Serving: Northwest and North Central Ohio
Enrollment in this plan is limited.
You must live or work in our geographic service area to enroll. See page 7 for requirments.
This plan has commendable accreditation from NCQA. See the 2002 Guide for more information on accreditation.
Enrollment codes for this plan:
U21 Self Only
U22 Self and Family
Authorized for distribution by the:
UNITED STATES OFFICE OF
PERSONNELMANAGEMENT
RETIREMENT AND INSURANCE SERVICE
http:// www.
opm. gov/ insure
RI 73-609 1
1 Page
2 3
2002 Paramount Health Care 2
Table of Contents
Table of Contents
Introduction…………………………………………………………………………………………………………………… 4
Plain
language…………………………………………………………………………………………………………………. 4
Inspector General Advisory………….………………………………………………………………………………………. 4-5
Section 1. Facts about this HMO plan……….……………………………………………………….……………………….. 6
How we pay providers…………………………………………………………………………………………….. 6
Who provides
my health care?…………………………………………………………………………………….. 6
Your
Rights………………………………………………………………………………………………………… 6
Service
Area……………………………………………………………………………………………………….. 7
Section 2. How we change for
2002…………………………………………………………………………………………… 8
Program-wide
changes…………………………………………………………………………………………….. 8
Changes to this
Plan………………………………………………………………………………………………. 8
Section 3. How you get
care……………………………………………………………………….…………………………. 9
Identification cards……………………………………………………………………………………………….. 9
Where you
get covered care……………………………………………………………………………………… 9
Plan
providers…………………………………………………………………………………………… 9 Plan
facilities……………………………………………………………………………………………. 9
What you must do to get covered care………………………………………………………………………….. 9
Primary care……………………………………………………………………………………………. 9 Specialty
care………………………………………………………………………………………….. 9
Hospital
care………………………………………………………………………………………….. 10
Circumstances beyond our
control…………………………………………………………………………….. 11
Services requiring our prior
approval………………………………………………………………………….. 11
Section 4. Your costs for covered
services………………………………………………………………………………... 12
Copayments……………………………………………………………………………………………. 12
Deductible……………………………………………………………………………………………… 12
Coinsurance……………………………………………………………………………………………. 12
Your catastrophic
protection out-of-pocket maximum……………..…………………………………………... 12 2
2 Page 3 4
2002 Paramount Health Care 3 Table of Contents
Section 5. Benefits……………………………………………………………………………………………………… 13
Overview……………………………………………………………………………………………………. 13
(a) Medical services
and supplies provided by physicians and other health care professionals………..
14-21 (b) Surgical and anesthesia services provided by physicians and other
health care professionals……... 22-24
(c) Services provided by a hospital or
other facility, and ambulance services…………………………. 25-26 (d) Emergency services/
accidents………………………………………………………………………. 27-28
(e) Mental health and substance
abuse benefits……………………………………………………………. 29 (f) Prescription drug
benefits…………………………………………………………………………… 30-31
(g) Dental
benefits………………………………………………………………………………………….. 32
Section 6. General
exclusions – things we don't cover…………………….…………………………………………… 33
Section 7.
Filing a claim for covered services………………………………………………………………………….. 34
Section
8. The disputed claims process…………………………………………………………………………………. 35
Section 9.
Coordinating benefits with other coverage………………………………………………………………….. 37 When you
have…
Other health coverage………………………………………………………………………………. 37 Original
Medicare…………………………………………………………………………………... 38
Medicare managed care
plan……………………………………………………………………….. 39
TRICARE/ Worker's Compensation/
Medicaid……………………………………………………………… 39
Other Government
agencies…………………………………………………………………………………. 40
When others are responsible for
injuries……………………………………………………………………. 40
Section 10. Definitions of terms we
use in this brochure…………………………………………………………….. 41
Section 11. FEHB
facts……………………………………………………………………………………………….. 42 Coverage
information…………………………………………………………………………………….. 42
No pre-existing condition
limitation……………………………………………………………… 42 Where you get information about enrolling
in the FEHB Program……………………………… 42
Types of coverage available for you and
your family……………………………………………. 42 When benefits and premiums
start……………………………………………………………….. 42
Your medical and claims records are
confidential………………………………………………. 42 When you
retire………………………………………………………………………………….. 42
When you lose benefits…………………………………………………………………………………… 43
When FEHB
coverage ends……………………………………………………………………… 43 Spouse equity
coverage………………………………………………………………………….. 43
Temporary Continuation of Coverage
(TCC)……………………………………………………. 43 Converting to individual
coverage………………………………………………………………. 44
Getting a Certificate of Group Health
Plan Coverage…………………………………………… 44
Long term care insurance is coming later
in 2002……………………………………………………………………….. 45
Index……………………………………………………………………………………………………………………… 46
Summary of
benefits……………………………………………………………………………………………………… 47
Rates……………………………………………………………………………………………………………… Back cover 3
3 Page 4 5
2002 Paramount Health Care 4 Introduction/
Plain Language/ Advisory
Introduction
Paramount Health Care
1901 Indian Wood Circle
Maumee, OH 43537-4068
This brochure describes the benefits of Paramount Health Care under its
contract (CS 2672) 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, limitation, 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 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 premiums with each plan annually.
Benefit changes are effective January 1, 2002, and are summarized on page 8.
Rates are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and understandable to
the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member; "we" means Paramount Health Care.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of Personnel Management. If we use others,
we tell you what they mean first.
Our brochure and other FEHB plans'
brochures have the same format and similar descriptions to help you compare
plans.
If you have comments or suggestions about how to improve this
brochure, let OPM know. Visit OPM's "Rate Us" feedback
area at www. opm.
gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may also write to
OPM at the Office of Personnel Management, Office of Insurance Planning and
Evaluation Division, 1900 E Street, NW, Washington,
DC 20415.
Inspector General Advisory
Stop health care fraud! Fraud increases
the cost of health care for everyone. If you suspect that a physician, pharmacy,
or hospital has charged you for services you did not receive, billed you twice
for the same service, or misrepresented any information, do the following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 419/ 887-2525 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. 4
4 Page 5 6
2002 Paramount
Health Care 5 Introduction/ Plain Language/ Advisory
Penalties
for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can
be prosecuted for fraud. Also, the Inspector General may investigate anyone who
uses an ID card if the
person tries to obtain services for someone who is
not an eligible family member; or is no longer enrolled in the Plan and tries to
obtain benefits. Your agency may also take
administrative action against
you. 5
5 Page 6 7
2002 Paramount Health Care 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that contract with us. These Plan providers
coordinate your health care services.
HMO's 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, and coinsurance described in this brochure. When you receive
emergency services from non-Plan providers,
you may have to submit claim
forms.
You should join an HMO because you prefer the plan's benefits, not
because a particular provider is available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or
other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or coinsurance.
