Serving: Cincinnati/ Dayton/ Springfield, Ohio
Enrollment in this Plan is limited; see page 6 for requirements.
This Plan has full accreditation From the NCQA. See the 2002
Guide for
more information On NCQA.
Enrollment codes for this Plan:
3U1 Self Only 3U2 Self and Family
Authorized for distribution by the:
RI 71-xxx
RI 73-608
RI 73-608
For changes
in benefits
see page 7 1
1
Page 2 3
2002
United Healthcare of Ohio, Inc. 2 Table of Contents
Table of
Contents
Introduction…………………………………………………………………................................................................
4
Plain
Language………………………………………………………………..............................................................
4
Inspector General Advisory
..........................................................................................................................................
4
Section 1. Facts about this HMO
plan..........................................................................................................................
5
How we pay providers
................................................................................................................................
5
Your Rights
.................................................................................................................................................
5
Service
Area................................................................................................................................................
6
Section 2. How we change for
2002……………………………………….................................................................
7
Program-wide changes
................................................................................................................................
7
Changes to this Plan
....................................................................................................................................
7
Section 3. How you get care
…………........................................................................................................................
8
Identification
cards......................................................................................................................................
8
Where you get covered care
........................................................................................................................
8
Plan providers
.......................................................................................................................................
8
Plan facilities
........................................................................................................................................
8
What you must do to get covered care
........................................................................................................
8
Primary
care..........................................................................................................................................
9
Specialty
care........................................................................................................................................
9
Hospital care
.........................................................................................................................................
9
Circumstances beyond our control
............................................................................................................
10
Services requiring our prior
approval........................................................................................................
10
Section 4. Your costs for covered services
................................................................................................................
11
Copayments
........................................................................................................................................
11
Deductible...........................................................................................................................................
11
Coinsurance
........................................................................................................................................
11
Your out-of-pocket
maximum...................................................................................................................
11
Section 5.
Benefits…………………………………………………………..............................................................
12
Overview...................................................................................................................................................
12
(a) Medical services and supplies provided by physicians and other health
care professionals .......... 13
(b) Surgical and anesthesia services
provided by physicians and other health care professionals....... 21
(c)
Services provided by a hospital or other facility, and ambulance
services..................................... 24
(d) Emergency services/
accidents
........................................................................................................
26
(e) Mental health and substance abuse benefits
...................................................................................
29
(f) Prescription drug
benefits...............................................................................................................
31
(g) Special
features...............................................................................................................................
34
(h) Dental
benefits................................................................................................................................
35
(i) Non-FEHB benefits available to Plan
members.............................................................................
36 2
2 Page 3 4
2002 United Healthcare of Ohio, Inc. 3 Table
of Contents
Section 6. General exclusions --things we don't
cover.............................................................................................
37
Section 7. Filing a claim for covered
services............................................................................................................
38
Section 8. The disputed claims
process......................................................................................................................
39
Section 9. Coordinating benefits with other
coverage................................................................................................
41
When you have…
Other health coverage
.........................................................................................................................
41
Original Medicare
...............................................................................................................................
41
Medicare managed care
plan...............................................................................................................
43
TRICARE/ Workers'Compensation/ Medicaid
...........................................................................................
43
Other Government agencies
......................................................................................................................
44
When others are responsible for injuries
...................................................................................................
44
Section 10. Definitions of terms we use in this
brochure...........................................................................................
45
Section 11. FEHB facts
..............................................................................................................................................
46
Coverage
information..............................................................................................................................
46
No pre-existing condition limitation
...............................................................................................
46
Where you get information about enrolling in the FEHB
Program................................................. 46
Types of
coverage available for you and your family
..................................................................... 46
When benefits and premiums start
..................................................................................................
47
Your medical and claims records are confidential
.......................................................................... 47
When you
retire..............................................................................................................................
47
When you lose benefits
...........................................................................................................................
47
When FEHB coverage
ends.............................................................................................................
47
Spouse equity coverage
..................................................................................................................
47
Temporary Continuation of Coverage
(TCC).................................................................................
47
Converting to individual coverage
.................................................................................................
48
Getting a Certificate of Group Health Plan
Coverage.................................................................... 48
Index
...........................................................................................................................................................................
49
Summary of benefits
...................................................................................................................................................
50
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2002 United Healthcare of Ohio, Inc. 4
Introduction/ Plain Language
Introduction
United
Healthcare of Ohio, Inc. 9050 Centre Pointe Drive, Suite 400
West Chester,
OH 45069
This brochure describes the benefits of United Healthcare of Ohio,
Inc. under our contract (CS 2671) with the Office of Personnel Management (OPM),
as authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates
with each plan annually. Benefit changes are effective January 1, 2002, and are
summarized on page 7. 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 United Healthcare of Ohio,
Inc.
We limit acronyms to one you know. FEHB is the Federal Employees
Health Benefits Program. OPM is the Office of Personal Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB
plans' brochures have the same format and similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the
structure of this brochure, let us know. Visit OPM's "Rate Us" feedback area at
www. opm. gov/ insure or email us at fehbwebcomments@ opm. gov.
Inspector General Advisory
Stop health care fraud! Fraud increases
the cost of health care for everyone. If you suspect that a phyician, pharmacy,
or hospital has charged you for services you did not
receive, billed you
twice for the same services 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 800-231-2918,
Monday-Friday 8: 00 A. M.– 5: 00 P. M. 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 United
Healthcare of Ohio 5 Section 1
Section 1. Facts about this HMO
plan
This Plan is a health maintenance organization (HMO). We require
you to see specific physicians, hospitals, and
other providers that contract
with us. These Plan providers coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well -baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, 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.
UnitedHealthcare of Ohio Inc. is a health maintenance organization. We
contract individually with over 18,000
physicians and 150 hospitals in the
state of Ohio to provide care to UnitedHealthcare of Ohio Inc. members. The
long list of UnitedHealthcare of Ohio Inc. contracting physicians assures
our physicians and health facilities will be
conveniently located.
You do not need to select a primary care physician and you do not need to get
written referral to see a participating
specialist for medical services. The
provider must be participating for services to be covered. You must call United
Behavioral Health at 1-800-860-1123 to obtain authorization for services to
use Mental Conditions/ Substance Abuse
Benefits. Women may see a Plan
gynecologist for their routine examinations.
