HealthPlus of Michigan http:// www.
healthplus. com
2002 A Health Maintenance Organization
Serving: Greater Flint and Saginaw areas
Enrollment in
this Plan is limited. You must live in our geographic service area to enroll.
See page 7 for requirements.
Enrollment codes for this Plan:
X51 Self Only X52 Self and Family
RI 73-648
Commercial
This Plan has Excellent accreditation
from the NCQA.
See the 2002 Guide
for more information on accreditation.
For changes
in benefits,
see page 8. 1
1 Page 2 3
2002 HealthPlus of Michigan 2 Table of Contents
Table of
Contents
Introduction....................................................................................................................................................................
4
Plain Language
..............................................................................................................................................................
4
Inspector General Advisory
...........................................................................................................................................
5
Section 1. Facts about this HMO
plan....................................................................................................................
6
How we pay providers
...........................................................................................................................
6
Who provides my healthcare?
...............................................................................................................
6
Your Rights
............................................................................................................................................
7
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
c Plan
providers..................................................................................................................................
9
c Plan facilities
...................................................................................................................................
9
What you must do to get covered care
..................................................................................................
9
c Primary care
..................................................................................................................................
10
c Specialty care
................................................................................................................................
10
c Hospital
care..................................................................................................................................
11
Circumstances beyond our control
......................................................................................................
11
Services requiring our prior approval
..................................................................................................
11
Section 4. Your costs for covered services
...........................................................................................................
12
c
Copayments...................................................................................................................................
12
c Deductible
.....................................................................................................................................
12
c
Coinsurance...................................................................................................................................
12
Your out-of-pocket
maximum..............................................................................................................
12
Section 5.
Benefits........................................................
13
Overview..............................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals ....... 14
(b) Surgical and anesthesia services provided
by physicians and other health care professionals.... 23
(c) Services
provided by a hospital or other facility, and ambulance services
.................................. 27
(d) Emergency services/
accidents.......................................................................................................
30
(e) Mental health and substance abuse benefits
.................................................................................
32
(f) Prescription drug benefits
..............................................................................................................
33 2
2 Page 3 4
2002 HealthPlus of Michigan 3 Table of Contents
(g) Special
features
.............................................................................................................................
37
c NCQA "Excellent" Accreditation c High risk pregnancies
........................................................ 37
c Centers of
Excellence for transplants, heart surgery,
etc.............................................................. 37
c
HealthQuest and Health Resource Library
...................................................................................
37
c College students c Flexible benefits
option.................................................................................
37
(h) Dental benefits
..............................................................................................................................
38
Section 6. General exclusions things we don't cover
......................................................................................
39
Section 7. Filing a claim for covered
services......................................................................................................
40
Section 8. The disputed claims process
................................................................................................................
41
Section 9. Coordinating benefits with other
coverage..........................................................................................
43
When you have
c Other health coverage
...................................................................................................................
43
c Original Medicare
.........................................................................................................................
43
c Medicare managed care plan
........................................................................................................
45
TRICARE/ Workers' Compensation/ Medicaid
....................................................................................
46
Other Government
agencies.................................................................................................................
46
When others are responsible for injuries
.............................................................................................
46
Section 10. Definitions of terms we use in this
brochure.......................................................................................
47
Section 11. FEHB
facts...........................................................................................................................................
51
Coverage information
..........................................................................................................................
51
c No pre-existing condition limitation
.............................................................................................
51
c Where you get information about enrolling in the FEHB Program
............................................. 51
c Types of coverage
available for you and your
family................................................................... 51
c When benefits and premiums
start................................................................................................
52
c Your medical and claims records are confidential
........................................................................ 52
c When you
retire.............................................................................................................................
52
c When you lose benefits
.................................................................................................................
52
c When FEHB coverage ends
..........................................................................................................
52
c Spouse equity
coverage.................................................................................................................
52
c Temporary Continuation of Coverage (TCC)
...............................................................................