Who provides my health care?
Paramount Health Care is an
Individual Practice Association (IPA) type HMO. IPA means that Plan providers
are in individual practice throughout the service area. All covered services
must be provided by in-network providers and
facilities, unless it is an
emergency medical condition, or authorized in advance by Paramount.
Paramount has over 590 primary care physicians (PCPs). Your PCP will be your
first contact when you are in need of medical care. All female members will have
open access to all participating OB/ GYNS for treatment of an OB/ GYN
condition without a referral from their PCP. Paramount has over 1,200
specialists in our network. If you need to be seen by a specialist, your PCP
will make a referral to the appropriate specialist. Paramount has 36 hospitals
and 3 Centers of
Excellence.
Each member may have a different PCP and
will receive their own Paramount Health Care ID card which indicates who the PCP
is, along with the doctor's phone number and appropriate copayment amounts.
Payment of your copayment is expected
at the time medical services are
delivered.
Your Rights
OPM requires that all FEHB Plans to provide certain
information to their FEHB members. You may get information about
us, our
networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure)
lists the specific types of information that we must make available to you.
If you want information about us, call 419/ 887-2525 or 1-800-462-3589, or
write to Paramount Health Care, 1901 Indian Wood Circle, Maumee, OH 43537. You
may also contact us by fax at 419/ 887-2018 or visit our website at
www.
paramounthealthcare. com. 6
6 Page 7 8
2002 Paramount
Health Care 7 Section 1
Service Area
To enroll in this
Plan, you must live in or work in our Service Area. This is where our providers
practice. Our service area is:
The Ohio counties of Defiance, Erie, Fulton, Hancock, Henry, Huron,
Lucas, Ottawa, Putnam, Sandusky, Seneca, Williams, and Wood, and portions of
Allen, Delaware, and Paulding as described by the following zip codes:
Allen
County: 45801,45804, 45805, 45806, 45807, 45817, 45820, 45833, 45850;
Delaware County: 43003, 43015, 43066;
Paulding County: 45813, 45821,
45849, 45855, 45861, 45873, 45879, 45886.
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. 7
7 Page 8
9
2002 Paramount Health Care 8 Section 2
Section 2. How we change for 2002
Do not rely on these change
descriptions; this page is not an official statement of benefits. For that, go
to Section 5 Benefits. Also, we edited and clarified language throughout the
brochure; any language change not shown here is a clarification that
does
not change benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of the non-Postal premium will
increase by 16. 6% for Self Only or 21. 4% for Self and Family. We now cover
certain intestinal transplants. (Section 5( b))
We changed speech therapy
benefits by removing the requirement that services must be required to restore
functional speech, and we now provide speech therapy coverage for 30 visits per
condition subject to a $10 copay per visit.
(Section 5( a)) Physical therapy
and occupational therapy now will have a combined 30 visit limitation per
condition, subject to a $10
copay per visit. (Section 5 (a)) We now have a
$20 copay for a visit to a specialist. (Section 5 (a))
Prescription drugs
prescribed by a Plan physician and obtained at a Plan pharmacy will be dispensed
for up to a 30-day supply per prescription unit or refill, subject to the
following copays:
--A $5 copay per prescription unit or refill for generic drugs; --A $15 copay
per prescription unit or refill for preferred name brand drugs; and
--A $25
copay per prescription unit or refill for non-preferred name brand drugs.
(Section 5 (f))
We now pay 80% of the cost of covered orthopedic and
prosthetic devices. (Section 5 (a)) We now pay 80% of the cost of covered
durable medical equipment (DME). (Section 5 (a))
We no longer have a
Non-FEHB page. 8
8 Page
9 10
2002 Paramount Health Care 9
Section 3
Section 3. What you must do to get covered care
Identification cards We will send you an identification (ID) card. You
should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a
prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health Benefits
Election Form, SF-2809, your health benefits enrollment confirmation
(for
annuitants), or your Employee Express confirmation letter.
If you do not receive your ID cards within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 419/ 887-2525
or 1-800/ 462-
3589.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, and/ or coinsurance, and you
will not have to file claims.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our members. We credential Plan
providers according to national
standards.
We list plan providers in the provider directory, which we update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in our provider directory,
which we update
periodically. This list is also on our website.
What you must do It depends on the type of care you need. First, you
and each family member must choose to get covered care a primary care
physician. This decision is important since your primary care physician
provides or arranges for most of your health care.
If you need
information about the qualifications of any participating physicians, you may
call the Academy of Medicine. You also can call any of the physician referral
services
listed in the Participating Physicians and Facilities
directory.
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 Your primary care physician will refer you to a
specialist for needed care. However, you do not need a referral for the
following: a visit to an OB/ GYN, have a routine eye exam,
are treated for
medical emergencies, or go to another doctor when a primary care physician has
designated another physician to see his or her patients. Referral to a
participating specialist is given at the primary care physician's
discretion; if non-Plan specialists or consultants are required, the primary
care physician will arrange
appropriate referrals. When you receive a
referral from your primary care physician, you must return to the primary care
physician after the consultation unless your physician
authorizes additional
visits. All follow-up care must be provided or authorized by the primary care
physician. Do not go to the specialist for a second visit unless your
primary care physician has arranged for, and the Plan has issued an
authorization for, the referral in advance. 9
9
Page 10 11
2002
Paramount Health Care 10 Section 3
Here are other things you
should know about specialty care:
If you need to see a specialist frequently
because of a chronic, complex, or serious medical condition, your primary care
physician will develop a treatment plan that
allows you to see your
specialist for a certain number of visits without additional referrals. Your
primary care physician will use our criteria when creating your
treatment
plan. Your PCP will consult with your specialist regarding a plan of treatment.
The specialist will send regular consultation reports to keep your PCP
advised of your progress. The PCP may authorize the referral for up to a
twelve (12) month period. Once this has been approved, you will receive a
"Referral
Confirmation." If further services are required beyond the twelve
(12) month period, you, your PCP and the specialist should agree to a new
treatment plan.
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment
you need. If he or
she decides to refer you to a specialist, ask if you can
see your current specialist. If your current specialist does not participate
with us, you must receive treatment from a
specialist who does. Generally,
we will not pay for you to see a specialist who does not participate with our
Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive services
from your current specialist until we can make
arrangements for you to see someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
--terminate our contract with your specialist for other than cause; or --drop
out of the Federal Employees Health Benefits (FEHB) Program and you enroll
in another 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 the necessary hospital
arrangements and supervise your care. This includes admission to a skilled
nursing or other
type of facility.
If you are in the hospital when your
enrollment in our Plan begins, call our Member Service Department immediately at
419/ 887-2525 or 800/ 462-3589. If you are new to the FEHB
Program, we will
arrange for you to receive care.