The Plan's provider directory list primary care doctors with their locations
and phone numbers, and note whether or
not the doctor is accepting new
patients. The directory is updated on a regular basis and is available at time
of
enrollment or upon calling the Customer Service Department at
800-231-2918 M-F, 8am-5pm, for 3U1/ 3U2. When
you enroll in this Plan,
services (except for emergency benefits) are provided through the Plan's
delivery system; the
continued availability and/ or participation of any one
doctor, hospital, or participation of any one doctor, hospital, or
other
provider, cannot be guaranteed.
The Plan will provide benefits for covered services only when the services
are medically necessary to prevent,
diagnose or treat your illness or
condition. Reimbursement for prosthetic devices or durable medical equipment,
when
the item cost is more than $1000 requires prior authorization.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may get information
about us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific
types of information that we must make available to you.
Some of the required information is listed below.
If you want more information about us, call 800-231-2918, M-F, 8am-5pm. You
may also contact us by fax at 937-436-
8813 or visit our website at myuhc.
com. 5
5 Page 6 7
2002 United Healthcare of Ohio 6 Section 1
Service Area
To enroll with us, you must live or work in our
service area. This is where our providers practice.
Our service area is:
Dayton/ Springfield/ Cincinnati area Enrollment code: 3U1 Self Only
3U2 Self and Family
The counties of Allen, Auglaize, Boone, Butler, Campbell, Champaign,
Clark, Clermont,
Clinton, Darke, Greene, Hamilton, Hardin, Highland, Kenton,
Logan, Mercer, Miami, Montgomery, Preble, Shelby, and Warren.
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. 6
6 Page
7 8
2002 United Healthcare of Ohio
7 Section 2
Section 2. How we change for 2002
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 46. 0% for Self Only or 42. 2% for Self and Family.
The office visit copayment will increase from $10 to $15 per visit. Members
pay no copay after the initial $15 copay for maternity benefits.
The copay for urgent care services will increase from $10 to $25 per visit.
The copay for emergency room services will increase from $50 to $75 per
emergency room visit.
The copay for ambulance services will increase from
nothing to 20% of charges.
The copay for outpatient rehabilitation
services (physical, speech and occupational) will increase from $10 to $15 per
visit
We no longer limit total blood cholesterol tests to certain age groups.
(Section 2( a)
United Healthcare will be the provider of Dental Benefits
rather than Superior Dental Care.
We now cover certain intestinal
transplants. Section 5( b)
We changed the address for sending disputed
claims to OPM. (Section 8) 7
7 Page 8 9
2002 United
Healthcare of Ohio 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it
whenever you receive services from a Plan provider, or fill a
prescription
at a Plan pharmacy. Until you receive your ID card, use your
copy of the
Health Benefits Election Form, SF-2809, your health benefits
enrollment
confirmation (for annuitants), or your Employee Express
confirmation
letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
800-231-2918,
M-F, 8am-5pm.
Where you get covered care You get care from "Plan providers" and
"Plan facilities". You will only pay copayments, deductibles and/ or
coinsurances and will not have to
file a claim.
Plan providers Plan providers are physicians and other health
care professionals in our service area that we contract with to provide covered
services to our
members. We credential Plan providers according to national
standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website www. myuhc. com.
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, www. myuhc. com.
What you must do to get covered care You do not need to select a primary
care physician and you do not
need to get written referral to see a
contracted specialist for medical
services. The provider must be
participating for services to be covered. You must call United Behavioral Health
at (800) 860-1123 to obtain
authorization for services to use Mental Conditions/ Substance Abuse
Benefits. A woman may see a Plan gynecologist for her routine
examinations.
The Plan's provider directory list primary care doctors (generally fami ly
practitioners, pediatricians, and internist), with their locations and
phones
numbers, and note whether or not the doctor is accepting new
patients.
The directory is updated on a regular basis and are available at
the time
of enrollment or upon calling the Customer Service Department at
(800)
231-2918 for 3U1/ 3U2. When you enroll in this Plan, services (except
for emergency benefits) are provided through the Plan's delivery system;
the continued availability and/ or participation of any one doctor,
hospital,
or participation of any one doctor, hospital, or other provider,
cannot be
guaranteed.
The Plan will provide benefits for covered services only when the
services are medically necessary to prevent, diagnose or treat your illness
or condition. Reimbursement for prosthetic devices or durable medical
equipment, when the item cost more than $1000, prior authorization is
required. 8
8 Page
9 10
2002 United Healthcare of Ohio
9 Section 3
Primary care Your primary care
physician can be a family practitioner, internist or pediatrician. Your
primary care physician will provide most of your
health care, or give you a
referral to see a specialist.
If you want to change primary care physicians
or if your primary care
physician leaves the Plan, call us. We will help you
select a new one.
Specialty care You do not need to have a referral to see a
participating specialist. If you need the care of a specialist, you may select a
specialist from our
Provider Directory or call your primary care doctor, who
will arrange for
you to see a specialist. If your current specialist is a
Plan contracted
doctor, you may continue to see that doctor without a
written referral
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic, complex, or seriour medical
condition, your primary care physician
will work with the Plan to
develop a treatment plan that allows you to
see your specialist for a
certain number of visits without additional
referrals. Your primary care
physician will use our criteria when
crating your treatment plan (the
physician may have to get an
authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk you 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. 9
9 Page 10 11
2002 United Healthcare of Ohio 10 Section 3
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 1-800-231-2918. If you
are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them.
In that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our
prior approval Your primary care physician
must notify us prior to any surgery/ treatment. United Healthcare will consider
if the service is
covered, medically necessary, and follows generally accepted medical
practice.
We call this review and approval process prior authorization. Your
physician must obtain prior authorization for services such as durable
medical equipment that costs more than $1000.
Your primary care physician must notify us prior to any
surgery/
treatment. United Healthcare will consider if the service is
covered,
medically necessary, and follows generally accepted medical
practice.
