. If you leave the FEHB Program, we will give you a Certificate of
Group Health Plan Coverage that indicates
how long you have been enrolled
with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting
periods, limitations, or exclusions for health related conditions based on
the information in the certificate, as long as you enroll within 63 days of
losing coverage under this Plan.
If you have been enrolled with us for less
than 12 months, but were previously enrolled in other FEHB plans, you may also
request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under
the FEHB Program. See also the FEHB website
(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.
Getting a Certificate of Group Health Plan Coverage 46
46 Page 47 48
2002 Group Health Cooperative of Eau Claire 47
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. It can supplement care provided by
family members,
reducing the burden you place on them. 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 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.
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? 47
47 Page 48 49
2002 Group Health Cooperative of Eau Claire 48 Long-term Care
Insurance
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.
How can I find out more about the program NOW? 48
48 Page 49 50
2002 Group Health Cooperative of Eau Claire 49
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 22,33 Allergy 13,17
Alternative treatment 20 Allogenetic( donor)
bone marrow transplant 23
Ambulance 13,24,25,28 Anesthesia 13,21,23,25
Autologous bone marrow transplant 17, 23 Biopsy 21
Blood and
blood plasma 14, 15, 19, 24, 25 Breast cancer screening 23
Casts 24, 25
Changes for 2002 4, 8, 47, 48, 50, 51
Chemotherapy 17 Childbirth 44
Chiropractic 9, 12, 13, 14, 20, 50 Cholesterol tests 15
Claims 8, 9, 32,
35-37, 39-40, 45 Coinsurance 6, 40
Colorectal cancer screening 15 Congenital
anomalies 21, 22
Contraceptive devices and drugs 16, 31 Coordination of
benefits 8, 14, 21, 24, 26,
29, 30, 32, 33, 38, 39, 45 Covered charges 40
Covered providers 6, 9, 29 (See also "Group Health Provider Directory")
Crutches 19 Deductible 6, 9, 12, 19, 35, 40, 42
Definitions 14,
21, 24, 26, 29, 30, 33, 42, 50 Dental care 22, 25, 33, 34, 50
Diagnostic
services 13, 14, 24, 25, 29, 50 Disputed claims review 8, 32, 36, 37
Donor
expenses (transplants) 23 Dressings 24, 25
Durable medical equipment (DME)
12, 13, 19 Educational classes and programs 13, 20
Effective date of
enrollment 42, 44, 47 Emergency 6, 12, 13, 26-28, 33, 34, 50
Experimental or
investigational 34, 42 Eyeglasses 18
Family planning 8, 13, 16 Fecal
occult blood test 15
General Exclusions 13, 34 Hearing
services 13, 15, 18
Home health services 12, 13, 20, 47 Hospice care 25,
47
Home nursing care 20, 42, 47 Hospital 4, 6, 9, 10, 13, 14, 16, 19, 21-26,
28,
29, 33, 35, 38, 40, 41-43, 47, 50 Immunizations 6, 15
Infertility 8, 13, 17
In-hospital physician care 10, 14, 21, 24, 26, 27, 42, 43, 50
Inpatient
Hospital Benefits 16, 22-24, 26, 28, 50
Insulin 19, 31 Laboratory and
pathological
services 14, 24, 25 Machine diagnostic tests 14, 24,
25, 29, 50 Magnetic Resonance Imagings
(MRIs) 14 Maternity Benefits 13,
16, 24
Medicaid 41, 47 Medically necessary 14, 16, 18,
21, 24, 25, 30,
33, 34 Medicare 8, 14, 21, 24, 26, 29,
30, 33, 38, 39, 40, 47 Members 4-7,
9, 10, 14, 21, 22,
24-2729, 30, 33, 35, 38, 39, 42-47, 51
Mental
Conditions/ Substance Abuse Benefits 13, 26, 29, 50
Newborn care 16 Non-FEHB
Benefits 45
Nurse Licensed Practical Nurse 20
Nurse Anesthetist 24 Nurse
Midwife 6
Nurse Practitioner 6 Registered Nurse 20, 32
Nursery charges
16 Obstetrical care 16
Occupational therapy 13, 18 Office visits 6,
12, 14-22, 28, 35,
40, 50 Oral and maxillofacial surgery 13, 22
