Serving: Connecticut
Enrollment in this Plan is limited. You
must live or work in our
Geographic service area to enroll. See page 4 for
requirements.
A Health Maintenance Organization
Enrollment codes for this Plan:
TE1 Self Only
TE2 Self and Family
For changes in benefits
see page 5.
This Plan has excellent accreditation
from the NCQA. See the 2002
Guide for more
information on NCQA.
RI 73-599 1
1 Page
2 3
2002 ConnectiCare Inc. 1 Table of
Contents
Table of Contents
Introduction...........................................................................
3
Plain
Language..........................................................................................................................................................
3
Inspector General
Advisory..........................................................................................................................................
3
Section 1. Facts about this HMO
plan...........................................................................................................................
4
How we pay
providers..................................................................................................................................
4
Who provides my health
care?.......................................................................................................................
4
Your
Rights...............................................................................................................................................
4
Service
Area...............................................................................................................................................
4
Section 2. How we change for
2002..............................................................................................................................
5
Program-wide
changes..................................................................................................................................
5
Changes to this
Plan....................................................................................................................................
5
Section 3. How you get care
.......................................................................................................................................
6
Identification
cards......................................................................................................................................
6
Where you get covered
care...........................................................................................................................
6
Plan
providers.......................................................................................................................................
6
Plan
facilities........................................................................................................................................
6
What you must do to get covered
care.............................................................................................................
6
Primary
care.........................................................................................................................................
6
Specialty
care........................................................................................................................................
6
Hospital
care.........................................................................................................................................
7
Circumstances beyond our
control..................................................................................................................
8
Services requiring our prior
approval...............................................................................................................
8
Section 4. Your costs for covered
services......................................................................................................................
9
Copayments.........................................................................................................................................
9
Deductible............................................................................................................................................
9
Coinsurance..........................................................................................................................................
9
Your out-of-pocket
maximum........................................................................................................................
9
Section 5.
Benefits...................................................................................................................................................
10
Overview.................................................................................................................................................
10
(a) Medical services and supplies provided by physicians and other health
care professionals.............................. 11
(b) Surgical and
anesthesia services provided by physicians and other health care
professionals............................ 20
(c) Services provided by a
hospital or other facility, and ambulance
services.................................................... 24
(d)
Emergency services/
accidents..............................................................................................................
26
(e) Mental health and substance abuse
benefits...........................................................................................
28
(f) Prescription drug
benefits..................................................................................................................
29
(g) Special features
...............................................................................................................................
32
Flexible benefits, services for deaf and hearing impaired, ConnectiCare
website, alternative treatments 2
2 Page 3 4
2002 ConnectiCare
Inc. 2 Table of Contents
Section 6. General exclusions things we don't
cover.....................................................................................................
33
Section 7. Filing a claim for covered
services................................................................................................................
34
Section 8. The disputed claims
process........................................................................................................................
35
Section 9. Coordinating benefits with other coverage
.....................................................................................................
37
When you have
Other health
coverage............................................................................................................................
37
Original
Medicare.................................................................................................................................
37
Medicare managed care plan
...................................................................................................................
39
TRICARE/ Workers' Compensation/ Medicaid
................................................................................................
39
Other Government
agencies.........................................................................................................................
40
When others are responsible for
injuries.........................................................................................................
40
Section 10. Definitions of terms we use in this
brochure...............................................................................................
41
Section 11. FEHB facts
.........................................................................................................................................
42
Coverage
information...............................................................................................................................
42
No pre-existing condition
limitation....................................................................................................
42
Where you get information about enrolling in the FEHB
Program............................................................. 42
Types of coverage available for you and your
family...............................................................................
42
When benefits and premiums
start.......................................................................................................
43
Your medical and claims records are
confidential....................................................................................
43
When you
retire...............................................................................................................................
43
When you lose
benefits.............................................................................................................................
43
When FEHB coverage
ends................................................................................................................
43
Spouse equity
coverage.....................................................................................................................
43
Temporary Continuation of Coverage
(TCC)........................................................................................
43
Converting to individual
coverage......................................................................................................
44
Getting a Certificate of Group Health Plan
Coverage..............................................................................
44
Long term care insurance is coming later in
2002...........................................................................................................
45
Index
...........................................................................................................................................................
46
Summary of
benefits.................................................................................................................................................
47
Rates.....................................................................................................................................................................
48 3
3 Page 4 5
2002 ConnectiCare Inc. 3 Introduction/ Plain
Language/ Advisory
Introduction
ConnectiCare, Inc.
30
Batterson Park Road, Farmington, CT 06032-2574
This brochure describes the benefits of ConnectiCare, Inc. under our contract
(CS2662) 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 5. 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 ConnectiCare, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you compare plans.
If you have comments or
suggestions about how to improve the structure of this brochure, let us know.
Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at
fehbwebcomments@ opm. gov . You may also write to OPM at the Office of
Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650.
Inspector General Advisory
Fraud increases the cost of health care
for everyone. If you suspect that a physician, pharmacy, or hospital has charged
you for services
you did not receive, billed you twice for the same service,
or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If
the provider does not resolve the matter, call us at 1-800-251-7722 and explain
the situation.
If we do not resolve the issue, call or write
THE
HEALTH CARE FRAUD HOTLINE 202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector
General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card if the person tries to obtain services
for someone who is not an eligible
family member, or is no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action
against you 4
4 Page 5 6
2002 ConnectiCare
Inc. 4 Section 1
Section 1. Facts about this HMO plan
This
Plan is a health maintenance organization (HMO). We require you to see specific
physicians, hospitals, and other providers that
contract with us. These Plan
providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to
treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments,
coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot change plans because a provider
leaves our Plan. We cannot guarantee that any one physician, hospital, or other
provider
will be available and/ or remain under contract with us.
How we
pay providers We contract with individual physicians, medical groups, and
hospitals to provide the benefits in this brochure. These Plan providers
accept a negotiated payment from us, and you will only be responsible for
your copayments or coinsurance.
Who provides my health care
ConnectiCare is an Independent Practice Association (IPA) model Health
Maintenance Organization (HMO). It offers you the services
of more than
8,000 physicians, including general practitioners and specialists. For Plan
records, all members and each family member
must select a primary care
doctor. However, members are free to choose the services of any participating
doctor, including specialists,
except as noted below (see What you must do,
specialty care). Your personal doctor may already participate in ConnectiCare.