The UnitedHealthcare of Ohio Inc. determines "Medical, surgical,
diagnostic, psychiatric, substance abuse or other health care technologies,
supplies, treatments, diagnostic procedures, drug therapies, or devices to
be experimental or investigational when one of the following applies (at
the time it makes a determination regarding coverage in a particular
case): 1) Not approved by the U. S. Food and Drug
Administration(" FDA")
to be lawfully marketed for the proposed use and
not identified in the
American Hospital Formulary Service as appropriate
for the proposed use; 2)
Subject to review and approval by any
Institutional Review Board for the
proposed use; 3) The subject of an
ongoing clinical trial that meets the
definition of a Phase 1, 2, or 3
Clinical Trial set forth in the FDA
regulations, regardless of when the
trial is actually subject to FDA
oversight; 4) Not demonstrated through
prevailing peer-reviewed medical
literature to be safe and effective for
treating or diagnosing the
condition, illness or diagnosis for which its use
is proposed.
UnitedHealthcare of Ohio Inc. Reserves the right to make
final judgement
regarding coverage for Experimental, Investigational or
Unproven Services.
10
10 Page 11 12
2002 United Healthcare of Ohio 11 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc. when you receive services.
Example: When you see your primary care physician you pay a
copayment of
$15 per office visit and when you go in the hospital, you
pay $100 per
admission.
Deductible We do not have a deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you
must pay for your care. Example: In our Plan, you pay 20% for durable medical
equipment.
Your castastrophic protection
out-of-pocket maximum for deductibles
copayments and coinsurance After your copayments and/ or coinsurance
total $500 per person or $1000 per family enrollment in any calendar year, you
do not have to pay
any more for covered services. However, copayment for the
following
services do not count toward your out-of-pocket maximum and you
must
continue to pay copayments for these services.
Orthopedic Devices Prosthetic Devices
Durable Medical Equipment
Medical Supplies (but not diabetic supplies
Growth Hormones Hospital
Emergency Room
Office Visit, Emergency Room & Urgent Care Copays
Pharmacy Copays
Be sure to keep accurate records of your copayments since
you are
responsible for informing us when you reach the maximum. 11
11 Page 12 13
2002 United Healthcare of Ohio 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our
benefits changed this year and page 49 for a benefits summary.)
NOTE: This benefits section is divided into subsections.
Please read the important things you should keep in mind at the beginning of
each subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the
following subsections. To obtain claims forms, claims
filing advice, or more information about our benefits, contact us
at
800-231-2918 or at our website at www. myuhc. com
(a) Medical services and supplies provided by physicians and other health
care professionals 13-20
Diagnostic and treatment services
Lab, X-ray,
and other diagnostic tests Preventive care, adult
Preventive care, children Maternity care
Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies
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
Alternative treatments Educational classes and
programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ....................... 21-23
Surgical procedures
Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue
transplants
Anesthesia
(c) Services provided by a hospital or other facility, and
ambulance services..................................................... 24-25
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice
care
Ambulance
(d) Emergency services/
accidents.........................................................................................................................
26-28
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
....................................................................................................
29-30
(f) Prescription drug benefits
...............................................................................................................................
31-33
(g) Special features
....................................................................................................................................................
34
Flexible Benefits Option
24 hour Nurseline Services for Deaf &
Hearing impaired
Centers of Excellence for Transplants Travel Benefit/ Services Iverseas
(h) Dental benefits
.....................................................................................................................................................
35
(i) Non-FEHB benefits available to Plan members
..................................................................................................
36 12
12 Page 13
14
2002 United Healthcare of Ohio 13 Section
5 (a)
Section 5 (a). Medical services and supplies provided by
physicians and
other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
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
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office $15 per
office
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial
examination of a newborn child covered under a family enrollment
Office medical consultations
Second surgical opinion
$15 per office visit
Nothing
Nothing
$15 per office visit
$15 per office visit
$15 per office visit
At home $15 per visit
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
$15 per office visit 13
13 Page 14 15
2002 United
Healthcare of Ohio 14 Section 5 (a)
Preventive care, adult You
pay
Routine screenings, such as:
Total Blood Cholesterol – once
every three years,
Colorectal Cancer Screening, including
Fecal
occult blood test
Sigmoidoscopy, screening – every five years starting at
age 50
$15 per office visit
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older
$15 per office visit
Routine pap test
Note: The office visit is covered
if pap test is received on the same day;
see Diagnostic and Treatment
Services, above.
$15 per office 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
$15 per office visit
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
$15 per office visit
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy of Pediatrics $15 per office visit
Well-child care charges for routine examinations, immunizations and care
(under age 22)
Examinations, such as:
Eye exams through age 17 to
determine the need for vision correction. (once every 12 months)
Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations (through age 22)
$15 per office visit 14
14 Page 15 16
2002 United
Healthcare of Ohio 15 Section 5 (a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in
mind:
You do not need to precertify your normal delivery; see pages 25-27 for
other circumstances, such as extended stays for you or your
baby.
You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
We cover routine nursery
care of the newborn child during the covered portion of the mother's maternity
stay. We will cover other
care of an infant who requires non-routine treatment only if we
cover the
infant under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits (Section 5b).
Internal feedings are covered when they are the sole source of nutrition or
is covered by Medicare Complete.
$15 per office visit for initial visit;
$100 for facility charges.
Not covered: Routine sonograms to determine fetal age, size or sex All
charges.
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)
Diaphragms
NOTE: We cover oral contraceptives under the prescription
drug
benefit.
$15 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, All charges. 15
15 Page 16 17
2002 United
Healthcare of Ohio 16 Section 5 (a)
Infertility services You
pay
Diagnosis and treatment of infertility, such as:
Artificial
insemination:
intravaginal insemination (IVI)
intracervical
insemination (ICU)
intrauterine insemination (IUI)
$15 per office visit
Not covered:
Assisted reproductive technology (ART)
procedures, such as:
in vitro fertilization
empryo
transfer, gamete GIFT and ztgote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor sperm
Cost of donor egg
All charges
Allergy care You pay
Testing and treatment
Allergy injection
$15 per office visit.
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy desensitization All charges.
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under
Organ/ Tissue
Transplants on page 22.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
Growth Hormone Therapy (GHT)
NOTE: Growth hormone is covered under the
prescription drug benefit
at 20% of charges. We will only cover GHT when we
preauthorize the
treatment. The participating provider must form information
that
establishes GHT is medically necessary. If the services are not
preauthorized or if we determine GHT is not medically necessary, we
will
not cover the GHT or related services and supplies.
$15 per office visit 16
16 Page 17 18
2002 United
Healthcare of Ohio 17 Section 5 (a)
Physical and occupational
therapies You pay
Physical therapy and occupational therapy
2
months per condition for the services of each of the following:
qualified
physical therapists;
occupational therapists.