Orthopedic devices 13, 19, 21 Out-of-pocket expenses 40
Outpatient
facility care 13, 23, 25, 26, 28 50
Oxygen 19, 20, 24, 25 Pap test
14, 15
Physical examination 6, 15 Physical therapy 13, 18
Physician 4,
6, 9-14, 17, 19-21, 24, 26, 27, 30, 31, 33, 35, 36,
42, 43, 50
Pre-certification 16, 21, 37
Preventive care, adult 6, 13, 15 Preventive
care, children 6, 13, 15, 18
Prescription drugs 9, 13, 16, 30, 31, 35, 38,
40, 50
Preventive services 6, 13, 15, 18
Prior approval 11, 37 Prosthetic devices 13, 19, 21, 22
Psychologist 29
Radiation therapy 17
Renal dialysis 38, 39 Room and board 24, 42
Second surgical opinion 14 Skilled nursing facility care 10, 13, 23,
25, 47
Smoking cessation 20 Speech therapy 8, 13, 18
Splints 24
Sterilization procedures 16, 21
Subrogation 41 Substance abuse 13, 26, 29,
50
Surgery 13, 16, 18, 19, 21, 22, 24 Anesthesia 13,21,25
Oral 13, 22
Outpatient 13, 25
Reconstructive 13, 21, 22 Syringes 31
Temporary
continuation of coverage 45, 46
Transplants 8, 13, 17, 18, 22, 23, 38
Vision services 13, 15, 18, 24, 50
Well child care 6, 15
Wheelchairs 19, 20
Workers' compensation 39, 41, 45 X-rays 13, 14,
24, 25 49
49 Page
50 51
2002 Group Health Cooperative of
Eau Claire 50 Summary
NOTES: 50
50 Page 51 52
2002 Group Health Cooperative of Eau Claire 51
Summary
Summary of benefits for the Group Health Cooperative of
Eau Claire -2002
Do not rely on this chart alone. All benefits
are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize
specific expenses we cover; for more detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover on
your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office .................
Office visit copay: $10 primary care; $10 specialist; $10 chiropractic 13, 14
Services provided by a hospital:
Inpatient
............................................................................................
Outpatient
.........................................................................................
Nothing
Nothing
13, 16, 22, 23,
26, 24, 28
13, 23, 25, 26,
28
Emergency benefits:
In-area
.............................................................................................
Out-of-area......................................................................................
$25 co-payment per visit
$25 co-payment per visit
13, 26, 28
6, 13, 26, 28,
27
Mental health and substance abuse treatment
..................................... Regular cost sharing. 13, 26, 29
Prescription
drugs.................................................................................
$10 co-payment per prescription 13, 30, 35, 38,
40
Dental
Care........................................................................................
No benefit. 13, 25,
33, 34
Vision
Care........................................................................................
Nothing for one annual exam. 13, 15,
18
Special features: FirstCare Nurseline services 13, 26, 27, 32 51
51 Page 52
2002
Group Health Cooperative of Eau Claire Summary
2002 Rate Information
for Group Health Cooperative of Eau Claire
Non-Postal rates apply to
most non-Postal enrollees. If you are in a special enrollment category, refer to
the FEHB Guide for that category or contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal
Service employees. Most employees should refer to the FEHB Guide for United
States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are
published for Postal Service Nurses, RI 70-2B; and
for Postal Service Inspectors and Office of Inspector General (OIG) employees
(see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only WT1 $ 97.86 $ 77.66 $ 212.03 $ 168.26 $ 115.52 $ 60.00
Self
and Family WT2 $ 223.41 $ 229.50 $ 484.06 $ 497.25 $ 263.75 $ 189.16 52