52
c Converting to individual coverage
................................................................................................
53
c Getting a Certificate of Group Health Plan Coverage
.................................................................. 53
Long term care insurance is coming later in 2002
......................................................................................................
54
Index
............................................................................................................................................................................
55
Summary of benefits
....................................................................................................................................................
59
Rates...............................................................................................................................................................
Back cover 3
3 Page
4 5
2002 HealthPlus of Michigan 4
Introduction/ Plain Language
Introduction
HealthPlus of
Michigan, Inc.
2050 South Linden Road
P. O. Box 1700
Flint, MI
48501-1700
This brochure describes the benefits of HealthPlus of Michigan under our
contract (CS 2712) with the Office of
Personnel Management (OPM), as
authorized by the Federal Employees Health Benefits law. This brochure is the
official statement of benefits. No oral statement can modify or otherwise
affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for
Self and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to
benefits that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and
changes are summarized on page 8. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible,
and
understandable to the public. For instance,
c Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family
member; "we" means HealthPlus of
Michigan.
c 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.
c Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help ;you
compare plans.
If you have comments or suggestions about how to improve the structure of
this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www.
opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You
may also
write to OPM at the Office of Personnel Management, Office of Insurance Planning
and Evaluation
Division, 1900 E Street, NW, Washington, DC 20415-3650. 4
4 Page 5 6
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:
c Call the provider and ask for an explanation. There may be an error.
c
If the provider does not resolve the matter, call us at (800) 332-9161 and
explain the situation.
c If we do not resolve the issue, call or write:
THE HEALTH CARE FRAUD
HOTLINE
202/ 418-3300
The United States Office of Personnel
Management
Office of the Inspector General Fraud Hotline
1900 E Street,
NW, Room 6400
Washington, DC 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone
who uses an ID card if the person tries to obtain
services for someone who
is not an eligible family member, or is no longer
enrolled in the Plan and
tries to obtain benefits. Your agency may also take
administrative action
against you.
2002 HealthPlus of Michigan 5 Inspector General 5
5 Page 6 7
2002 HealthPlus of Michigan 6 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and
other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations,
in addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only
pay the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency
services
from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is
available. You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one
physician,
hospital, or other provider will be available and/ or remain under contract with
us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure.
These Plan providers accept a negotiated payment from us, and you will only
be responsible for your copayments.
Who provides my healthcare
Each family member that is covered by
HealthPlus must choose a Primary Care Physician from the Provider
Directory
(parents are expected to select for their children). This list includes more
than 1,000 doctors who
specialize in Family Practice, Internal Medicine, or
Pediatrics. The listing for each Primary Care Physician also
shows a
"primary hospital." This is the hospital where your Primary Care Physician will
direct you for hospital
services in most instances. When you select a
Primary Care Physician, you also are agreeing to use the hospital
listed.
The Primary Care Physician you choose will coordinate your overall medical
care, including arranging for hospital
admissions or care by a specialist
when medically necessary with the following exception: a woman may see her
Plan gynecologist for her annual routine examination without a referral.
HealthPlus strives to keep the Provider Directory as up-to-date as possible.
However, information may change
after the Directory has been printed. If the
physician you select is no longer accepting patients, please select
another.
You may want to call the physician you have chosen prior to calling the
HealthPlus Customer Department
at (800) 332-9161 with your selection. You
must notify HealthPlus before receiving covered services from the new
Primary Care Physician. 6
6 Page 7 8
Your Rights
OPM requires that all FEHB Plans provide certain information to their
FEHB members. You may get information
about us, our networks, providers, and
facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the
required information is listed below.
c HealthPlus service area
c HealthPlus Subscriber Contract
Covered
benefits, including prescription drug coverage
Description of emergency
health coverages and benefits
Out-of-area coverage and benefits
An
explanation for copayments and any other out-of-pocket expense
c Continuity of treatment
Arrange for the continuation of treatment by
that provider; or
Assist the member in selecting a new provider
c Additional information
Provider information
Physician
credentials
Physician status/ discipline
Specific benefits
Financial arrangement with physicians
Who to contact
c Years in existence
c Profit status
If you want more information about us, call (800) 332-9161, or write to our
Customer Service Department at:
2050 South Linden Road, P. O. Box 1700,
Flint Michigan 48501-1700 . You may also contact us by fax at
(810) 230-2093
or visit our website at www. healthplus. com.