Note: We only cover
therapy to restore bodily function when there
has been a total or partial
loss of bodily function or functional
speech due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery
or a
myocardial infarction, is provided for up to 36 sessions.
$15 per office visit. Nothing in
inpatient.
Not covered:
long-term rehabilitative therapy
exercise programs
All charges
Speech therapy
2 months per condition.
Note: We only cover
Therapy to restore speech when there has been a
total or partial loss of
functional speech due to illness or injury.
$15 per office visit. Nothing in
inpatient.
Not covered:
Exercise Programs
All charges
Hearing services (testing, treatment, and supplies)
First
hearing aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care, children)
$15 per office visit
Not covered:
all other hearing testing hearing aids,
testing and examinations for them
All charges
Vision services (testing and treatment and supplies) You pay
Annual eye refractions (to provide a written lense prescription)
Preventive eye exams (once every 12 months)
Diagnosis and treatment of
diseases of the eye
$15 per office visit
Not covered:
Corrective lenses or frames
Eye
exercises
Contact lenses
All charges 17
17 Page 18 19
2002 United
Healthcare of Ohio 18 Section 5 (a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$15 per office visit.
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
Treatment of weak, strained or flat
feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot (unless the
treatment is by open cutting surgery)
All Charges
Orthopedic and prosthetic devices You pay
Orthopedic devices
such as braces; foot orthotics; medical supplies including colostomy supplies;
dressings, catheters and related
supplies.
Prosthetic devices such as
breast protheses and surgical bras, including necessary replacement following a
mastectomy. Plan
prior authorization is required for items that cost $100 or more.
Corrective orthopedic appliances for non-dental treatment of temporomamidibalar
joint (TMJ) pain dysfunction syndrome.
You pay 20% of the charges.
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 than 3 years after the last one we
covered
All charges 18
18 Page 19 20
2002 United
Healthcare of Ohio 19 Section 5 (a)
Durable medical equipment
(DME) You pay
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, we also cover:
wheel chair hospital beds
blood glucose monitors insulin pumps
artificial limbs external
lenses following cataract removal
crutches walkers
Plan prior authorization is required for items that cost $1000 or more.
Repairs and replacements are covered if needed due to a change in the
member's medical condition.
You pay 20% of the charges.
Not covered:
Hearing Aids
Motorized wheel chairs
All charges
Home health services You pay
Home health care ordered by a Plan
physician and provided by a registered nurse (R. N.), licensed practical nurse
(L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
Services include oxygen therapy, intravenous therapy and medications.
$15 per office visit
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
services primarily for hygiene, feeding, exercising, moving the patient,
homemaking, companionship or giving oral medication.
All charges
Chiropractic Treatment You pay
No Benefit All charges 19
19 Page 20 21
2002 United Healthcare of Ohio 20 Section 5
(a)
Alternative treatments You pay
Acupuncture – by a doctor
of medicine or osteopathy for:
anesthesia, pain relief.
$15 per office visit.
Not covered:
naturopathic services hypnotherapy
biofeedback
All charges.
Educational classes and programs You pay
Coverage is limited to:
Diabetes self-management $15 per office visit. 20
20 Page 21 22
2002 United Healthcare of Ohio 21 Section 5(
b)
Section 5 (b). Surgical and anesthesia services provided by
physicians and other
health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services for valuable information about
how cost sharing works. Also read Section 9 about coordinating benefits with
other coverage, including with
Medicare.
The amounts listed below are for the charges billed by a
physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility (i. e. hospital,
surgical center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION OF
SOME SURGICAL PROCEDURES and PRENOTIFICATION OF ALL SURGERIES PRIOR TO RECEIVING
THE SERVICE.. 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)
Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal
weight according
to current underwriting standards; eligible
members must be age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic braces and
prosthetic devices for device coverage information.
Norplant (a surgically implanted contraceptive) and intrauterine devices
(IUDs). Note: Devices are covered under 5( a).
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.
$15 per office visit. 21
21 Page 22 23
2002 United
Healthcare of Ohio 22 Section 5( b)
Surgical procedures
(Continued) You pay
Not covered:
Reversal
of voluntary sterilization Routine treatment of conditions of the foot;
see Foot care.
Surgical treatment of morbid obesity
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.
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.
$15 per office visit.
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
Removal of
birth marks
All charges
Oral and maxillofacial surgery You Pay
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.
Dental care necessary to release pain in treatment of temporomandibular
joint pain dysfunction.
$15 per office visit for spcialist;
Nothing for inpatient hospital
Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the
periodontal membrane, gingiva, and alveolar bone)
All charges. 22
22 Page 23 24
2002 United
Healthcare of Ohio 23 Section 5( b)
Organ/ tissue transplants
You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and peripheral
stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ
cell tumors
Intestinal transplants (small intestine) and the small intestine with the
liver or small intestine with multiple organs such as the liver,
stomach,
and pancreas
United Resource Network (URN – network used for organ tissue
transplants)
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 for inpatient
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as
covered
All charges
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in
Hospital (outpatient)
Skilled
nursing facility
Ambulatory surgical center
Office
$15 per office visit 23
23 Page 24 25
2002 United
Healthcare of Ohio 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
Section 5( a) or (b).
YOUR PHYSICIAN MUST GET PRIOR NOTIFICATION PRIOR TO HOSPITAL STAYS.
Please refer to Section 3 to be sure which services
require precertification.
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.
Other hospital services and supplies, such as:
Operating,
recovery, maternity, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and x-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and
equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home
$100 per admission for facility
Not covered:
Custodial care Non-covered facilities,
such as nursing homes
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges. 24
24 Page 25 26
2002 United
Healthcare of Ohio 25 Section 5( c)
Outpatient hospital or
ambulatory surgical center You pay
Operating, recovery, and other
treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and
blood plasma, if not donated or replaced Pre-surgical testing
Dressings,
casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and
supplies related to dental
procedures when necessitated by a non-dental
physical impairment. We
do not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits You pay
All necessary services are covered, including:
bed, board and general nursing drugs, biologicals, supplies and equipment
ordinarily provided or
arranged by the skilled nursing facility when prescribed by a Plan doctor
The Plan provides a comprehensive range of benefits for up to 180 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
$100 co-pay per admission for facility charges.