If so,
you may receive comprehensive coverage with no change in your
established doctor/ patient relationship. Also, a wide range of
hospitals,
laboratories and pharmacies participate with ConnectiCare.
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.
ConnectiCare complies with all State and Federal health care regulations.
Years in existence: 20
Profit status: For-profit
If you want more information about us, call 1-800-251-7722, or write to
ConnectiCare, Inc., 30 Batterson Park Road, Farmington,
CT 06032-2574. You
may also contact our Member Services Department by fax at 860-674-2232 or visit
our website at
www. connecticare. com
Service Area To enroll in this Plan, you must live in or work in our
Service Area. This is where our providers practice. Our service area is: the
state of Connecticut.
Ordinarily, you must get your care from providers
who contract with us. If you receive care outside our service area, we will pay
only
for emergency care benefits. We will not pay for any other health care
services out of our service area unless the services have prior
plan
approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the
area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO
that has agreements with
affiliates in other areas. If you or a family member move, you do not have to
wait until Open Season to
change plans. Contact your employing or retirement
office. 5
5 Page 6
7
2002 ConnectiCare Inc 5 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 14.0% for Self Only or 14.1% for Self and Family.
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover certain intestinal transplants. (Section 5(
b))
We changed the address for sending disputed claims to OPM. (Section 8)
6
6 Page 7 8
2002 ConnectiCare Inc. 6 Section 3
Section
3. How you get care
Identification cards We will send you an
identification (ID) card. 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.
To get your cards quickly, fax us a copy of your Health Benefits Election
Form with the
payroll code printed on the bottom. List your PCP and provider
number for you and each
family member on a separate page.
Fax everything to ConnectiCare's Enrollment Department at 860-409-8991. If
you do not
receive your ID card within 30 days after the effective date of
your enrollment, or if you
need replacement cards, call us at
1-800-251-7722.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and/ or coinsurance, and you
will not have to file claims.
Plan providers Plan providers are
physicians and other health care professionals in our service area with whom we
contract 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. Since this list
changes, it's best to contact us to confirm that a
provider participates.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in the provider directory, which
we update
periodically. The list is also on our website.
What you must do to get It depends on the type of care you need.
First, you and each family member must choose
covered care a primary
care physician. This decision is important since your primary care physician
provides for most of your health care. You can choose a PCP from our provider
directory. If you don't provide us with your PCP, we will select one for you,
which you
can change at any time by calling 1-800-251-7722.
Primary care Your primary care physician can be a family practitioner,
internist, general practitioner 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 physician or if your primary
care physician leaves the
Plan, call us. We will help you select a new one.
Specialty care Members may see any participating doctor for covered
services without a referral with the following exceptions. You must get a
referral from a participating doctor for:
cardiovascular lab, cardiac
rehabilitation, lab work, pain management and behavioral
medicine, pulmonary
rehabilitation, radiology, radiation therapy, and physical, speech
and
occupational therapy.
Your doctor will both refer you and get Plan authorization for: hospital
admissions
(except out-of-service area emergencies), use of surgical
facilities, outpatient alcohol and
substance abuse treatment, durable
medical equipment, prostheses, orthopedic devices,
home health care, speech
therapy, occupational therapy, out-of-Plan services (non-participating
providers), human organ transplants, skilled nursing facilities and surgical
treatment of morbid obesity. 7
7 Page 8 9
2002 ConnectiCare
Inc. 7 Section 3
For information on how to obtain specialty care
services, contact us at 1-800-251-7722.
A Plan doctor can make arrangements
for appropriate referrals. Do not go to a specialist
for services listed
above unless a referral or an authorization and a referral has been issued
in advance.
Here are other things you should know about specialty care:
If you are
seeing a specialist when you enroll in our Plan, talk to your primary care
physician. Your primary care physician will decide what treatment you need.
If he or
she decides to refer you to a specialist, ask if you can see your
current specialist. If
your current specialist does not participate with us,
you must receive treatment from a
specialist who does. Generally, we will
not pay for you to see a specialist who does
not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call
your primary care
physician, who will arrange for you to see another
specialist. You may receive
services from your current specialist until we
can make arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your
specialist because
we:
terminate our contract with your specialist for other than cause; or
drop
out of the Federal Employees Health Benefits (FEHB) Program and you enroll in
another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact
your new
plan.
If you are in the second or third trimester of pregnancy and you lose access
to your
specialist based on the above circumstances, you can continue to see
your specialist until
the end of your postpartum care, even if it is beyond
the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of
facility.
If you are in the
hospital when your enrollment in our Plan begins, call our customer
service
department immediately at 1-800-251-7722. 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 92nd day
after you become a member of this Plan, whichever happens first.
These
provisions apply only to the benefits of the hospitalized person. 8
8 Page 9 10
2002 ConnectiCare Inc. 8 Section 3
Circumstances beyond Under certain extraordinary circumstances,
such as natural disasters, we may have to
our control delay your
services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Services requiring our Your primary care physician or specialist has
authority to refer you for most services. For
prior approval certain
services, however, your physician must obtain approval from us. Before giving
approval, we consider if the service is covered, medically necessary, and
follows
generally accepted medical practice. We call this review and approval process
Plan
authorization.
Your doctor will both refer you and get Plan authorization for: hospital
admissions
(except out-of-service area emergencies), outpatient alcohol and
substance abuse
treatment, durable medical equipment, prostheses, orthopedic
devices, home health care,
out-of-Plan services (non-participating
providers), human organ transplants, skilled
nursing facilities and surgical
treatment of morbid obesity. For a complete listing, call
our Member
Services Department at 1-800-251-7722.
For information on how to obtain specialty care services, contact us at
1-800-251-7722.
A Plan doctor can make arrangements for appropriate
referrals. Do not go to a specialist
for services listed above unless a
referral or an authorization and a referral has been issued
in advance.
Otherwise, the services may not be covered. 9
9
Page 10 11
2002
ConnectiCare Inc. 9 Section 4
Section 4. Your costs for
covered services
You must share the cost of You are responsible for:
some services.
Copayments A copayment is a fixed amount of money you pay to the
provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician, you pay a copayment of $10
per
office visit and when you go in the hospital, you pay $100 per
admission.