If you changed from another FEHB plan to
us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or The
day your benefits from your former plan run out; or
The 92nd day after you
became a member of this Plan, whichever happens first.
These provisions
apply only to the benefits of the hospitalized person. 10
10 Page 11 12
2002 Paramount Health Care 11 Section 3
Circumstances Under certain extraordinary circumstances, such as
natural disasters, we may have to delay beyond our your services or we
may be unable to provide them. In that case, we will make all reasonable
control efforts to provide you with the necessary care.
Services requiring Your primary care physician has authority to refer
you for most services. For certain services, our prior however, your
physician must obtain approval from us. Before giving approval, we consider
approval 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 the following services:
Growth Hormone
Treatment (GHT) Surgical treatment of morbid obesity
Transplant procedures
Sleep studies
Before giving approval, we consider if the service is medically necessary,
and if it follows generally accepted medical practice. A service is "medically
necessary" if: 1) It is needed to
prevent, diagnose and/ or treat a specific
condition; 2) It is specifically related to the condition being treated or
evaluated and; 3) It is provided in the most medically appropriate
setting;
that is, an outpatient setting must be used rather than a hospital or inpatient
facility, unless the services cannot be provided safely in an outpatient
setting. It is the responsibility
of the Plan physician or provider to
obtain authorization when required. 11
11 Page 12 13
2002 Paramount
Health Care 12 Section 4
Section 4. Your costs for covered
services
You must share in the cost of some services. You are
responsible for:
Copayments A copayment is a fixed amount of money
you pay to the provider when you receive services.
Example: When you see
your primary care physician you pay a copayment of $10 per office visit, and
when you see a specialist you pay a copayment of $20 per visit.
Deductible We do not have a deductible.
Note: If you change plans
during open season, you do not have to start a new deductible under your old
plan between January 1 and the effective date of your new plan. If you
change plans at another time during the year, you must begin a new
deductible under your new plan.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 20% of charges for
nicotine patches or other smoking deterrents, as well as for charges for durable
medical equipment and orthopedic and
prosthetic devices, and 30% of charges
for diagnosis and treatment of infertility.
Your catastrophic After your copayments and/ or coinsurance total
$1,500 per person or $3,000 per family protection out-of-pocket
enrollment in any calendar year, you do not have to pay any more for covered
services.
maximum for However, copayments and/ or coinsurance for the following
services do not count toward coinsurance and your out-of-pocket maximum
and you must continue to pay copayments and/ or
copayments
coinsurance for these services:
Prescription drugs Durable Medical
Equipment
Orthopedic and prosthetic devices Infertility services
Vision
Care Services Office visits
Emergency Care Urgent Care visits
Be sure to keep accurate records of your copayments and/ or coinsurance since
you are responsible for informing us when you reach the maximum. 12
12 Page 13 14
2002 Paramount Health Care 13 Section 5
Section 5. Benefits – OVERVIEW (See page 8 for how our
benefits changed this year and page 47 for a benefits summary.)
NOTE: This benefits section is divided into subsections.
Please read the important things you should keep in mind at the beginning of
each subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following
subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at 419/
887-2525
or 1-800/ 462-3589 or at our website at www. paramounthealthcare.
com.
(a) Medical services and supplies provided by physicians and other health
care professionals………………………… 14-21
i Diagnostic and treatment services
Speech therapy
i Lab, X-ray, and other diagnostic tests i Hearing services
(testing, treatment, and supplies)
i Preventive care, adult i Vision
services (testing, treatment, and supplies)
i Preventive care, children i
Foot care
i Maternity care i Orthopedic and prosthetic devices
i Family
Planning i Durable medical equipment (DME)
i Infertility services i Home
health services
i Allergy care i Chiropractic
i Treatment therapies i
Alternative treatments
i Physical and occupational therapies i Educational
classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals……………………… 22-24
i Surgical procedures i Oral and
maxillofacial surgery
i Reconstructive surgery i Organ/ tissue transplants
i Anesthesia
(c) Services provided by a hospital or other facility, and ambulance
services………………………………………….. 25-26
i Inpatient hospital i Extended care
benefits/ skilled nursing care
i Outpatient hospital or ambulatory facility
benefits
surgical facility i Hospice care i Ambulance
(d) Emergency services/ accidents………………………………………………………………………………………… 27-28
i Medical emergency i Ambulance
(e) Mental health and substance abuse benefits………………………………………………………………………………
29
(f) Prescription drug benefits……………………………………………………………………………………………. 30-31
(g) Dental benefits…………………………………………………………………………………………………………… 32
Summary
of benefits……..…………………………………………………………………………………………………… 47 13
13 Page 14 15
2002 Paramount Health Care 14 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits.
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary. Plan physicians must provide or
arrange your care.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about
coordinating benefits with other coverage, including 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 $10 per visit
to your primary care physician $20 per visit to a specialist
Professional services of physicians In an urgent care center
During a
hospital stay In a skilled nursing facility
Office medical consultations
Second surgical opinion
Nothing
At home $10 per visit by your primary care physician $20 per visit by a
specialist 14
14 Page
15 16
2002 Paramount Health Care
15 Section 5( a)
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
Nothing if you receive these services during your office visit: otherwise,
$10 per visit at your primary
care physician; $20 per visit at a specialist
Preventive care, adult
Annual routine vision exam Annual GYN exam
Total Blood Cholesterol – One annually Colorectal Cancer Screening
Prostate Specific Antigen (PSA) test – one annually Routine pap test
$10 per visit at your primary care physician $20 per visit at a specialist
Routine mammogram – covered for women age 35 and older, as follows:
From
age 35 through 39, one during this five year period From age 40 through 64, one
every calendar year
At age 65 and older, one every two consecutive calendar
years
$10 per visit at your primary care physician $20 per visit at a specialist
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, ages 19
and over (except as provided for under Childhood
immunizations) Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per visit 15
15 Page
16 17
2002 Paramount Health Care
16 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of
Pediatrics $10 per visit
Well-child care charges for routine examinations, immunizations and care (up
to age 22)
Examinations, such as: --Eye exams through age 17 to determine
the need for vision
correction. --Ear exams through age 17 to determine the
need for hearing
correction. --Examinations done on the day of immunizations
(up to age
22).
$10 per visit at your primary care physician $20 per visit at a specialist
Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery Postnatal care
Note: Here are some things to keep in mind:
You may remain in the
hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery. We will extend
you inpatient stay if medically necessary. 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)
Nothing
Not covered: Routing sonograms to determine fetal age, size or sex All
charges.
Family planning
A broad range of voluntary family
planning services, limited to Voluntary sterilization
Surgically implanted
contraceptives (such as Norplant) Injectable contraceptive devices (such as Depo
provera)
Intrauterine devices (IUDs) Diaphragms
NOTE: We cover oral contraceptives under the prescription drug benefit.