Not covered: custodial care All charges
Hospice care You pay
Inpatient Care
Outpatient Care
Family Counseling
Supportive and palliative care for a terminally ill member is covered in the
home or hospice facility.
Note: 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.
$100 inpatient admission and
nothing for outpatient care.
Not covered: Independent nursing, homemaker services 20% of charges
Ambulance You pay
Local professional ambulance service when
medically appropriate
Benefits are provided for emergency ambulance
transportation ordered or authorized by a Plan doctor.
Nothing. 25
25 Page
26 27
2002 United Healthcare of Ohio
26 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe
endangers your life or could result in serious
injury or disability, and requires immediate medical or
surgical care. Some
problems are emergencies because, if not treated promptly, they might become
more
serious; examples include deep cuts and broken bones. Others are
emergencies because they are
potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or sudden inability
to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are
unable to contact your doctor, contact the local emergency system (e. g., the
911 telephone system) or go to the
nearest hospital emergency room. Be sure
to tell the emergency room personnel you are a Plan member so they
can
notify the Plan. You or a family member must notify the Plan within 48 hours. It
is your responsibility to
ensure the Plan has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 48 hours or on the first
working day following your
admission, unless it was not reasonably possible to notify the Plan within that
time.
If you are hospitalized in non-Plan facilities and 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-participating providers in a medical
emergency only if delay in reaching
a contracted 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.
Plan pays . . .
Reasonable charges for emergency services to the
extent the services would have been covered if received from
Plan providers.
26
26 Page 27 28
2002 United Healthcare of Ohio 27 Section 5(
d)
Emergencies outside our service area:
Benefits are
available for any medically necessary health service that is immediately
required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day
following your admission, unless it was not
reasonably possible to notify the Plan within that time. If a
Plan doctor
believes care will or 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.
Plan pays . . .
Reasonable charges for emergency care services to
the extent the services would have been covered if received
from Plan
providers.
What is covered …
emergency care at a doctor's office or an urgent care center
emergency care as an outpatient or inpatient at a hospital including doctors'
services
ambulance service if approved by the Plan
What is not
covered…
medical and hospital costs resulting from a normal full-term delivery of a
baby outside the Service Area
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 27
27 Page 28 29
2002 United Healthcare of Ohio 28 Section 5(
d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
$15 per office visit
$25 per visit.
$75 per hospital
emergencyroom visit. If the
emergency results in
admission to a
hospital,
emergency care copay is
waived.
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a doctor's office Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$15 per office visit
$25 per visit
$75 per emergency room
visit.
If the
emergency results in
admission to a
hospital, the
emergency care co-pay
is waived.
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 You pay
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
Benefits are provided
for emergency ambulance transportation ordered
or authorized by a Plan
doctor.
20% of charges.
Not covered: air ambulance All charges. 28
28 Page 29 30
2002 United Healthcare of Ohio 29 Section 5(
e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
You may choose to get care Out-of-Network or In-Network. When you receive
In-Network
care, you must get our approval for services and follow a
treatment plan we approve. If you do,
cost-sharing and limitations for
In-Network mental health and substance abuse benefits will be
no greater
than for similar benefits for other illness and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in
this brochure.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF
THESE SERVICES. See the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing
responsibilities are no
greater than for other
illness
or conditions.
Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers
Medication management
$15 per office visit 29
29 Page 30 31
2002 United
Healthcare of Ohio 30 Section 5( e)
Mental health and
substance abuse benefits (Continued) You pay
Diagnostic
tests $15 per office visit
Services provided by a hospital or other facility
Services in
approved alternative care settings such as partial
hospitalization, half-way
house, residential treatment, full-day
hospitalization, facility based
intensive outpatient treatment
$100 per hospitalization;
nothing for outpatient.
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain your treatment and follow all the following authorization processes:
Call United Behavioral Health at 800-860-1123 before obtaining care
and
for a list of participating providers.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 30
30 Page
31 32
2002 United Healthcare of Ohio
31 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed plan physician must
write the prescription.
Where you can obtain them. You must fill
the prescription at a plan pharmacy, or by mail for a maintenance medication
We use a formulary. The Preferred Drug List (PDL) includes
brand-name and generic prescription drugs that have been approved by the Food
and Drug Administration (FDA). Generic drugs on the
PDL are available to you
at the lowest copayment. Brand name drugs are also covered on the PDL
at a
higher copay. If a drug is not on the PDL, it may be covered at a higher copay.
Coverage for
some drugs may be limited to specific dosage and/ or strengths,
quantity limits and/ or prior
authorization. Please refer to your 2002 PDL
for specific drug coverage.
These are the dispensing limitations. Prescription drugs prescribed
by a contracted or referral doctor and obtained at a contracted pharmacy will be
dispensed for up to a 31-day supply or 100-unit
supply, whichever is less; 240 milliliters of liquid (8 oz.); 60 grams of
ointment, creams or topical
preparation; or one commercially prepared unit
(e. g., one inhaler, one vial ophthalmic medication or
2 vials of insulin).
Why use generic drugs? Generic drugs are lower-priced drugs that are
the therapeutic equivalent to more expensive brand-name drugs. They must contain
the same active ingredients and must be
equivalent in stringth and dosage to the original brand-name product. Generic
cost less than the
equivalent brand-name product. The U. S. Food and Drug
Administration sets quality standards for
generic drugs to ensure that the
drugs meet the same standards of quality and stringth as brand-name
drugs.
When you have to file a claim. Claims will be filed automatically by
the plan pharmacy.
. 31
31 Page
32 33
2002 United Healthcare of Ohio
32 Section 5( f)
Benefit Description You pay
Covered
medications and supplies
We cover the following medications and supplies
prescribed by a Plan
physician and obtained from a Plan pharmacy or through
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; copay charge applied every 2 vials
Disposable needle and syringes for the administration of covered
medication
Drugs for sexual dysfunction are limited. Contact the plan for prior
authorization and dose limits.
Contraceptive drugs and devices that
require a perscription
Injectible contraceptive drugs, such as
Depo-Provera
Contraceptive devices and supplies that require a
prescription
Implanted contraceptive drugs such as Norplant
IV
fluids and medications
Diabetic supplies, including insulin syringes,
needles, glucose test tablets and test tape, Benedict's solution or equivalents
and acetone
test tablets.
Intravenous fluids and medication for home use,
implantable drugs, and some injectible drugs are covered under medical and
surgical
benefits.