Service Area
To enroll in this plan, you must live in our Service
Area. This is where our providers practice.
Our service area is: All of
Arenac (except Moffat and Clayton Township), Bay, Genesee, Lapeer, Livingston,
Saginaw, Shiawassee, and Tuscola Counties in Michigan.
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 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, you should
consider enrolling in a fee-for-service plan or an HMO that has
agreements
with affiliates in other areas. Eligible college students are covered for
emergency illnesses or injuries
that occur when they are out of the service
area. 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.
2002 HealthPlus of Michigan 7 Section 1 7
7 Page 8 9
2002 HealthPlus of Michigan 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
c We changed speech therapy benefits by
removing the requirement that services must be required to restore
functional speech. (Section 5( a))
Changes to this Plan
c Your share of the non-Postal premium will
increase by 14.1% for Self Only or 14.2% for Self and Family.
c We no longer
limit total blood cholesterol test to certain age groups. (Section 5( a))
c
We now cover certain intestinal transplants. (Section 5( b))
c We changed
the address for sending disputed claims to OPM. (Section 8) 8
8 Page 9 10
2002 HealthPlus of Michigan 9 Section 3
Section 3. How you get care
Identification cards We will send
you an identification (ID) card when you enroll. You should carry your ID card
with you at all times. You must show it whenever you
receive services from a
Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive
your ID card, use your copy of the Health
Benefits Election Form, SF-2809,
your health benefits enrollment
confirmation (for annuitants), or your
Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at (800)
332-9161.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments and you will not have to file
claims.
c 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.
Participating providers strive to provide quality health care
consistent with
recognized medical standards, HealthPlus policy, and your
subscriber
benefits. Health care services must be obtained through, or under
the
direction of, your Primary Care Physician. He or she will coordinate
your
health care and, when medically necessary, refer you to a specialist
from our
network of health care providers. Your role is to always work with
your
Primary Care Physician for your health care needs. The selection of
your
Primary Care Physician is the key to obtaining the benefits available
to you.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. The HealthPlus Provider
Directory is a convenient reference that lists independent primary
physicians, specialist physicians, and other health care providers who have
agreed to provide services to HealthPlus members. This directory will assist
you in the selection of a Primary Care Physician for you and each member
of your family.
c Plan facilities Plan facilities are hospitals and other facilities
in our service area that we
contract with to provide covered services to our
members. We list these in
the provider directory, which we update
periodically. The list is also on our
website.
What you must do Each family member that is covered by us must choose
a Primary Care to get covered care Physician from the Provider Directory
(parents are expected to select for
their children). This list includes
doctors who specialize in Family Practice,
Internal Medicine, or Pediatrics.
The listing for each Primary Care
Physician also shows a "primary hospital."
This is the hospital where your
Primary Care Physician will direct you for
hospital services in most
instances. When you select a Primary Care
Physician you are also agreeing
to use the hospital listed. The Primary Care
Physician you choose will
coordinate your overall medical care, including
arranging for hospital
admissions or care by a specialist when medically
necessary. HealthPlus
strives to keep the Provider Directory as up-to-date
as possible. However,
information may change after the Directory has been
printed. If the
Physician you select is no longer accepting patients, please
select another.