$10 per visit at your primary care physician $20 per visit at a specialist 16
16 Page 17 18
2002 Paramount Health Care 17 Section 5( a)
Family planning (Continued) You pay
Not
covered: reversal of voluntary surgical sterilization, genetic
counseling.
All charges.
Infertility services
Diagnosis and treatment of infertility, such
as: Artificial insemination:
--intrauterine insemination (IUI) Fertility
drugs administered in physician's office
30% of charges
Not covered:
Intracervical insemination (ICI)
Intravaginal insemination (IVI)
Assisted reproductive technology (ART) procedures, such as: --in vitro
fertilization
--embryo transfer, gamete GIFT and zygote ZIFT
--Zygote
transfer
Services and supplies related to excluded ART procedures Cost of
donor sperm
Cost of donor egg Self-administered fertility drugs
All charges.
Allergy care
Testing $25 per visit
Allergy injection $10 per visit at your primary care physician $20 per visit
at a specialist
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 17
17 Page 18 19
2002 Paramount Health Care 18 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants is limited to those transplants listed under
Organ/
Tissue Transplants on page xx.
Respiratory and inhalation therapy Dialysis –
Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy –
Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: -We
will only cover GHT when we preauthorize the treatment. The treatment must be
ordered by a Plan Endocrinologist. The
specialist must call our Utilization
Review department for prior authorization. If prior authorization is not
requested or if we determine
GHT is not medically necessary, we will not
cover the GHT or related services and supplies. See Services requiring our
prior approval in
Section 3.
$20 per visit
Physical and occupational therapies
30 visits combined per
condition for the services of each of the following:
--qualified physical
therapists and --occupational therapists.
. Note: We only cover therapy to
restore bodily function when there has
been a total or partial loss of
bodily function due to illness or injury.
$10 per visit
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction is covered at a Plan facility Nothing
Not covered:
long-term rehabilitative therapy exercise programs
All
charges.
Speech therapy
30 visits per condition for the services of
qualified speech therapists $10 per visit 18
18
Page 19 20
2002
Paramount Health Care 19 Section 5( a)
Hearing services
(testing, treatment, and supplies) You pay
First hearing aid and testing
only when necessitated by accidental injury $20 per visit
Hearing testing for children through age 17 (see Preventive care,
children) $10 per visit at your primary care physician $20 per visit at a
specialist
Not covered:
All other hearing testing
Hearing aids, testing and examinations for them, except as above.
All
charges.
Vision services (testing, treatment, and supplies)
Eye exam to
determine the need for vision correction for children through age 17 (see
Preventive care, children)
Annual eye refractions
$20 per visit
Not covered:
Eye exercises and orthoptics Corrective
lenses and frames
Radial keratotomy and other refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment
for a metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$20 per 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. 19
19 Page 20 21
2002 Paramount
Health Care 20 Section 5( a)
Orthopedic and prosthetic devices
You pay
Artificial limbs and lenses following cataract removal (only
initial prosthetic device required as a result of surgery)
Externally worn
breast prostheses and surgical bras, including necessary replacements, following
a mastectomy
Internal prosthetic devices, such as artificial joints,
pacemakers, and surgically implanted breast implant following mastectomy.
Note: See 5( b) for coverage of the surgery to insert the device. Corrective
orthopedic appliances for non-dental treatment of
temporomandibular joint
(TMJ) pain dysfunction syndrome.
20% of charges
Not covered:
Orthopedic and corrective shoes Arch
supports
Foot orthotics Heel pads and heel cups
Lumbosacral
supports and braces Corsets and trusses
The cost of a cochlear
implanted device The cost of a penile implanted device
Repair
and/ or replacement of Prosthetic devices
All charges.
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of durable medical equipment prescribed by your
Plan physician, such as
oxygen and dialysis equipment. Under this benefit,
we also cover:
Hospital beds; Standard wheelchairs;
Crutches; Walkers;
Ostomy supplies; Blood glucose monitors;
Lancets; Chem strips; and
Medical support hose
NOTE: We follow Medicare Part B Guidelines for DME
20% of charges
Not covered:
Exercise equipment Bite plates
Disposable medical supplies
Services not covered by Medicare
Part B
All charges. 20
20 Page 21 22
2002 Paramount
Health Care 21 Section 5( a)
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, medications,
physician services, skilled
nursing care, physical, occupation and other related therapies, supplies and
equipment.
Nothing
Not covered:
Nursing care requested by, or for the convenience
of, the patient or the patient's family;
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative;
Convalescent and custodial services.
All charges.
Chiropractic
No benefit All charges.
Alternative treatments
Not covered:
Naturopathic
services Acupuncture
Hypnotherapy Biofeedback
Massage therapy
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $300 for one smoking cessation program per member
per lifetime, including all related expenses
such as drugs.
20% of charges for nicotine patches or other smoking deterrents furnished on
a prescription
basis, if you have completed a smoking cessation class
approved by the Plan..
Diabetes self-management Nothing 21
21 Page 22 23
2002 Paramount
Health Care 22 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 PLAN DOCTOR MUST GET PRECERTIFICATION OF SOME SURGICAL
PROCEDURES. Please refer to the precertification information
shown in
Section 3 to be sure which services require precertification and identify which
surgeries require precertification.
I M
P O
R T
A N
T
Benefit Description You pay Surgical procedures
A comprehensive
range of services, such as: Operative procedures
Treatment of fractures,
including casting Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus Endoscopy procedures
Biopsy
procedures Removal of tumors and cysts
Correction of congenital anomalies
(see reconstructive surgery) Surgical treatment of morbid obesity – a condition
in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible members must
be
age 18 or over Insertion of internal prosthetic devices. See 5( a) – Orthopedic
and
prosthetic devices for device coverage information. Voluntary
sterilization
Treatment of burns
Note: Generally, we pay for internal
prostheses (devices) according to where the procedure is done. For example, we
pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of
the pacemaker.
$20 per office visit; nothing for hospital visits
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care All charges. 22
22 Page 23 24
2002 Paramount Health Care 23 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a
functional defect Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the
condition can reasonably be expected to be corrected by such
surgery Surgery
to correct a condition that existed at or from birth and is a
significant
deviation from the common form or norm. Examples of congenital anomalies are:
protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed
fingers; and webbed toes. 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.
$20 per office visit; nothing for hospital visits
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges.
Oral and maxillofacial surgery
Oral surgical procedures, limited
to: Reduction of fractures of the jaws or facial bones;
Surgical correction
of cleft lip, cleft palate or severe functional malocclusion;
Removal of
stones from salivary ducts; Excision of leukoplakia or malignancies;
.
Excision of cysts and incision of abscesses when done as independent procedures;
and
Other surgical procedures that do not involve the teeth or their
supporting structures.