Prescription drugs prescribed by a plan physician can also be
obtained via a mail order program for up to a 90-day supply. To
access the mail order program, call 1-800-231-2918 for mail order
customer service.
$10 copay per prescription unit or
refill for generic drugs on the
Plan's Formulary Drug List.
$15 copay per prescription unit or
refill for name brand drugs on the
Plan's Formulary Drug List.
$30 copay per prescription unit or
refill for drugs not on the Plan's
Formulary Drug List.
20% Coinsurance
$20 copay per prescription unit or
refill for generic
drugs on the
Plan's Formulary Drug List. and a
$30 copay per prescription unit or
refill for name brand drugs on the
Plan's Formulary Drug List.
$60 copay per prescription unit or
refill for drugs not on the Plan's
Formulary Drug List. 32
32 Page 33 34
2002 United
Healthcare of Ohio 33 Section 5( f)
Covered medications and
supplies (continued) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins and
nutritional substances that can be purchased without a prescription
Nonprescription medicine
Drug obtained at a non-Plan
pharmacy except for out-of-area emergencies
Medical supplies such as dressings and anticeptics
Drugs to
enhance athletic performance
Smoking cessation drugs and medication
Fertility Drugs
Dental prescriptions
Appetite suppressants
All Charges 33
33 Page 34 35
2002 United
Healthcare of Ohio 34 Section 5( g)
Section 5 (g). Special
Features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative
benefit.
Alternative benefits
are subject to our ongoing review.
By approving an alternative benefit, we
cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call Care 24 at 1-877-365-7950 and talk with a registered
nurse who will discuss treatment options and answer your health questions.
Services for deaf and hearing impaired For any of your health
concerns, 24 hours a day, 7 days a week, you may call Care 24 at 1-800-855-7950
and talk with a registered nurse who will discuss treatment options and answer
your health questions
Centers of excellence for transplants/ heart
surgery/ etc
United Resource Network
Travel benefit/ services overseas Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness. Please refer to Emergency Benefits for coverage
details. 34
34 Page
35 36
2002 United Healthcare of Ohio
35 Section 5 (h)
Section 5 (h). Dental benefits
I M
P
O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover
hospitalization for dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the
patient; we do not
cover the dental procedure unless it is described below.
Be sure to
read Section 4, Your costs for covered services for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.
Nothing
Dental Benefits You pay
The following dental services are covered
when provided by plan
dentists. Contact United Healthcare at 877-816-3596,
M-TH, 8: 30 a. m.
– 8: 00 p. m. . Friday, 9: 00 a m. – 8: 00 p. m. eastern
or through the
website at myuhc. com.
Preventive and diagnostic treatment:
Oral Exam (one per six month
period) Prophylaxis (cleaning – two per year)
Fluoride (once per six month period under age 14) Bitewing x-rays (one
set per year)
Complete dental series or panoramic survey (once every 36
months)
Sealants (once per first or second permanent molar every 5 years
for covered persons under the age of 16 years)
Space maintenance (once per
lifetime, under age of 12)
50% of charges; maximum annual
benefit is $500 per person
Emergency treatment (limited to the relief of pain, bleeding, swelling,
or other life threatening conditions, but not the cure of disease).
50% of charges
Not Covered: all other dental services not shown as covered. All Charges
35
35 Page 36
37
2002 United Healthcare of Ohio 36 Section
5 (i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an
FEHB disputed claim about them. Fees you pay
for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Wellness Programs For information pertaining to our wellness programs,
please call Customer Service at 1-800-231-2918, M – F, 8am –
5pm.
Medicare Prepaid Plan Enrollment
This plan offers Medicare
recipients the opportunity to enroll in the Plan (referred to as
UnitedHealthcare of Ohio
Inc. 's Medicare Complete) through Medicare.
Annuitants and former spouses with FEHB converge and Medicare
Part B may
elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one
is available in their
area. They may then later re-enroll in the FEHB
program. Most federal annuitants have Medicare Part A. Those
without
Medicare Part A may join this Medicare prepaid plan but will probably have to
pay for hospital coverage in
addition to the Part B premium. Before you join
the plan, ask whether the plan covers hospital benefits and, if so,
what you
will have to pay. Contact your retirement system for information on dropping
your FEHB enrollment and
changing to a Medicare prepaid plan. Contact us at
800-504-4848 for information on the Medicare prepaid plan and
the cost of
that enrollment.
If you are Medicare eligible and are interested in enrolling in a Medicare
HMO sponsored by this
Plan without dropping your enrollment in this Plan's
FEHB plan, call 800-504-4848 for information on the benefits available under the
Medicare HMO.
Benefits on this page are not part of the FEHB contract 36
36 Page 37 38
2002 United Healthcare of Ohio 37 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we
will not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or
treat your
illness, disease, or condition.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you are not enrolled in this
Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of
medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered if the fetus were carried to term or when the
pregnancy is the result of an act of rape or
incest
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility
barred from the FEHB Program. 37
37 Page 38 39
2002 United
Healthcare of Ohio 38 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at
Plan
pharmacies, you will not have to file claims. Just present your identification
card and pay your copayment,
coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical and hospital benefits In most cases, providers and facilities
file claims for you. Physicians must file on the form HCFA-1500, Health
Insurance Claim Form.
Facilities will file on the UB-92 form. For claims
questions and
assistance, call us at 1-800-231-2918.
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: UHC
of Ohio Claims, Route #2904, P. O.
Box 659752, San Antonio, TX 78265-9752
Prescription drugs Submit your claims to: Paid Prescriptions, LLC, Merck
Medco, P. O. Box 2096, Lee's Summit, MO 64063-7096
Other supplies or services Submit DENTAL claims to: United Healthcare
Dental: Claims Division, P. O. Box 30650, Bethesda, MD 20824-0560
Deadline
for filing your claim Send us all of the documents for your claim as soon as
possible. You must submit the claim by December 31 of the year after the year
you
received the service, unless timely filing was prevented by
administrative
operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 38
38 Page
39 40
2002 United Healthcare of Ohio
39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on
your claim or request for
services, drugs, or supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must:
Write to us within 6 months from the date of our decision; and
Send your
request to us at: UHC of Ohio, Marketing Dept., P. O. Box 751090, Dayton, OH
45475-1090; and
Include a statement about why you believe our initial decision was wrong,
based on specific benefit provisions in this brochure; and
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. 39
39 Page 40 41
2002 United Healthcare of Ohio 40 Section 8
Section 8. The disputed claims process (continued)
Note: You
are the only person who has a right to file a disputed claim with OPM. Parties
acting as your
representative, such as medical providers, must include a
copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied
precertification or prior
approval. This is the only deadline that may not
be extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or death if not treated as soon as
possible), and
(a) We haven't responded yet to your initial request for care
or preauthorization /prior approval, then call us at
1-800-231-2918 and we
will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so
that they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m. eastern time. 40
40
Page 41 42
2002
United Healthcare of Ohio 41 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under another
group health plan or have automobile insurance that pays health
care medical
expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the
secondary
payer. We, like other insurers, determine which coverage is primary according to
the National Association of Insurance
Commissioners' guidelines.