You may want to call the physician you have chosen prior to
calling our 9
9 Page
10 11
2002 HealthPlus of Michigan
10 Section 3
Customer Service Department at (800) 332-9161 with
your selection. You
must notify us before receiving covered services from
the new Primary Care
Physician.
c 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 Physician or if Primary Care Physician
leaves the Plan, call us. We will help you select a new one.
c Specialty care Your Primary Care Physician will refer you to a
specialist for needed care.
When you receive a referral from your Primary
Care Physician, you must
return to the Primary Care Physician after the
consultation, unless your
Primary Care Physician authorized a certain number
of visits without
additional referrals. Your Primary Care Physician must
provide or authorize
all follow-up care. Do not go to the specialist for
return visits unless your
Primary Care Physician gives you a referral.
Here are other things you should know about specialty care:
c If you need
to see a specialist frequently because of a chronic, complex,
or serious
medical condition, your Primary Care Physician will work
with specialist and
us to develop a treatment plan that allows you to see
your specialist for a
certain number of visits without additional referrals.
Your Primary Care
Physician will use our criteria when creating your
treatment plan (the
physician may have to get an authorization or
approval beforehand).
c 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.
c 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.
c 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. 10
10 Page
11 12
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.
c Hospital care Your Plan Primary Care Physician or specialist will
make necessary hospital
arrangements and supervise your care. This includes
admission to a skilled
nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
Customer Service Department immediately at (800) 332-9161. 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:
c You are discharged, not merely moved to an alternative care center; or
c The day your benefits from your former plan run out; or
c The 92nd day
after you become a member of this Plan, whichever
happens first.
These provisions apply only to the hospital benefits of the hospitalized
person.
Circumstances beyond Under certain extraordinary circumstances, such
as natural disasters, we our control may have to delay your services or
we may be unable to provide them. In
that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our Your Primary Care Physician has authority to
refer you for most services. prior approval For certain services,
however, your physician must obtain approval from us.
Before giving
approval, we consider if the service is covered, medically
necessary, and
follows generally accepted medical practice.
Your Primary Care Physician or specialist, to whom you have been
appropriately referred, is responsible for coordinating any necessary
hospitalizations. Scheduled admissions require advance authorization from
HealthPlus. Emergency admissions require notification of HealthPlus
within 24 hours, or as soon thereafter as possible. Authorization occurs
when we approve the admission and issue a complete authorization number
to the hospital. The telephone number to call is on the back of your
identification card.
2002 HealthPlus of Michigan 11 Section 3 11
11 Page 12 13
2002 HealthPlus of Michigan 12 Section 4
Section 4. Your costs for covered services
You must share the
cost of some services. You are responsible for:
c Copayments A
copayment is a fixed amount of money you pay to the provider, facility,
pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment
of
$10 per office visit and when you go in the hospital, you pay nothing per
admission.
c Deductible A deductible is a fixed expense you must incur for
certain covered services
and supplies before we start paying benefits for
them. We have no
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.
c Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for
your care. We have no coinsurance.
Your catastrophic protection We do not have an out-of-pocket maximum.
out-of-pocket maximum 12
12 Page 13 14
Section 5.
Benefits OVERVIEW
(See page 8 for how our benefits changed this
year and page 59 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in
mind at the beginning of each
subsection. Also read the general exclusions in Section 6; they apply to the
benefits
in the following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits,
contact us at (800) 332-9161
or at our website at www. healthplus. com.
(a) Medical services and supplies provided by physicians and other health
care professionals.......................... 14-22
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ...................... 23-26
(c) Services provided by a
hospital or other facility, and ambulance
services..................................................... 27-29
(d) Emergency services/ accidents
.........................................................................................................................
30-31
(e) Mental health and substance abuse benefits
....................................................................................................
32-33
(f) Prescription drug benefits
................................................................................................................................
34-36
(g) Special features
.....................................................................................................................................................
37
c NCQA "Excellent Accreditation"
c High Risk Pregnancies
c
Centers of Excellence for transplants/ heart surgery/ etc.
c HealthQuest
Health Resource Library
c College Students
c Flexible benefits option
(h) Dental benefits
......................................................................................................................................................