Deductible The only deductible this plan has is for Durable Medical
Equipment, the (DME) benefit.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care. DME has coinsurance.
Your catastrophic
protection
out-of-pocket maximum for
deductibles, coinsurance, and
copayments We do not have an
out-of-pocket maximum 10
10 Page 11 12
2002
ConnectiCare Inc. 10 Section 5
Section 5. Benefits OVERVIEW
(See page 5 for how our benefits changed this year and page 47 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. For more information about our benefits, contact us at
1-800-251-7722 or at our website at
www. connecticare. com
(a) Medical services and supplies provided by physicians and other health
care professionals............................................... 11-19
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care
Family planning
Infertility services Allergy care
Treatment
therapies Physical and occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies) Foot care
Orthopedic and prosthetic devices Durable medical equipment (DME)
Home health services Chiropractic
Alternative treatments Educational
classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals.......................................... 20-23
Surgical
procedures Reconstructive surgery Oral and maxillofacial surgery Organ/
tissue transplants
Anesthesia
(c) Services provided by a hospital or
other facility, and ambulance
services.................................................................. 24-25
Inpatient hospital Outpatient hospital or ambulatory surgical center
Extended care benefits/ skilled nursing care facility benefits Hospice care
Ambulance
(d) Emergency services/
accidents............................................................................................................................
26-27
Medical emergency Ambulance
(e) Mental health and substance abuse
benefits.............................................................................................................
28
(f) Prescription drug
benefits................................................................................................................................
29-31
(g) Special features
..................................................................................................................................................
32
Flexible benefits option, services for deaf and hearing impaired, our
website, alternative treatments
Summary of
benefits.................................................................................................................................................
47 11
11 Page 12
13
2002 ConnectiCare Inc. 11 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange for your care.
We have no
calendar year deductible, except for DME.
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 $10 per
office visit
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical
consultations
Second surgical opinion
$20 per office visit
Nothing.
Nothing for up to 90 days per calendar
year.
$10 per office visit.
$10 per office visit.
At home $10 per house call by a doctor.
Diagnosis and treatment of illness or injury in physician's office,
Including specialty care
$10 per office visit.
Diagnostic tests in hospital Nothing.
Vaccines for pediatric and adult
immunizations
Nondental treatment of temporomandibular joint( TMJ) syndrome
Services for which a member has no responsibility to pay
Services for
intentionally inflicted injuries
Services for injuries resulting from
hazardous activities
Nothing if you receive these services during
your office visit.
Injuries received in connection with the commission of a felony All charges.
12
12 Page 13 14
2002 ConnectiCare Inc. 12 Section 5( a)
Lab, X-ray and other diagnostic tests
Tests, such as:
Cardiovascular lab
Blood tests Cardiac rehabilitation
Urinalysis
Lab work
Non-routine pap tests Pain management and
Pathology
behavioral medicine
X-rays Pulmonary rehabilitation
Non-routine
Mammograms Radiology
Cat Scans/ MRI Radiation therapy
Ultrasound
Physical, speech and
Electrocardiogram and EEG occupational therapy
Nothing if you receive these services during
your office visit;
otherwise, $10 per office
visit
Preventive care, adult
Routine screenings, such as periodic
check-ups and routine
immunizations including these tests as ordered by your
doctor
Total Blood Cholesterol once every three years
Colorectal Cancer
Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50
$10 per office visit
Prostate Specific Antigen (PSA test) one annually for men age 40 and
older
$10 per office visit
Routine pap test
Note: The office visit is covered if pap test is
received on the same
day; see Diagnosis and Treatment, above.
Nothing if you receive these services during
your office visit;
otherwise, $10 per visit.
Routine mammogram covered for women age 35 and older, as follows:
From
age 35 through 39, one during this five year period
From age 40 through
64, one every calendar year
At age 65 and older, one every two consecutive
calendar years
$10 per office visit.
Preventive Care continued on next page 13
13 Page 14 15
2002 ConnectiCare Inc. 13 Section 5( a)
Preventive care, adult (continued) You pay
Not
covered: Physical exams required for obtaining or continuing
employment or
insurance, attending schools or camp, or travel.
All charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster
once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
Nothing if you receive these services during
your office visit; otherwise
$10 per visit.
Check with your doctor to see if this plan covers other immunizations.
Preventive care, children
Childhood immunizations recommended
by the American Academy of Pediatrics Nothing if you receive these services
during your office visit; otherwise $10 per visit.
Well-child care charges for routine examinations, immunizations and care
(up to age 22)
Examinations, such as: Eye exams to determine the need for
vision correction.
Ear exams up to age 18 to determine the need for hearing
correction
Examinations done on the day of immunizations (up to age 22)
$10 per office visit
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery. This is done by your
Plan Provider.
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 for initial visit, then nothing. 14
14
Page 15 16
2002
ConnectiCare Inc. 14 Section 5( a)
Family planning You pay
A
broad range of voluntary family planning services, limited to:
Voluntary
sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices
(IUDs)
NOTE: We cover oral contraceptives, injectable contraceptive and
diaphragms under the prescription drug benefit.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling
All charges.
Infertility services
Diagnosis and treatment of infertility, such
as:
Artificial insemination: intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit (up to $1,500 per
calendar year.)
$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
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 15
15 Page 16 17
2002 ConnectiCare Inc. 15 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation
therapy Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/
Tissue Transplants on page 22.
Respiratory and inhalation therapy
Dialysis Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: We will only
cover GHT when we pre-authorize the treatment.
Your doctor would have to
submit your case in writing to the Plan.
Your case will be reviewed for
medical necessity and, if approved, you
may then seek treatment.
Nothing.
Not covered:
Vision Therapies
Physiotherapy (such as therapeutic
muscle exercises, galvanic
or thanscutaneous nerve stimulation, vapocoolant
sprays, ultrasound
or diathermy)
All charges.
Physical and occupational therapies
60 visits per condition per
calendar year 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 .
$10 per outpatient visit.
Nothing per visit during covered inpatient
admission.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided as part of your rehabilitation. Nothing.
Chiropractic manipulation therapy is provided on an outpatient basis for
up to 20 visits per calendar year. $10 copayment per visit.
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
60 visits per condition per calendar year $10 per
outpatient visit. Nothing per visit during covered inpatient
admission.