$20 per office visit; nothing for hospital visits
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. 23
23 Page 24 25
2002 Paramount
Health Care 24 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Bowel 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
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
$20 per office visit to evaluate the need for a transplant; nothing for
hospital visits
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs Transplants not listed as covered
All charges.
Anesthesia
Professional services provided in – Hospital
(inpatient) Nothing
Professional services provided in - Hospital outpatient department
Skilled nursing facility Ambulatory surgical center
Office
$20 per visit 24
24 Page
25 26
2002 Paramount Health Care
25 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 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 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 care. Any costs
associated with the professional charge (i. e., physicians, etc.) are
covered in Sections 5 (a) or (b).
I M
P O
R T
A N
T
Benefit Description You pay Inpatient hospital
Room and board,
such as Ward, semiprivate, or intensive care accommodations;
General nursing
care; and Meals and special diets.
Note: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Other hospital
services and supplies, such as: Operating , recovery, maternity, and other
treatment rooms
Prescribed drugs and medicines Diagnostic laboratory tests
and X-rays
Administration of blood and blood products Blood or blood plasma,
if not donated or replaced
Dressings, splints, casts, and sterile tray
services Medical supplies and equipment, including oxygen
Anesthetics,
including nurse anesthetist services Take-home items
Medical supplies,
appliances, medical equipment, and any covered items billed by a hospital for
use at home
Nothing
Not covered:
Custodial care Non-covered facilities, such
as nursing homes, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges. 25
25 Page 26 27
2002 Paramount
Health Care 26 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 or blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including
oxygen
Anesthetics and anesthesia service
NOTE: -We cover hospital
services and supplies related to dental procedures when necessitated by a
non-dental physical
impairment. We do not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/ skilled nursing care facility
benefits
Extended care benefit: We provide a comprehensive range of benefits for up to
100 days per calendar year when full-time skilled nursing care
is necessary
and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan physician and approved by the
Plan.
Nothing
Not covered: custodial care All charges.
Hospice care
Supportive and palliative care for a terminally ill member is covered in
the home or hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the direction
of a Plan physician who certifies that the patient is in the
terminal stages
of illness, with a life expectancy of approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically
appropriate Nothing 26
26 Page
27 28
2002 Paramount Health Care
27 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits.
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency? A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or
could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are
emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken
bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings,
gunshot
wounds, or sudden inability to breathe. There are many other acute conditions
that the Plan may determine are
medical emergencies --what they all have in
common is the need for quick action.
What to do in case of emergency: Call your Primary Care Physician
first, unless you believe the situation to be life-threatening. Follow the
doctor's instructions.
Emergencies within our service area: If you are in an emergency
situation, please call your primary care physician. In extreme emergencies, if
you are unable to
contact your physician, contact the local emergency system
(e. g., the 911 telephone system) or go to the nearest hospital emergency room.
Be sure to tell the emergency room personnel that you are a Plan member so they
can notify the Plan. You
or a family member should notify the Plan unless it
was not reasonably possible to do so. It is your responsibility to ensure that
the Plan has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 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-Plan providers in a medical
emergency only if delay in reaching a Plan provider would result in death,
disability or significant jeopardy to your condition.
To be covered by this
Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or
provided by Plan providers.
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, you or a family member must notify the Plan within 48 hours or on
the first
working day following your admission, unless it was not reasonably
possible to do so. If a Plan physician believes care can be better provided in a
Plan hospital, you will be transferred when medically feasible with any
ambulance charges covered in
full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or
provided by Plan providers. 27
27 Page 28 29
2002 Paramount Health Care 28 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a
hospital,
including doctors' services
$10 per visit at your primary care physician
$20 per visit at a
specialist
$25 per visit
$50 per visit, waived if admitted to a hospital
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office
Emergency care at an urgent care center
Emergency care
as an outpatient or inpatient at a
hospital, including doctors' services
$10 per visit at your primary care physician
$20 per visit at a
specialist
$25 per visit
$50 per visit, waived if admitted to a hospital
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the
need for
care could have been foreseen before leaving
the service area
Medical and hospital costs resulting from a normal full-term
delivery
of a baby outside the service area
All charges.
Ambulance
Professional ambulance service, including air ambulance,
when medically appropriate
See 5 (c) for non-emergency service.
Nothing 28
28 Page
29 30
2002 Paramount Health Care
29 Section 5( e)
Section 5 (e). Mental health and substance
abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost-sharing and limitations for Plan mental health and substance abuse
benefits will be no
greater than for similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about
these benefits:
All benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about
coordinating benefits with other
coverage, including with Medicare. YOU MUST GET PREAUTHORIZATION OF THESE
SERVICES. See
the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay Mental health and substance abuse benefits
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 illnesses or
conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists,
or clinical social workers Medication
management
Diagnostic tests
$20 per visit
Services provided by a hospital or other facility Services in approved
alternative care settings such as
partial hospitalization, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment
plans on the treatment plan's clinical
appropriateness.
OPM will generally not order us to pay or provide one
clinically appropriate treatment plan in favor of another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
!!"
# $
! $!"% # %
&
# ! '() *
+ ,-.*//01,% 1 /*/.-12
Limitation We may limit your benefits if you do not obtain a treatment
plan. 29
29 Page
30 31
2002 Paramount Health Care
30 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations, and exclusions in
this brochure and are payable only when we determine they are medically
necessary.
Be sure to read Section 4, Your costs for covered services,
for valuable information about how cost sharing works. Also read Section 9
about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A Plan physician or licensed dentist
must write the prescription.
Where you can obtain them. You must fill
the prescription at a Plan pharmacy.
We use a preferred drug list. In
the wake of dramatic increases in drug costs, employer groups, physicians and
members challenged us to develop an innovative prescription drug benefit that
helps reduce drug benefit costs while maintaining
physicians' freedom to select the most appropriate drugs. In response to this
request, we have introduced the Three-Tier Preferred Drug prescription
benefit with the following copay structure:
Generic drugs at the lowest copay -$5 Preferred name brand drugs at a
mid-level copay -$15
Non-preferred name brand drugs at the highest copay
-$25
When generic pharmaceuticals are used, you are assured the lowest
copay. A preferred name brand drug is a name brand drug found on the Paramount
Health Care Preferred Drug List. Preferred drugs are selected name brand
medications that
are periodically reviewed and updated by a committee of
physicians, pharmacists and other allied health professionals (Pharmacy and
Therapeutics Working Group) to ensure the highest level of clinical efficacy and
cost effectiveness. Non-preferred
name brand medications are also covered
(subject to any benefit limits), but at a higher copay. To order a preferred
prescription drug list, call 1-800/ 462-3589 or 419/ 887-2525.