38
Summary of benefits
....................................................................................................................................................
59
c Medical emergency c Ambulance
c Inpatient hospital
c Outpatient
hospital or ambulatory surgical center
c Extended care benefits/ skilled
nursing care
facility benefits
c Hospice care
c Ambulance
c Surgical procedures
c Reconstructive surgery
c Oral and
maxillofacial surgery
c Organ/ tissue transplants
c Anesthesia
c Diagnostic and treatment services
c Lab, X-ray, and other diagnostic
tests
c Preventive care, adult
c Preventive care, children
c
Maternity care
c Family planning
c Infertility services
c Allergy
care
c Treatment therapies
c Physical and occupational therapies
c Speech therapy
c Hearing services (testing, treatment, and supplies)
c Vision services (testing, treatment, and supplies)
c Foot care
c
Orthopedic and prosthetic devices
c Durable medical equipment (DME)
c
Home health services
c Chiropractic
c Alternative treatments
c
Educational classes and programs
2002 HealthPlus of Michigan 13 Section 5 13
13 Page 14 15
2002 HealthPlus of Michigan 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
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
c 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.
c Plan physicians must provide or arrange your care.
c We have no
calendar year deductible.
c 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.
Benefit Description You Pay
Diagnostic and treatment services
Professional services of physicians
c In physician's office $10 per
office visit
Professional services of physicians
c In an urgent care center
c
During a hospital stay
c In a skilled nursing facility
c Initial
examination of a newborn child covered under a family
enrollment by the
Member's Primary Care Physician
c Office medical consultations
c Second surgical opinion
Nothing
Nothing
Nothing
Nothing if examination occurs during
hospital stay; otherwise, $10 per visit
$10 per office visit
$10 per office visit
At home $10 per visit 14
14 Page 15 16
2002 HealthPlus
of Michigan 15 Section 5( a)
Lab, X-ray and other diagnostic
tests You Pay
Tests, such as:
c Blood tests
c Urinalysis
c
Non-routine pap tests
c Pathology
c X-rays
c Non-routine Mammograms
c CAT Scans/ MRI
c Ultrasound
c Electrocardiogram and EEG
Nothing
Routine screenings, such as:
c Total Blood Cholesterol once every three
years
c Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening once every five years starting at
age 50
$10 per office visit
Preventive care, adult You Pay
Routine pap test every 1-3 years beginning at age 18
Note: The office
visit is covered if pap test is received on the same day;
see Diagnostic
and Treatment.
Routine mammogram covered for women age 35 and older, as follows:
c
Baseline by the age of 40
c From age 40 through 49, one mammogram every one
or two years
c At age 50, one yearly
$10 per office visit
$10 per office visit
Not covered:
c Physical exams required for obtaining or
continuing employment or
insurance, attending schools or camp, or travel.
c Examinations, reports, or any other services related to requirements
or documentation of health status for employment, licenses,
insurance,
travel, or for educational or sports/ recreational
purposes;
All charges
Preventive Care, Adult-Continued on next page
Prostate Specific Antigen (PSA test) one annually for men age
50 and
older $10 per office visit 15
15 Page 16 17
2002 HealthPlus
of Michigan 16 Section 5( a)
Preventive care, adult
(Continued) You Pay
Routine immunizations, limited to:
c Tetanus-diphtheria (Td) booster once every 10 years, ages 18 and
over (except as provided for under Childhood immunizations)
c Influenza -annually age 65 and older
c Pneumococcal recommended at age
65
Nothing
c Childhood immunizations recommended by the American Academy
of
Pediatrics
Nothing
c Well-child care charges for routine examinations, immunizations and
care (under age 22)
c Examinations, such as:
Eye exams through age 17 to determine the need
for visiion
correction.
Ear exams through age 17 to determine the need for hearing
correction.