Not covered:
Non-authorized, non-medically necessary treatment All
charges. 16
16 Page
17 18
2002 ConnectiCare Inc. 16
Section 5( a)
Hearing services (testing, treatment, and supplies) You
pay
First hearing aid and testing only when necessitated by accidental
injury
Hearing testing for children through age 18 (see Preventive care,
children)
$10 per office visit
Not covered:
all other hearing testing
hearing aids, testing and
examinations for them
First hearing aid and testing only when necessitated
by accidental injury
All charges.
Vision services (testing, treatment, and supplies)
Our vision
program includes: frames and lenses, prescription contact lenses available only
at Plan routine vision providers (offered at
various discounts, not at $10
copay). For a full description of the
Vision Care Coverage, please see the
routine vision information
located in the enrollment packet.
25% discount on frames and lenses at or
below $250; 30% discount over
$250 at
plan routine vision providers
Eye exam to determine the need for vision correction for children (see
Preventive care, children)
Annual eye refractions once per calendar year,
when obtained by Plan providers
$10 per office visit
$10 per office
visit
Not covered:
Eye exercises and orthoptics
Radial keratotomy and
other refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or
peripheral vascular disease, such as diabetes.
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. 17
17 Page
18 19
2002 ConnectiCare Inc. 17
Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes; stump hose
Note: Plan authorization is required
and coverage is limited to the initial
acquisition. This benefit paid under
Durable Medical Equipment.
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant
following
mastectomy. Note: See 5( b) for coverage of the surgery
to insert the
device.
$10 per office visit
Not covered:
orthopedic and corrective shoes
arch supports
foot orthotics
heel pads and heel cups
lumbosacral supports
corsets, trusses, elastic stockings, support hose, and other supportive devices
prosthetic replacements provided less 3 years after the last one we covered
All charges.
Durable medical equipment (DME)
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 (Motorized chairs covered only with plan
approval
of doctors written request detailing medical necessity.)
crutches;
walkers;
blood glucose monitors; and
insulin
pumps.
You must get your equipment from our vendors. Your doctor can help
you
or you can call member services at 1-800-251-7722.
$100 deductible per calendar year and 20%
of charges up to a maximum Plan
payment
of $1,500 per calendar year.
Note: Prior Plan authorization is required
and coverage is limited to the
initial
acquisition. 18
18 Page 19 20
2002
ConnectiCare Inc. 18 Section 5( a)
Disposable medical supplies You
pay
Certain disposable medical supplies, which are used in conjunction
with
covered durable medical equipment or covered medical treatment received
in the home are covered. Examples: BiPAP, CPAP masks.
Not all disposable medical supplies are covered. See your doctor or call
Member Services.
$100 deductible and 20% of charges up to a
maximum Plan payment of $300
per
calendar year.
Note: Prior plan authorization is required.
Ostomy equipment and supplies
Ostomy equipment and supplies
prescribed by your Plan physician. $100 deductible per calendar year and 20%
of charges up to a maximum Plan payment
of $1,000 per calendar year.
Note: Prior Plan authorization is required
and coverage is limited to the
initial
acquisition.
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 aides when
prescribed by
your Plan doctor, who will periodically review the program for
continuing appropriateness and need.
Services include oxygen therapy, intravenous therapy and medications.
Nothing.
Not covered:
nursing care requested by, or for the convenience of, the
patient or the patient's family;
home care primarily for personal assistance that does not include a medical
component and is not diagnostic, therapeutic or
rehabilitative.
All charges.
Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application
$10 per office visit
20 visits per calendar year. 19
19 Page 20 21
2002 ConnectiCare Inc. 19 Section 5( a)
Alternative treatments You pay
Naturopathic Doctors if Plan
Doctors $10 per office visit
Not covered:
hypnotherapy biofeedback All charges.
Educational classes and programs
Coverage is limited to: Diabetes,
Heart, Asthma and Smoking
Cessation programs are available. Information can
be obtained by
calling Member Services at 1-800-251-7722.
Nothing. 20
20 Page
21 22
2002 ConnectiCare Inc. 20
Section 5( b)
Section 5 (b). Surgical and anesthesia services
provided by physicians and other health care professionals
I M
P O
R
T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
We have no
calendar year deductible.
Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e. hospital,
surgical center, etc.).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3
to be sure which services require
precertification and identify which surgeries require precertification.
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)
$10 per office visit
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 and Plan
must approve in advance.
Nothing when approved in advance by
Plan.
Insertion of internal prosthetic devices must be medically necessary to
restore bodily function and require a surgical incision (as opposed
to an
external prosthetic device).
Examples: artificial joints, pacemakers,
defibrillators and penile
implants.
Nothing.
Surgical procedures continued on next page. 21
21 Page 22 23
2002 ConnectiCare Inc. 21 Section 5( b)
Surgical procedures (continued) You pay
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.
Skin Tag removal
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if: the
condition produced a major effect on the member's
appearance and
the condition can reasonably be expected to be corrected
by
such surgery
Surgery to correct a condition that existed at or from
birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$10 per office visit
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.
See above.
Not covered:
Cosmetic surgery any surgical procedure (or any portion
of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges. 22
22 Page
23 24
2002 ConnectiCare Inc. 22
Section 5( b)
Oral and maxillofacial surgery
Oral surgical
procedures, limited to:
Reduction of fractures of the jaws or facial
bones; Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or
their supporting structures.
$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.
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
National Transplant Program (NTP)
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
Note: Plan authorization is required at the
time of
diagnosis, prior to any evaluative
services and will only be authorized at
Plan
facilities, contracted Centers of Excellence,
or at facilities that
have a predetermined,
negotiated, daily rate. 23
23 Page 24 25
2002 ConnectiCare Inc. 23 Section 5( b)
Organ/ tissue transplants You pay
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 when prescribed by a Plan doctor. 24
24
Page 25 26
2002
ConnectiCare Inc. 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
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:
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. 25
25 Page
26 27
2002 ConnectiCare Inc. 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
Extended care benefits/ skilled nursing care facility
benefits
Skilled nursing facility (SNF): The Plan provides a comprehensive
range
of benefits for up to 90 days when full-time skilled nursing care
is
necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan.
All
necessary services are covered, including:
Bed, board and general nursing care
Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a Plan
doctor.