These are the dispensing limitations. Prescription drugs obtained at a
Plan pharmacy will be dispensed for up to a 30-day supply. Specific maintenance
legend drugs may be dispensed for up to a 30-day supply or 100-unit
supply,
whichever is greater. The maintenance list is reviewed periodically, and the
Plan reserves the right to change the maintenance list. When generic
substitution is permissible (i. e., a generic drug is available and the
prescribing doctor does not require the use of a name brand drug), but you
request the name brand drug, you pay the price difference between the generic
and name brand drug, as well as the applicable copay. A generic
equivalent
will be dispensed, unless the prescribing physician has specified on the
prescription, "Dispense as Written" or "DAW."
Why use generic drugs? Generic drugs offer a safe and economic way to
meet your prescription drug needs. The generic name of a drug is its chemical
name; the name brand is the name under which the manufacturer advertises
and
sells a drug. Under federal law, generic and name brand drugs must meet the same
standards for safety, purity, strength, and effectiveness. You can save money by
using generic drugs. However, you and your physician have
the option to
request a name brand if a generic option is available. Using the most
cost-effective medication saves money.
When you have to file a claim. Send your claim to Paramount Health
Care, P. O. Box 928, Toledo, OH 43697. 30
30
Page 31 32
2002
Paramount Health Care 31 Section 5( f)
Benefit Description You
pay Covered medications and supplies
We cover the following medications
and supplies prescribed by a Plan physician and obtained from a Plan pharmacy:
. Drugs and medicines that by State law or Federal law of the United States
require a physician's prescription for their purchase, except
those listed
as Not covered.
Insulin; a copay charge applies to each 30 day supply
Disposable needles and syringes for the administration of covered
medications, including insulin
Oral contraceptive drugs Sexual
dysfunction drugs are subject to dosage limits set by the
Plan. Contact the Plan for details.
For up to a 30-day supply:
A $5 copay per prescription unit or refill for
generic drugs;
A $15 copay per prescription unit or refill for preferred name brand drugs;
and
A $25 copay per prescription unit or refill for non-preferred name brand
drugs.
Note: If there is no generic equivalent available, you will still
have to pay the name brand copay.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs available without a prescription or for which there is a
nonprescription equivalent available
Drugs obtained at a non-Plan
pharmacy except for out-of-area emergencies
Vitamins and nutritional substances that can be purchased without a
prescription
Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Fertility drugs, except
those administered in a doctor's office (See Section 5( a)— Infertility
services)
Growth Hormones
All charges. 31
31 Page 32 33
2002 Paramount
Health Care 32 Section 5( g)
Section 5 (g). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are
medically necessary.
We cover hospitalization for
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. Treatment
must be received within 48 hours of the accident, unless the member's medical
condition indicates
the dental care must be delayed.
Nothing
Dental benefits
We have no other dental benefits. 32
32 Page 33 34
2002 Paramount Health Care 33 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it unless your Plan physician
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease,
injury, or condition and we agree, as discussed under
What Services Require Our Prior Approval on page 11.
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. 33
33 Page 34 35
2002 Paramount Health Care 34 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or fill your
prescription drugs at Plan pharmacies, you will not have to file claims. Just
present your identification card and pay your copayment, or coinsurance.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes, these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, hospital In most cases, providers and facilities file claims
for you. Physicians must file on and drug benefits the form HCFA-1500,
Health Insurance Claim Form. Facilities will file on the
UB-92 form. For
claims questions and assistance, call us at 419/ 887-2525 or 1-800/ 462-3589.
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: Paramount Health Care Claims Department, P. O. Box
928, Toledo, OH 43697.
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. 34
34 Page
35 36
2002 Paramount Health Care
35 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for services,
drugs, or supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial
decision. You must:
(a) Write to us within 6 months from the date of our
decision; and (b) Send your request to us at: Paramount Health Care Claims
Department, P. O. Box 928, Toledo, OH 43697.
(c) Include a statement about
why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that
support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to:
(a)
Pay the claim (or, if applicable, arrange for the health care provider to give
you the care); or (b) Write to you and maintain our denial – go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request – go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within: 90 days after the date of our letter upholding
our initial decision; or
120 days after you first wrote to us – if we did not answer that request in
some way within 30 days; or 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW, Washington, DC 20415-3630
Send OPM the following information:
. A statement about why you believe
our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim; Copies of all letters
we sent to you about the claim; and
Your daytime phone number and the best
time to call.
Note: If you want OPM to review different claims, you must
clearly identify which documents apply to which claim.
Note: You are the
only person who has a right to file a disputed claim with OPM. Parties acting as
your representative, such as medical providers, must include a copy of your
specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons beyond your control. 35
35 Page 36 37
2002 Paramount Health Care 36 Section 8
The Disputed Claims process (Continued)
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 419/ 887-2525 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited treatment too, or
You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 36
36
Page 37 38
2002
Paramount Health Care 37 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other You must tell us if you
are covered or a family member is covered under another group health coverage
health plan or have automobile insurance that pays health care expenses
without regard to
fault. This is called "double coverage."
When you have
double coverage, one plan normally pays its benefits in full as the primary
payer and the other plan pays a reduced benefit as the secondary payer. We, like
other
insurers, determine which coverage is primary according to the
National Association of Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up to
our regular benefit. We will not pay
more than our allowance.
What is
Medicare? Medicare is a Health Insurance Program for:
People 65 years of
age and older. Some people with disabilities, under 65 years of age.
People
with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to
qualify for premium-free
Part A insurance. (Someone who was a Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if you are age 65 or older, you
may be able to buy it. Contact 1-800-MEDICARE for more information. Part B
(Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or your
retirement check.
If you are eligible for Medicare, you may have choices in
how you get your health care. Medicare managed care plan is the term used to
describe the various health plan choices
available to Medicare
beneficiaries. The information in the next few pages shows how we coordinate
benefits with Medicare, depending on the type of Medicare managed care plan
you have.
The Original Medicare Plan The Original Medicare Plan
(Original Medicare) is available everywhere in (Part A or Part B) the
United States. It is the way everyone used to get Medicare benefits and is the
way most
people get their Medicare Part A and Part B benefits now. You may
go to any doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and
you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow the rules in this brochure for us to cover your care. Your care
must continue to be
authorized by your Plan PCP.
We will not waive any
of our copayments or coinsurance.
(Primary payer chart begins on next
page). 37
37 Page
38 39
2002 Paramount Health Care
38 Section 9
The following chart illustrates whether the
Original Medicare Plan or this Plan should be the primary payer for you
according to your employment status and other factors determined by Medicare. It
is crucial 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),
2) Are an annuitant, 3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or b) The position
is not excluded from FEHB
(Ask your employing office which of these applies
to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your covered
spouse is
this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B services) (for other
services) 6) Are a former Federal
employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are unable
to return to duty,
(except for claims related to Worker's
Compensation) B. When you – or a covered family member – have Medicare
based on end stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A benefits
solely because of ESRD,
2) Have completed the 30-month ESRD
coordination period and are still eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary
for you under another provision.