Examinations done on the day of immunizations
(under age 22).
$10 per office visit
Preventive care, children You Pay
Maternity care You Pay
Complete maternity (obstetrical) care, such
as:
c Prenatal care
c Delivery
c Postnatal care
Note: Here are
some things to keep in mind:
c You do not need to precertify your normal
delivery; see page 11 for
other circumstances, such as extended stays for
you or your baby.
c You may remain in the hospital up to 48 hours after a regular
delivery
and 96 hours after a cesarean delivery. We will extend your
inpatient stay
if medically necessary.
c We cover routine nursery care of the newborn child during the
covered
portion of the mother's maternity stay. We will cover other
care of an
infant who requires non-routine treatment only if we
cover the infant under
a Self and Family enrollment.
c We pay hospitalization and surgeon services (delivery) the same as
for
illness and injury. See Hospital benefits (Section 5c) and
Surgery benefits
(Section 5b).
$10 for initial visit;
nothing thereafter
Not covered: Routine sonograms to determine fetal age, size or sex All
charges. 16
16 Page
17 18
2002 HealthPlus of Michigan
17 Section 5( a)
Family planning You Pay
A broad range
of voluntary family planning services, limited to:
c Voluntary sterilization
c Surgically implanted contraceptives (such as Norplant)
c Injectable
contraceptive drugs (such as Depo provera)
c Intrauterine devices (IUDs)
c Diaphragms
c Medically-indicated genetic testing and counseling per
generally
accepted medical practice
Note: We cover oral contraceptives under the prescription drug benefit.
Nothing
Not covered:
c Reversal of voluntary surgical sterilization and
all associated cost
c Premarital exams or classes
All charges
Diagnosis and treatment of infertility, such as:
c Artificial
insemination:
intravaginal insemination (IVI)
intracervical
insemination (ICI)
intrauterine insemination (IUI)
c Fertility
drugs
Note: We cover injectable fertility drugs under medical benefits and
oral
fertility drugs under the prescription drug benefit.
Nothing
Infertility services You Pay
Not covered:
c Assisted reproductive technology (ART)
procedures, such as:
in vitro fertilization
embryo
transfer, GIFT and zygote ZIFT
zygote transfer
c
Services and supplies related to excluded ART procedures
c
Reversal of a voluntary sterilization and all associated costs
c
Pre-embryo cyro preservation techniques and associated services
c
Infertility services if one of the partners has previously undergone
surgical sterilization or if one of the partners is menopausal or post
menopausal
c All services related to a surrogate parenting arrangements of any
kind
c Cost of donor sperm and all associated costs
c Cost of donor
egg
All charges 17
17 Page 18 19
2002 HealthPlus
of Michigan 18 Section 5( a)
Allergy serum Nothing
Not
covered: provocative food testing and sublingual allergy
desensitization
All charges
c Chemotherapy and radiation therapy
Note: High dose chemotherapy in
association with autologous bone
marrow transplants are limited to those
transplants listed under
Organ/ Tissue Transplants on page 24.
c Respiratory and inhalation therapy
c Dialysis Hemodialysis and
peritoneal dialysis
c Intravenous (IV)/ Infusion Therapy Home IV and
antibiotic therapy
c Growth hormone therapy (GHT)
Note: Growth hormone
is covered under the prescription drug benefit.
Note: We will only cover
GHT when we preauthorize the treatment.
Your Primary Care Physician calls us
for a referral. We will ask the
Primary Care Physician to submit information
that establishes that GHT
is medically necessary. The submitted request is
reviewed by our Medical
Director to determine medically necessity. Ask us to
authorize GHT
before you begin treatment; otherwise, we will only cover GHT
services
from the date you submit the information. If you do not ask 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.