Nothing for up to 90 days per calendar
year.
Not covered: custodial care All charges.
Hospice care
Hospice
Care: Supportive and palliative care for a terminally ill member
is covered
in the home or hospice facility. Services include inpatient
and outpatient
care, and family counseling; these services are provided
under the direction
of a Plan doctor who certifies that the patient is in
the terminal stages of
illness, with a life expectancy of approximately
six months or less.
Nothing.
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Emergency Ambulance services are covered
Non-Emergency use must be requested by your doctor and pre-approved by the Plan
Nothing 26
26 Page
27 28
2002 ConnectiCare Inc. 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.
We have no calendar year deductible.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with
Medicare
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or
could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are emergencies
because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are
emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we
may determine are medical emergencies what
they all have in common is the
need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an urgent care situation within our service area, please call
your primary care doctor (available 24 hours a day through their answering
service). In extreme emergencies, contact the local emergency
system (e. g., the 911 telephone system) or go to the nearest hospital
emergency room. Be sure to tell the emergency room
personnel that you are a
Plan member so they can notify the Plan. You or a family member should notify
the Plan within
24 hours of an admission to the hospital unless it was not
reasonably possible to do so. It is your responsibility to ensure
that the
Plan has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 24 hours or on the first working day
following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If you are hospitalized
in non-Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital, you will be transferred
when
medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider
would result in death,
disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or
provided by Plan providers.
The Plan pays reasonable charges for emergency services to the extent the
services would have been covered if received from
Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 24 hours of
an admission or on the first working day
following your admission, unless it
was not reasonably possible to notify the Plan within that time. If a Plan
doctor
believes care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance
charges covered in
full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or
provided by Plan providers. 27
27 Page 28 29
2002 ConnectiCare Inc. 27 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 within the service area
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$10 per office visit.
$20 for emergency services that are covered
benefits of this Plan. Copayment waived if
emergency results in hospital
admission.
$40 for emergency services that are covered
benefits of this Plan.
Copayment waived if
emergency results in hospital admission.
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 outside of the service area
Emergency care outside of the service area, at an outpatient or inpatient
at a hospital, including doctors' services
$10 per office visit.
$20 for emergency services that are covered
benefits of this Plan. Copayment waived if
emergency results in hospital
admission.
$40 for emergency services that are covered
benefits of this Plan.
Copayment waived if
emergency results in hospital admission.
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 ConnectiCare Inc. 28 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations
for Plan mental health and substance
abuse benefits will be no greater than for similar benefits for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
Be sure to read Section 4, Your costs for
covered services for valuable information about how cost sharing works. Also
read Section 9 about coordinating benefits with other coverage, including with
Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See
the instructions after the benefits description below
I M
P O
R T
A N
T
Benefit Description You pay
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 office visit.
Diagnostic tests Nothing.
Services provided by a hospital or other
facility
Services in approved alternative care settings such as partial
hospitalization, residential treatment, full-day hospitalization, facility
based intensive outpatient treatment
Nothing
$10 per office visit or nothing depending
on service.
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on
the treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one
clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes: Please
call 1-800-424-5669 for all mental health
requests. This number is printed
on the back of your ConnectiCare, Inc. member card
as well.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 29
29 Page
30 31
2002 ConnectiCare Inc. 29
Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P
O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with
Medicare.
A generic equivalent will be dispensed if it is available. If you receive a
name brand drug when a Federally-approved generic drug is available, you have to
pay the difference in cost between the name
brand drug and the generic.
We have an open formulary. If your physician believes a name brand product
is necessary or there is no generic available, your physician may prescribe a
name brand drug from a formulary list. This list of
name brand drugs is a preferred list of drugs that we selected to meet
patient needs at a lower cost. To
order a formulary listing, call
1-800-251-7722.
I M
P O
R T
A N
T 30
30
Page 31 32
2002
ConnectiCare Inc. 30 Section 5( f)
There are important features you
should be aware of. These include:
Who can write your prescription.
A licensed physician must write the prescription.
Where you can
obtain them. You must fill the prescription at a Express Scripts pharmacy,
or by mail for a maintenance medication. The only exception is for out-of-area
emergencies.
Pharmacy: You may obtain your prescriptions at any Express Scripts,
Inc. pharmacy. (in 98% of US Pharmacies)
Mail order: Maintenance
medication, those medications needed for conditions such as diaget5es, high
blood pressure, epilepsy and heart conditions, can be obtained either via mail
order or at the pharmacy in a 100-day
supply. If you choose mail order at 2x
the copay, call Member Services at 1-800-251-7722 to request and
order form.
If you choose to go to your pharmacy, the co-pay will be 3X the co-pay. All
rules that apply to
the regular Prescription Plan apply to the Mail Order
Program as well. Note: Not all drugs are available via
mail order and your
doctor must write a maintenance prescription
We use a formulary. We work with our network physicians and our
pharmacy network, Express Scripts, Inc., to build a Formulary Drug List. This
Formulary Drug List includes over 80% of the drugs currently
available in the market, including all generic and some name brand drugs.
Formulary and Non-Formulary
drugs are available at a cost difference when a
generic is available. Our Formulary is available by calling
Member Services
at 1-800-251-7722 or on the Web at www. connecticare. com
All members receive educational information describing the Formulary drug
program. Members using non-Formulary
drugs are sent a series of letters
recommending that they speak to their physician about preferred
alternatives.
We have an open formulary. If your physician believes a name brand product is
necessary or there is no
generic available, your physician may prescribe a
name brand drug from a formulary list. This list of name
brand drugs is a
preferred list of drugs that we selected to meet patient needs at a lower cost.
To order a
prescription drug brochure, call 1-800-251-7722.
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 34-day supply; 240 milliliters of liquid (8oz.);
60 grams of ointment, creams or topical preparation; or one commercially
prepared unit (i. e., one inhaler,
one vial ophthalmic medication or
Insulin) of medication per prescription or refill. You pay a $10 copay
per
prescription unit or refill for generic drugs or a $20 copay for name brand
Formulary drugs when
generic substitution is not permissible. When generic
substitution is permissible and, you or your doctor
request the Formulary
name brand drug, you pay the price difference between the generic and name brand
drug as well as the $10 copay per prescription unit or refill. 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 a Plan
doctor, but at a higher copay.