C. When you or a covered family
member have FEHB and… 1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an
annuitant, or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare.
Claims process when you have the
Original Medicare Plan – You probably will never have to file a claim form
when you have both our Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first. When Original
Medicare is the primary payer, Medicare processes the 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
419/ 887-2525 or
800/ 462-3589 or visit our website at www. paramounthealthcare. com. 38
38 Page 39 40
2002 Paramount Health Care 39 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 HMO's) in some areas of the country. In most Medicare managed care
plans, you can only go to doctors, specialists, or
hospitals that are part
of the plan. Medicare managed care plans provide all the benefits that Original
Medicare covers. Some cover extras, like prescription drugs.
To learn more
about enrolling in a Medicare managed care plan, contact Medicare at
1-800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In this
case, we do
not waive any of our copayments or coinsurance for your FEHB
coverage.
This Plan and another plan's Medicare managed care plan:
You may enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB
plan. We will still provide benefits when your Medicare
managed care plan is primary, even out of the managed care plan's network and/
or service area (if you use
our Plan providers), but we will not waive any
of our copayments or coinsurance. If you enroll in a Medicare managed care plan,
tell us. We will need to know whether
you are in the Original Medicare Plan
or in a Medicare managed care plan so we can correctly coordinate benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB coverage and
enroll
in a Medicare managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your Medicare managed care plan premium.) For information
on
suspending your FEHB enrollment, contact your retirement office. If you
later want to re-enroll in the FEHB Program, generally you may do so only at the
next open
season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area.
If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered under the Medicare Part A or FEHB
Program. We will not require you to enroll in Medicare Part B and, if you
Part B 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 determine they
must provide; or
OWCP or a similar agency pays for through a third party
injury settlement or other similar proceeding that is based on a claim you filed
under OWCP or
similar laws.
Once OWCP or similar agency pays its maximum
benefits for your treatment, we will cover your care. You must use our
providers. 39
39 Page
40 41
2002 Paramount Health Care
40 Section 9
Medicaid When you have this Plan and
Medicaid, we pay first.
When other Government agencies We do not
cover services and supplies when a local, State, or Federal are responsible
for your care Government agency directly or indirectly pays for them.
When others are When you receive money to compensate you for medical
or hospital care responsible for for injuries or illness caused by
another person, you must reimburse us for any
injuries 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. 40
40 Page
41 42
2002 Paramount Health Care
41 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on December 31 of the same
year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this
brochure.
Experimental or Paramount investigates all requests for
coverage of new technology using the HAYES investigational Medical
Technology Directory as a guide. If further information is needed, Paramount
services utilizes additional sources including Medicare and Medicaid
policy, Food and Drug Administration (FDA) releases and current medical
literature. This information is evaluated
by Paramount's Medical Director
and other physician advisors.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in different ways. We determine our
allowances as follows: base
Plan allowance on the reasonable and customary charge. Plan providers accept the
plan allowance as payment in full .
Us/ We Us and we refer to Paramount Health Care.
You You
refers to the enrollee and each covered family member. 41
41 Page 42 43
2002 Paramount Health Care 42 Section 11
Section 11. FEHB Facts
No pre-existing We will not refuse to
cover the treatment of a condition that you had before you enrolled in this
condition limitation Plan solely because you had the condition before you
enrolled.
Where you can get See www. opm. gov/ insure. Also, your employing or
retirement office can answer your information about questions, and give
you a Guide to Federal Employees Health Benefits Plans, brochures for
enrolling in the other plans, and other materials you need to make an
informed decision about: FEHB Program
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 The next Open Season for
enrollment.
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 Self only coverage is for you alone. Self and Family
coverage is for you, your spouse, and available for you your unmarried
dependent children under age 22, including any foster children or stepchildren
and your family your employing or retirement office authorizes
coverage for. Under certain circumstances, you may also continue coverage for a
disabled child 22 years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60
days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to Self and
Family because you marry, the change is effective on the first day of the
pay period that begins after your employing office receives your enrollment
form; benefits will not be available to your
spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or
remove family members from your coverage
for any reason, including divorce, or when your child under age 22 marries or
turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another FEHB
plan.
When The benefits in this brochure are effective on January 1. If you
joined this Plan during Open benefits and Season, your coverage and
premiums begin on the first day of your first pay period that starts
premiums start on or after January 1. Annuitants' coverage and
premiums begin January 1. If you joined at any other time during the year, your
employing office will tell you the effective date of coverage. 42
42 Page 43 44
2002 Paramount Health Care 43 Section 11
Your medical and We will keep your medical and claims information
confidential. Only the following will have claims records are access to
it:
confidential 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 When you retire, you can usually stay in the FEHB Program.
Generally, you must have been retire 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 You will receive an
additional 31 days of coverage, for no additional premium, when: coverage
ends Your enrollment ends, unless you cancel your enrollment, or
You are
a family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not continue to get benefits coverage under your
former spouse's enrollment. But, you may be eligible for your own FEHB coverage
under the spouse equity law. If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's employing or retirement office
to get RI 70-5, the Guide to Federal Employees
Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or
other
information about your coverage choices.
Temporary If you leave Federal service, or if you lose coverage
because you no longer qualify as a family Continuation of member, you may
be eligible for Temporary Continuation of Coverage (TCC). For example,
Coverage (TCC) you can receive TCC if you are not able to continue
your FEHB enrollment after you retire, if you lose your job, if you are a
covered dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former
Spouse Enrollees, from
your employing or retirement office or from www. opm. gov/ insure. It
explains what you have to do to enroll. 43
43
Page 44 45
2002
Paramount Health Care 44 Section 11
Converting You may
convert to a non-FEHB individual policy if: to 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 The Health Insurance Portability and Accountability Act of
1996 (HIPAA) is a Federal law that Certificate of offers limited Federal
protections for health coverage availability and continuity to people who
Group Health lose employer group coverage. If you leave the FEHB
Program, we will give you a Certificate of Plan Coverage 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 RI79-27, 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 questions. These highlight HIPAA rules, such as
the requirement that Federal employees must exhaust any TCC eligibility as
one condition for guaranteed access to individual health coverage under HIPAA,
and have information about
Federal and State agencies you can contact for
more information. 44
44 Page
45 46
2002 Paramount Health Care
45 Long Term Care Insurance
Long Term Care Insurance Is Coming
Later in 2002!
Many FEHB enrollees think that their health plan and/ or
Medicare will cover their long-term care needs. Unfortunately, they are
WRONG!
How are YOU planning to pay for the future custodial or
chronic care you may need?