When we
are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left 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-State 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 Manage Care Plan is the term used to
describe the various health plan choices available to Medicare beneficiaries.
The information in the next few pages shows how we
coordinate benefits with
Medicare, depending on the type of Medicare managed care plan you have.
The Original Medicare Plan The Original Medicare Plan is available
everywhere in the United (Part A or Part B) 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.
We will
not waive any of our copayments or coinsurances.
The Primary Payer Chart begins on page 41. 41
41
Page 42 43
2002
United Healthcare of Ohio 42 Section 9
The following chart
illustrates whether Original Medicare or this Plan should be the primary payer
for you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered
family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either you
--or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a family member are eligible for
Medicare solely because of a disability), 3 33 3
2) Are an annuitant, 3 33 3
3) Are a reemployed annuitant with the
Federal government when…
a) The position is excluded from FEHB, or 3 33 3
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you.
3 33 3
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), 3
5) Are enrolled in Part B only, regardless of your employment status, 3 33 3
(for Part B
services)
3 33 3
(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,
3 33 3
(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, 3 33 3
2) Have completed the 30-month
ESRD coordination period and are still eligible for Medicare due to ESRD, 3 33 3
3) Become eligible for Medicare due to ESRD after Medicare became primary
for you under another provision, 3 33 3
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 3 33 3
b) Are an active employee, or
c)
Are a former spouse of an annuitant, or
d) Are a former spouse of an active
employee
3 33 3
Tell us if you or a family member is enrolled in Medicare Part A or B.
Medicare will determine who is responsible for paying for medical services and
we will coordinate the payments. On occasion, you may need to file a Medicare
claim form.
Claims process when you have the Original Medicare Plan
– You probably will never have to file a claim form when you have both our
Plan and the Original Medicare.
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 800-231-2918.
We waive some costs when you have the Original
Medicare – When medicare is the primary care payer, we will not waive any
out-of-pocket costs. 42
42 Page
43 44
2002 United Healthcare of Ohio
43 Section 9
Medicare managed care plan If you are
eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from another type of Medicare+ Choice plan a
Medicare managed care
plan. These are health care choices (like HMOs) in some areas of the country. In
most Medicare managed care plans, you
can only go to doctors, specialists, or hospitals that are part of the plan.
Medicare managed care plans provide all the benefits that Original
Medicare
covers. Some cover extras, like prescription drugs. To learn more about
enrolling in a Medicare managed care plan, contact Medicare
at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov. If you enroll in a
Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also
remain enrolled
in our FEHB plan. We will still provide benefits when your Medicare managed care
plan is primary, even out of the managed
care plan's network and/ or service
area (if you use our Plan providers), but we will not waive any of our
copayments or coinsurance. If you enroll
in a Medicare managed care plan,
tell us. We will need to know whether you are in the Original Medicare Plan or
in a Medicare managed care
plan so we can correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care
plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare
managed care plan
premium.). For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll
in the FEHB Program,
generally you may do so only at the next open season unless you involuntarily
lose coverage or move out of the
Medicare Managed Care Plan service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered Medicare Part A or Part B 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.
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 benefits. You must use
our providers.
Medicaid When you have this Plan and Medicaid, we pay first. 43
43 Page 44 45
2002 United Healthcare of Ohio 44 Section 9
When other Government agencies We do not cover services and
supplies when a local, State, are responsible for your care or Federal
Government agency directly or indirectly pays for them.
When others are
responsible When you receive money to compensate you for medical or hospital
care for injuries for injuries or illness caused by another person, you
must reimburse us
for any expenses we paid. However, we will cover the cost
of treatment
that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 44
44 Page 45 46
2002 United
Healthcare of Ohio 45 Section 10
Section 10. Definitions of
terms we use in this brochure
Calendar year January 1 through December
31 of the same year. For new enrollees, the calendar year begins on the
effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 11.
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Services
that are non-health related, such as daily living activities, or services which
are health related but do not seek to cure, or services
which do not require
a trained medical professional.
Deductible A deductible is a fixed amount of covered expense you must
incur for certain covered services and supplies before we start paying benefits
for
those services.
Experimental or
Investigational Services The UnitedHealthcare of
Ohio Inc. determines "Medical, surgical, diagnostic, psychiatric, substance
abuse or other health care technologies,
supplies, treatments, diagnostic procedures, drug therapies, or devices to
be experimental or investigational when one of the following applies (at
the time it makes a determination regarding coverage in a particular
case): 1) Not approved by the U. S. Food and Drug
Administration(" FDA")
to be lawfully marketed for the proposed use and
not identified in the
American Hospital Formulary Service as appropriate
for the proposed use; 2)
Subject to review and approval by any
Institutional Review Board for the
proposed use; 3) The subject of an
ongoing clinical trial that meets the
definition of a Phase 1, 2, or 3
Clinical Trial set forth in the FDA
regulations, regardless of when the
trial is actually subject to FDA
oversight; 4) Not demonstrated through
prevailing peer-reviewed medical
literature to be safe and effective for
treating or diagnosing the
condition, illness or diagnosis for which its use
is proposed.