Why use generic drugs? Per the FDA (Federal Drug Administration),
generic drugs and name brand drugs share identical basic ingredients. The color
and shape may differ but the result should be the same. Many
generic patents are owned by the name brand drug companies. Generic drugs are
an affordable alternative.
You can always get the name brand, you just pay
more.
NOTE: Not all prescriptions are available through the Maintenance Mail Order
Program depending on the
type of drug, etc. We follow FDA dispensing
guidelines. If you send in your order too soon, it can't be
filled.
Maintenance Mail Order refills should be requested after 75% of the prescription
is used. Over the
counter when you have 5 days left. If your prescription is
for more than 34 days (1 month) prescription, you
will be charged two and
sometime three copays depending on how much was dispensed.
If you choose a non-Formulary drug when a generic or Formulary name brand
drug is available, you pay a
$10 copayment in addition to the cost
difference between the Formulary and non-Formulary drug, up to
50% of the
cost of the drug. If the cost is less than the copayment, you pay the lesser
amount.
When you have to file a claim. There are no claims to file for
prescription services received at Express Scripts, Inc. drug stores. If you are
new to the plan and don't have your card when you first join and need a
prescription, you must pay for it and call Member Services at 1-800-251-7722
for a prescription
reimbursement form. Refunds take up to 8 weeks so always
use your card when you get it. 31
31 Page 32 33
2002
ConnectiCare Inc. 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 or through our mail order
program:
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 (contact the plan for dose limits)
Contraceptive drugs and devices (oral and injectable plus diaphragms)
Fertility drugs are subject to a $1,500 annual limit
Intraveneous
fluids and medicine for home use (covered implantable drugs and covered
injectable drugs are covered under medical and
surgical benefits).
You pay a $10 copay per prescription unit or refill
for generic drugs, a
$20 copay for name brand
Formulary drugs and a $35 copay for non-Formulary
drugs. When a generic drug is
available, but you or your doctor request
the
Formulary name brand drug, or non-Formulary
brand drug, you pay the
price difference between
the generic and name brand drug as well as the $10
copay per prescription unit or refill. Drugs are
prescribed by Plan
doctors and dispensed in
accordance with the Plan's drug Formulary.
Our
Formulary is open and available by calling
Member Services at 800-251-7722
or by going to
our website www. connecticare. com . Mail Order
forms are
also available by calling Member
Services. Mail Order follows the same rules
(cost
sharing) and provides a 100 day supply for 2X the
copay.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to
enhance athletic performance
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
All charges. 32
32 Page
33 34
2002 ConnectiCare Inc. 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 reviews.
By approving
an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Services for deaf and
hearing impaired
Call the TDD/ TTY number for the hearing impaired: 1-800-251-7722.
Our website
www. connecticare. com
You can change or add your PCP, look up a doctor or check our drug formulary
at
our website.
Alternative treatments Discounts on homeopathic treatments, massage
therapy, etc. See flyer enclosed in your enrollment kit or, call Member Services
at 1-800-251-7722 and ask for a
"Healthy Alternatives" brochure. 33
33 Page 34 35
2002 ConnectiCare Inc. 33 Section 6
Section 6. General exclusions things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover
it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury or condition and we agree, as discussed under "What
Services Require Our Prior Approval" on page 8.
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.
Expenses you incurred while you were not enrolled in
this Plan. 34
34 Page
35 36
2002 ConnectiCare Inc. 34
Section 7
Section 7. Filing a claim for covered services
When
you see Plan physicians, receive services at Plan hospitals and facilities, or
obtain your prescription drugs at Plan pharmacies,
you will not have to file
claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us
directly. Check with
the provider. If you need to file the claim, call Member Servicers at 800
251-7722 to obtain an out-of-area claim
form. Then, here is the process:
Medical, hospital, and In most cases, providers and facilities file
claims for you. Physicians must file on the
drug benefits form
HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form.
For claim questions and assistance, call us at 1-800-251-7722.
When you must file a claim such as for out-of-area care submit it on the
HCFA-1500
or a claim form that includes the information shown below. Bills
and receipts should be
itemized and show:
Covered member's name and ID number;
Name and address of the
physician or facility that provided the service or supply;
Dates you
received the services or supplies;
Diagnosis;
Type of each service
or supply;
The charge for each service or supply;
A copy of the
explanation of benefits, payments, or denial from any primary
payer such as
the Medicare Summary Notice (MSN); and Receipts, if you paid for
your
services.
Submit your claims to: Member Services
ConnectiCare, Inc.
30
Batterson Park Road
Farmington, CT 06032-2574
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you received the service, unless timely
filing was prevented
by administrative operations of Government or legal incapacity,
provided the
claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 35
35 Page
36 37
2002 ConnectiCare Inc. 35
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: Member Services, 30 Batterson Park Road, Farmington, CT
06032-2574; 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.
Send OPM the following information:
A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative,
such as medical providers, must include a copy of your
specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons
beyond your control. 36
36 Page 37 38
2002 ConnectiCare Inc. 36 Section 8
5
OPM will review your disputed claim request and will use the information it
collects from you and us to decide whether our decision is correct. OPM will
send you a final decision within 60 days. There are no other administrative
appeals.
6 If you do not agree with OPM's decision, your only
recourse is to sue. If you decide to sue, you must file the suit against OPM in
Federal court by December 31 of the third year after the year in which you
received the disputed services, drugs, or supplies or from the year in which you
were denied precertification or prior approval. This is the only deadline that
may not
be extended.
OPM may disclose the information it collects during
the review process to support their disputed claim decision. This
information will become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit,
benefits, and payment of
benefits. The Federal court will base its review on the record that was before
OPM when OPM
decided to uphold or overturn our decision. You may recover
only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization/ prior approval, then call us at 1-800-251-7722
and we
will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 37
37
Page 38 39
2002
ConnectiCare Inc. 37 Section 9
Section 9. Coordinating benefits with
other coverage
When you have other health You must tell us if you are
covered or a family member is covered under another group
coverage
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 a plan that is available
everywhere in
the United States. It is the way everyone used to get Medicare
benefits and is the way
most people get their Medicare Part A and Part B
benefits now. You may go to any
doctor, specialist, or hospital that accepts
Medicare. The Original Medicare Plan pays its
share and you pay your share.