You should consider buying long-term care
insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality
long-term care insurance program effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is long term care It's insurance to help pay for long term care
services you may need if you can't take care of (LTC) insurance? yourself
because of an extended illness or injury, or an age-related disease such as
Alzheimer's. LTC insurance can provide broad, flexible benefits for nursing
home care, care in an
assisted living facility, care in your home, adult day
care, hospice care, and more. LTC insurance can supplement care provided by
family members, reducing the burden you
place on them.
I'm healthy, I won't Welcome to the club! need long term care.
76% of Americans believe they will never need long term care, but the facts
are that about
Or, will I? half of them will. And it's not just the
old folks. About 40% of people needing long term care are under age 65. They may
need chronic care due to a serious accident, a stroke, or
developing
multiple sclerosis, etc. We hope you will never need long term care, but
everyone should have a plan just in case.
Many people now consider long
term care insurance to be vital to their financial and
retirement planning.
Is long term care Yes, it can be very expansive. A year in a nursing
home can exceed $50,000. Home care expensive? for only three 8-hour
shifts a week can exceed $20,000 a year. And that's before inflation!
Long
term care can easily exhaust your savings. Long term care insurance can
protect your savings.
But won't my FEHB Not FEHB. Look at the "Not covered" blocks in
sections 5( a) and 5( c) of your FEHB Plan, Medicare or brochure. Health
plans don't cover custodial care or a stay in an assisted living facility
Medicaid cover my or a continuing need for a home health aide to help
you get in and out of bed and with long term care? other activities of
daily living. Limited stays in skilled nursing facilities can be covered in
some circumstances. Medicare only covers skilled nursing home care (the
highest level of nursing care) after a
hospitalization for those who are
blind, age 65 or older or fully disabled. It also has a 100 day limit.
Medicaid covers long term care for those who meet their state's poverty
guidelines, but has restrictions on covered services and where they can be
received. Long term care insurance
can provide choices of care and
preserve your independence.
When will I get more Employees will get more information from their
agencies during the LTC open enrollment information on how to period in
the late summer/ early fall of 2002.
apply for this new Retirees will
receive information at home. insurance coverage?
How can I find out more Our toll-free teleservice center will begin
mid-2002. In the meantime, you can learn more
about the program NOW?
about the program on our web site at www. opm. gov/ insure/ ltc. 45
45 Page 46 47
2002 Paramount Health Care 46 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury
48 Inhospital physician care 25 Radiation therapies 18 Allergy tests 17
Inpatient hospital benefits 25 Room and board 25
Allogeneic (donor) bone
marrow Insulin 31 Second surgical opinion 14 Transplant 24 Laboratory
and pathological services 26 Skilled nursing facility care 26
Alternative treatment 13 Machine diagnostic tests 15 Smoking
cessation 21 Ambulance 25 Magnetic Resonance Imagings (MRIs) 15 Speech therapy
18
Anesthesia 26 Mammograms 15 Splints 20 Autologous bone marrow transplant
24 Maternity Benefits 16 Sterilization procedures 16
Benefits 13
Medicaid 40 Subrogation 40 Biopsies 22 Medically necessary 11 Substance abuse 29
Blood and blood plasma 26 Medicare 38 Surgery Breast cancer screening 24
Mental Conditions/ Substance Anesthesia 22
Casts 25 Abuse Benefits 29
Oral 23 Changes for 2002 8 Newborn care 16 Outpatient 26
Chemotherapy
18 Nurse Reconstructive 23 Childbirth 16 Licensed Practical Nurse 21 Syringes 20
Cholesterol tests 15 Registered Nurse 21 Temporary continuation of
coverage 43 Claims 35 Nursery charges 16 Transplants 24
Coinsurance 12
Obstetrical care 16 Treatment therapies 18 Colorectal cancer screening 15
Occupational therapy18 Vision services 16
Contraceptive devices and
drugs 16 Office visits 15 Well child care 16 Coordination of benefits 37
Oral and maxillofacial surgery 23 Wheelchairs 20
Covered charges 38
Orthopedic devices 20 Workers' compensation 39 Covered providers 6 Ostomy and
catheter supplies 20 X-rays 15
Crutches 20 Out-of-pocket expenses 12
Deductible 12 Outpatient facility care 26
Definitions 41 Oxygen 20
Dental care 32 Pap test 15
Diagnostic services 14 Physical
examination 6 Disputed claims review 35 Physical therapy 18
Donor expenses
(transplants) 17 Physician 14 Dressings 25 Pre-admission testing 25
Durable
Medical Equipment (DME) 20 Precertification 22 Educational classes and
programs 21 Prescription drugs 40
Effective date of enrollment 42 Preventive
care, adult 15 Emergency 27 Preventive care, children 16
Experimental or
investigational 41 Preventive services 15 Eyeglasses 16 Prior approval 11
Family planning 16 Prostate cancer screening 15 Fecal occult blood
test 15 Prosthetic devices 20
General exclusions 33 Psychologist 29
Hearing services 19
Home health services 21 Home nursing care 21
Hospice care 26 Hospital 10
Immunizations 15 Infertility 17 46
46 Page 47 48
2002 Paramount Health Care 47 Index
Summary of benefits for Paramount Health Care – 2002
Do
not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the definitions, limitations, and exclusions in
this brochure. On this page we summarize specific expenses we cover; for more
detail,
look inside.
If you want to enroll or change your enrollment in
this Plan, be sure to put the correct enrollment code from the cover on your
enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by
physicians:
Diagnostic and treatment services provided in the
office.............. Office visit copay: $10 primary care; $20 specialist 14
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
..........................................................................
Nothing
Nothing
25
26
Emergency benefits:
In-area..............................................................................................
Out-of-area
........................................................................
$50 per visit
$50 per visit
28
28
Mental health and substance abuse
treatment...................................... Regular cost sharing 29
Prescription drugs
.................................................................................
Up to a 30-day supply per prescription unit or refill
$5 copay for
generic drugs
$15 copay for preferred name brand drugs
$25 copay for non-preferred name brand drugs
30
Dental Care
.......................................................................................
Accidental injury benefit only
Nothing 32
Vision Care
.......................................................................................
Annual eye refractions from Plan providers
$10 copay per visit 19
Protection against catastrophic costs (your out-of-pocket
maximum)......................................................... Nothing
after $1,500/ Self Only or $3,000/ Family enrollment per year
Some costs do
not count toward this protection
12 47
47
Page 48
2002 Paramount Health Care
48 Rates
2002 Rate Information for
PARAMOUNT HEALTH CARE
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits
enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and special
FEHB guides are published for
Postal Service Nurses, RI 70-2B; and for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization who are not career postal
employees. Refer to the applicable FEHB
Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only U21 $97.31 $32.44 $210.85 $70.28 $115.15 $14.60
Self and
Family U22 $223.41 $120.62 $484.06 $261.34 $263.75 $80.28 48