UnitedHealthcare of Ohio Inc. Reserves the right to make
final judgement
regarding coverage for Experimental , Investigational or
Unproven Services.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Fee-for-service plans
determine their
allowances in different ways. We determine our allowance as
follows
Us/ We Us and we refer to United Healthcare of Ohio
You You
refers to the enrollee and each covered family member. 45
45 Page 46 47
2002 United Healthcare of Ohio 46 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm.
gov/ insure. Also, your employing or retirement office
about enrolling in
the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans,
and other materials you
need to make an informed decision about:
When you may change your
enrollment;
How you can cover your family members;
What happens when
you transfer to another Federal agency, go on leave without pay, enter military
service, or retire;
When your enrollment ends; and
When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in
most cases,
cannot change your enrollment status without information from
your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for
for you and your family you, your spouse,
and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is
effective
on the first day of the pay period that begins after your
employing office
receives your enrollment form; benefits will not be
available to your spouse
until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please
tell us immediately when you add or remove family members
from your coverage
for any reason, including divorce, or when your child
under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 46
46 Page
47 48
2002 United Healthcare of Ohio
47 Section 11
When benefits and premiums start The
benefits in this brochure are effective on January 1. If you joined this Plan
during Open Season, your coverage begins on the first day of your first pay
period that starts on or after January 1. Annuitants' coverage and premiums
begin on
January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they
administer this contract;
This Plan and appropriate third parties, such as
other insurance plans and the Office of Workers' Compensation Programs (OWCP),
when
coordinating benefit payments and subrogating claims;
Law enforcement
officials when investigating and/ or prosecuting alleged civil or criminal
actions;
OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
When FEHB coverage ends You
will receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are
a family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may coverage 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.
You may not elect TCC if you are fired from
your Federal job due to
gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary
Continuation of Coverage and Former Spouse Enrollees,
from your
employing or retirement office or from www. opm. gov/ insure.
It explains
what you have to do to enroll. 47
47 Page 48 49
2002 United
Healthcare of Ohio 48 Section 11
Converting to You
may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot
convert;
You decided not to receive coverage under TCC or the spouse
equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not
notify you. You must apply in writing to us within 31 days after you are no
longer eligible for coverage.
Your benefits and rates will differ from
those under the FEHB Program;
however, you will not have to answer questions
about your health, and
we will not impose a waiting period or limit your
coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a
Group Health Plan Coverage
Federal law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If you
leave the
FEHB Program, The Plan 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. It HIPAA rules, such as a
requirement that Federal employees must
exhaust any TCC eligibility as
one condition for guaranteed access to
individual health coverage under
HIPAA, and it has information about Federal
and State agencies you can
contact for more information. 48
48 Page 49 50
2002 United Healthcare of Ohio 49 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Allergy tests 16
Alternative treatment 20
Ambulance 25,28 Anesthesia 23
Autologous bone
marrow transplant 23
Breast cancer screening 14 Changes for 2002 7
Chemotherapy 16 Childbirth 15
Cholesterol tests 14 Claims 38-40
Coinsurance 11 Colorectal cancer screening 14
Contraceptive devices and
drugs 32 Coordination of benefits 41
Covered charges 45 Covered providers 8
Deductible 11 Definitions 45
Dental care 35 Diagnostic services
15
Disputed claims review 39-40 Donor expenses (transplants) 23
Durable
medical equipment (DME) 19
Educational classes and programs 20
Effective date of enrollment 47
Emergency 26-28 Experimental or
investigational 37
Eyeglasses 34 Family planning 15
Fecal occult
blood test 14 General Exclusions 37
Hearing services 17 Home health services 19
Hospice care 25 Home
nursing care 19
Immunizations 14 Infertility 16
Inpatient
Hospital Benefits 24-25 Insulin 31
Laboratory and pathological
services 13
Magnetic Resonance Imagings (MRIs) 13
Mail Order
Prescription Drugs 31 Mammograms 14
Maternity Benefits 15 Medicaid 43
Medicare 43 Mental Conditions/ Substance
Abuse Benefits 29-30 Newborn
care 15
Non-FEHB Benefits 36 Nursery charges 15
Obstetrical care
15 Occupational therapy 17
Office visits 13 Oral and maxillofacial surgery
21
Orthopedic devices 18 Out-of-pocket expenses 11
Outpatient facility
care 24 Oxygen 19
Pap test 14 Physical examination 14
Physical
therapy 19
Physician 8 Preventive care, adult 14
Preventive care, children 14
Prescription drugs 31-33
Preventive services 14 Prior approval 10
Prostate cancer screening 16 Prosthetic devices 18
Psychologist 28-29
Psychotherapy 28-29
Radiation therapy 16 Rehabilitation therapies 17
Room and board 24 Second surgical opinion 13
Skilled nursing
facility care 25 Speech therapy 17
Sterilization procedures 15 Substance
abuse 29-30
Surgery 21-23
Anesthesia 23 Oral 22
Reconstructive 22 Temporary continuation of
coverage 47
Transplants 23
Treatment therapies 16 Vision services 17
Well
child care 14 Wheelchairs 19
Workers' compensation 43 X-rays 25
49
49 Page 50 51
2002 United Healthcare of Ohio 50 Summary
Summary of benefits for the United Healthcare of Ohio, 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: $15 13
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
$100 per admission copay
Nothing
24
25
Emergency benefits:
In-area.............................................................................................
Out-of-area
.....................................................................................
$75 per visit
$75 per visit
26
27
Mental health and substance abuse
treatment..................................... Regular cost sharing 29
Prescription drugs
...............................................................................
$10 (retail) $20 (mailorder) copay per prescription unit or refill for
generic drugs and a
$15 (retail) $30 (mailorder) copay
per
prescription unit or refill for
name brand drugs on the Plan's
Formulary
Drug List.
$30 (retail) $60 (mailorder) copay
per prescription unit or refill for
drugs not on the Plan's Formulary
Drug List.
31
Dental
Care......................................................................................
50% of charges to annual
maximum $500 per person 35
Vision
Care......................................................................................
$15 office visit 14
Special
features................................................................................
See text for diversity of features 34
Protection against catastrophic costs
(your out-of-pocket maximum)
.......................................................
Nothing after $500/ Self Only or
$1,000/ Family enrollment per year
Some costs do not count toward
this protection
11 50
50 Page
51 52
2002 Rate Information for
United Healthcare of Ohio
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
Govt Your Govt Your
Share
Share Share Share
Postal Premium
Biweekly
USPS Your
Share Share
High Option
Self Only
High Option
Self & Family
3U1
3U2
$97.86 $50.90 $212.03 $110.28
$223.41 $118.74 $484.06
$257.27
115.52 33.24
263.75 78.40 51
51
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Title: The Benefit Plan
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