Some things are not covered under Original Medicare, like
prescription
drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to
follow the rules in this brochure for us to cover your care. Your
care must continue to be
authorized by your Plan PCP, or precertified as
required.
When Medicare is primary, we will cover what they don't assuming all other
rules have
been followed.
(Primary payer chart begins on next page.)
38
38 Page 39
40
2002 ConnectiCare Inc. 38 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
A. When either you or your covered spouse are
age 65 or over and Then the primary payer is
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when
you or a family member are eligible for
Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a 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,
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee 39
39 Page 40 41
2002 ConnectiCare Inc. 39 Section 9
In most
cases, if you inform your provider that your have two coverages, they will send
the claims to the carriers. But, this is something they do as a convenience.
You are
always ultimately responsible to submit your claims to the carriers
you deal with.
Claims process when you have the Original Medicare You probably will
never have to file a claim form when you have both our Plan and the Original
Medicare Plan.
When we are the primary payer, we process the claim first.
When
Original Medicare is the primary payer, Medicare processes your claim first. In
most cases, your claims will be coordinated automatically and we will pay
the
balance of covered charges. You will not need to do anything. To find
out if you
need to do something about filing your claims, call us at
1-800-251-7722.
We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your Medicare
benefits from another type of
Medicare+ Choice plan a Medicare managed care plan.
These are health care
choices (like HMOs) in some areas of the country. In most Medicare
managed
care plans, you can only go to doctors, specialists, or hospitals that are part
of
the plan. Medicare managed care plans provide all the benefits that
Original Medicare
covers. Some cover extras, like prescription drugs. To
learn more about enrolling in a
Medicare+ Choice plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and another plan's Medicare Managed Care
plan: You may enroll in another plan's Medicare managed care and also remain
enrolled in our FEHB plan. We
will still provide benefits when your Medicare
managed care plan is primary and will
supplement that plan assuming you went
to our providers and follow our rules. If you
enroll in a Medicare managed
care plan, tell us. We will need to know whether you are in
the Original
Medicare Plan or in a Medicare managed care plan so we can correctly
coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare Managed Care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage and
enroll in a
Medicare managed care plan. For information on suspending your
FEHB enrollment,
contact your retirement office. If you later want to
re-enroll in the FEHB Program,
generally you may do so only at the next open
season unless you involuntarily lose
coverage or move out of the Medicare
managed care plan's service area.
If you do not enroll in Medicare Part A or Part B 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. 40
40 Page
41 42
2002 ConnectiCare Inc. 40
Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of
Workers'
Compensation Programs (OWCP) or a similar Federal or State agency
determines they
must provide; or
OWCP or a similar agency pays for through a third party injury settlement
or other similar proceeding that is based on a claim you filed under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will
cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government We do not cover services and supplies when a
local, State, or Federal Government
agencies are responsible for
agency directly or indirectly pays for them.
your care
When others are responsible 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. 41
41 Page
42 43
2002 ConnectiCare Inc. 41
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.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 9.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 9.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Home Health Care, light duty services at your home.
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 9.
Experimental or How do you decide if a service is experimental or
investigational?
investigational services ConnectiCare uses outside
medical experts and scientific literature reviews for determining whether a
medical service is considered investigational and/ or experimental.
Group health coverage Health Insurance sold only to group employers
Medical necessity Medical care provided for illness or injury that is
determined by national standards to be Medically Necessary. Like a Mammogram,
etc.
Us/ We Us and we refer to ConnectiCare, Inc.
You
You refers to the enrollee and each covered family member. 42
42 Page 43 44
2002 ConnectiCare Inc. 42 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had
limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www. opm. gov/ insure . Also, your
employing or retirement office can answer your
about enrolling in the
and questions, give you a Guide to Federal Employees Health Benefits
Plans
FEHB Program brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases, cannot change your
enrollment status without information from
your employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, your spouse,
for you and your family
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. 43
43 Page
44 45
2002 ConnectiCare Inc. 43
Section 11
When benefits and The benefits in this brochure are
effective on January 1. If you joined this Plan
premiums start during
Open Season, your coverage begins on the first day of your first pay period that
starts on or after January 1. Annuitants' coverage and premiums begin on January
1. If
you joined at any other time during the year, your employing office will tell
you the
effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the following
records are confidential
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
coverage If you are divorced from a Federal employee or annuitant, you may
not continue to get benefits under your former spouse's enrollment. But, you may
be
eligible for your own FEHB coverage under the spouse equity law. If you are
recently
divorced or are anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal
Employees Health Benefits Plans for
Temporary Continuation of Coverage and
Former Spouse Enrollees, or other information about your coverage choices.
Temporary Continuation of coverage (TCC) If you leave Federal service,
or if you lose coverage because you no longer qualify as a
family member,
you may be eligible for Temporary Continuation of Coverage (TCC).
For
example, you can receive TCC if you are not able to continue your FEHB
enrollment
after you retire, if you lose your job, if you are a covered
dependent child and you turn
22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of
Coverage and Former Spouse Enrollees, from
your employing or retirement office or from www. opm. gov/ insure . It explains
what you have to do to enroll. 44
44 Page 45 46
2002
ConnectiCare Inc. 44 Section 11
Converting You may convert to a
non-FEHB individual policy if: individual coverage
Your coverage
under TCC or the spouse equity law ends (If you canceled your coverage or did
not pay your premium, you cannot convert;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to
convert. If you wish to continue on individual coverage, you must
call HRA (Health
Reinsurance Association), the state uninsured pool at
800-842-0004. They will send you
information as to how you can continue your
coverage. If, for some reason you are
ineligible to join the pool, you must
contact us within 31 days. However, if you are a
family member who is losing
coverage, the employing or retirement office will not
notify you.
Your benefits and rates will differ from those under the FEHB Program;
however, you
will not have to answer questions about your health, and we
will not impose a waiting
period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a Federal
Group Health Plan
Coverage law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If you
leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long
you have
been enrolled with us. You can use this certificate when getting
health insurance or other
health care coverage. Your new plan must reduce or
eliminate waiting periods,
limitations, or exclusions for health related
conditions based on the information in the
certificate, as long as you
enroll within 63 days of losing coverage under this Plan. If
you have been
enrolled with us for less than 12 months, but were previously enrolled in
other FEHB plans, you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB Program. See also the FEHB web site
( www.
opm. gov/ insure/ health); refer to the "TCC and HIPAA" frequently asked
question.
These highlight HIPAA rules, such as the requirement that Federal
employees must
exhaust any TCC eligibility as one condition for guaranteed
access to individual health
coverage under HIPAA, and have information about
Federal and State agencies you can
contact for more information. 45
45 Page 46 47
2002 ConnectiCare Inc. 45 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office
of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in October
2002. As part of its educational
effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease
such as Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice care, and more.
LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
Welcome to the club!
76% of Americans believe they will never need
long term care, but the facts are that about half them will. And it's not just
the old folks. About 40% of people needing
long term care are under age 65. They may need chronic care due to a serious
accident, a stroke, or developing multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their
financial and retirement planning.
Yes, it can be very expensive. A
year in a nursing home can exceed $50,000. Home care for only three 8-hour
shifts a week can exceed $20,000 a year. And that's before
inflation!
Long term care can easily exhaust your savings. Long term
care insurance can protect your savings.
Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a stay in
an assisted
living facility or a continuing need for a home health aide to
help you get in and out
of bed and with other activities of daily living.
Limited stays in skilled nursing
facilities can be covered in some
circumstances.
Medicare only covers skilled nursing home care (the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or older
or fully disabled. It
also has a 100 day limit.
Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC
open enrollment period in the late summer/ early fall of 2002.
Retirees will receive information at home.
Our toll-free teleservice
center will begin in mid-2002. In the meantime, you can learn more about the
program on our web site at www. opm. gov/ insure/ ltc . 46
46 Page 47 48
2002 ConnectiCare Inc. 46 Index
Index
Do not rely on this page; it is for your convenience may not show all
pages where the terms appear.
Accidental injury 26 Allergy tests 14
Alternative treatment 19
Allogenic (donor) bone marrow
transplant 22
Ambulance 27
Anesthesia 23
Autologous bone marrow
transplant 22
Biopsies 20 Birthing centers 13
Blood and blood plasma 24
Breast cancer screening 12
Casts 24
Catastrophic protection 9
Changes for 2002 5
Chemotherapy 15
Childbirth 13
Chiropractic 18
Cholesterol tests 12
Circumcision 20
Claims 35
Coinsurance 9
Colorectal cancer screening 12
Congenital anomalies 20
Contraceptive
devices and drugs 31
Coordination of benefits 37
Covered providers 6
Crutches 17
Deductible 9 Definitions 41
Diagnostic services 11
Disputed claims review 35
Donor expenses
(transplants) 23
Dressings 24
Durable medical equipment (DME)
17
Educational classes and programs 19 Effective date of enrollment 43
Emergency 26
Experimental or investigational 41
Eyeglasses 16
Family
planning 14 Fecal occult blood test 12
General Exclusions 33 Hearing services 16
Home health
services 18
Hospice care 25
Home nursing care 18
Hospital 24
Immunizations 13 Infertility 14
Inhospital physician care 12
Inpatient Hospital Benefits 24
Insulin
31
Laboratory and pathological services 12
Machine diagnostic tests 11 Magnetic Resonance Imagings
(MRIs) 12
Mail Order Prescription Drugs 30
Mammograms 12
Maternity Benefits 13
Medicaid 40
Medically necessary 41
Medicare 37
Mental
Conditions/ Substance Abuse
Benefits 28
Neurological testing 12
Newborn care 13
Nursery charges 13
Obstetrical care 13 Occupational therapy 15
Ocular injury 11
Office visits 11
Oral and maxillofacial surgery 22
Orthopedic devices 17
Ostomy and catheter supplies 18
Out-of-pocket
expenses 9
Outpatient facility care 25
Oxygen 17
Pap test 12 Physical examination 12
Physical therapy 15
Physician 6
Precertification 8
Preventive
care, adult 12
Preventive care, children 13
Prescription drugs 29
Preventive services 12
Prior approval 8
Prostate cancer screening 12
Prosthetic devices 17
Psychologist 28
Psychotherapy 28
Radiation
therapy 12
Room and board 24
Skilled nursing facility care 25
Speech therapy 15
Splints 24
Sterilization procedures 21
Subrogation 40
Substance
abuse 28
Surgery 20
Anesthesia 23
Oral 22
Outpatient 25
Reconstructive 21
Syringes 31
Temporary continuation of
coverage 43
Transplants 22
Treatment therapies 15
Vision services 16
Well child care 13
Wheelchairs 17
Workers' compensation 40
X-rays 12 47
47 Page 48 49
2002 ConnectiCare Inc. 47 Summary
Summary of benefits for ConnectiCare, Inc. 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 11
Services provided by a hospital:
Inpatient.............................................................................
Outpatient...........................................................................
Nothing
Day surgery, Nothing
Walk-In, $20 copay
24-25
Emergency benefits:
In-area...............................................................................
Out-of-area.........................................................................
$40 per.
$40 per
27
27
Mental health and substance abuse
treatment................................ $10 copay outpatient
100%
inpatient
28
Prescription
drugs.................................................................... $10
Generic
$20 Name Brand Formulary
$35 Name Brand Non-Formulary
Cost-sharing applies when generic is available
29-31
Dental
Care..........................................................................
No benefit.
Vision
Care..........................................................................
$10 Routine Exam, Discounts available on
eyewear and contacts 16
Special features:
Flexible benefits, services for deaf and hearing
impaired, ConnectiCare website, alternative treatments
............................ Nothing 32
Protection against catastrophic costs
(your out-of-pocket
maximum)................................................
You must share the cost of some services.
This is called either a
copayment (a set dollar
amount) or coinsurance (a set percentage of
charges). Please remember you must pay this
amount when you receive
services.
9 48
48 Page 49
2002 ConnectiCare Inc. 48
2002 Rate Information for
ConnectiCare
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.
Type of
Enrollment
Code Non-Postal Premium
Biweekly Monthly
Gov't Your Gov't Your
Share Share Share Share
Postal Premium
Biweekly
USPS Your
Share Share
All of Connecticut
High Option Self Only
High Option
Self & Family
TE1
TE2
$84.11 $28.03 $182.23 $60.74
$220.28 $73.42 $477.26.
$159.09
$99.52 $12.62
$260.66 $33.04 49