$10 per office visit
Treatment therapies You Pay
Allergy care You Pay
Testing and treatment
Allergy injection
$10 per office visit 18
18 Page 19 20
2002 HealthPlus
of Michigan 19 Section 5( a)
Physical and occupational
therapies You Pay
c Two consecutive months per condition are covered if
significant
improvement can be expected within the two months. Services are
covered for 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.
c Cardiac rehabilitation following a heart transplant, bypass surgery
or
a myocardial infarction, is covered with no visit limits.
Nothing
Benefits for a hearing aid and hearing tests for fitting and post
performance evaluation of a hearing aid
Nothing
Not covered:
c Hearing aids ordered prior to the effective date
of coverage under
this Contract
c Replacement and/ or repair because of loss or misuse;
c
Batteries
c The additional cost of an eyeglass-type Hearing Aid or
other
Hearing Aid with special features that are not Medically Necessary
over the conventional type of Hearing Aid.
All charges
Hearing services (testing, treatment, and supplies)
You Pay
Speech therapy You Pay
c 60 visits per condition Nothing
Not covered:
c long-term rehabilitative therapy
c
exercise programs
c vocational rehabilitation services
All charges 19
19 Page 20 21
2002 HealthPlus
of Michigan 20 Section 5( a)
Foot care You Pay
Routine
foot care when you are under active treatment for a metabolic
or peripheral
vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe
inserts.
$10 per office visit
Not covered:
c 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.
c Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)
All charges
Orthopedic and prosthetic devices You Pay
Orthotic appliances and
prosthetic devices (including breast prosthesis
following a mastectomy)
c Artificial limbs and eyes; stump hose
c Externally worn breast
prostheses and surgical bras, including
necessary replacements, following a
mastectomy.
c Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: See 5( b) for coverage of the surgery to insert the
device.
c Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Nothing
Vision services (testing, treatment, and supplies)
c Initial pair
of glasses after cataract surgery
Not covered:
c Refractions
c Eyeglasses or contact
lenses and, examinations for them
c Eye exercises and orthoptics
c Radial keratotomy and other refractive surgery
c
Eyeglasses for ocular injury
You Pay
$10 per office visit
All charges
c Eye exam to determine the need for vision correction
for children
through age 17. (See Preventive Care, Children)
$10 per
office visit 20
20 Page
21 22
2002 HealthPlus of Michigan
21 Section 5( a)
Durable medical equipment (DME) You Pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
c Hospital beds;
c Wheelchairs;
c Crutches;
c Walkers;
c
Blood glucose monitors; and
c Insulin pumps.
Nothing
c Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed pratical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
c Services include oxygen therapy, intravenous therapy and
medications.
Nothing
Not covered:
c Nursing care requested by, or for the
convenience of, the patient or
the patient's family
c Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative
c Personal comfort or convenience items such as television and
telephone services
c Skilled Nursing Services provided on a twenty-four (24) hours basis
in the home
c Private duty nursing services (except if medically necessary in an
inpatient hospital setting).
All charges
Home health services You Pay
Not
covered:
c Equipment that is not deemed medically necessary or is an
upgrade
to accepted standards.
All charges
Orthopedic and prosthetic devices (Continued) You Pay
Not covered:
c Equipment that is not deemed medically
necessary or is an
upgrade to accepted standards.
c Orthotic appliances when they are not used to support, align,
prevent, correct or improve a defect of body form or function.
c Prosthetic devices when they do not replace a limb or other part of
the body after accidental or surgical removal and/ or when your
body
growth necessitates a replacement.
All charges 21
21 Page 22 23
2002 HealthPlus
of Michigan 22 Section 5( a)
Educational classes and programs
You Pay
Not covered:
c Premarital exams or classes All
charges
c Medical Self-Care program utilizing the Healthwise Handbook
c Tobacco
Cessation Program based upon the Stages of Change
behavioral model.
c Health Resource Library stocked with over 200 books, videos, and
audiocassettes for members to checkout.
c Anonymous telephonic depression screening available 24 hours
seven days
a week.
c Extensive community resource directory that identifies health
promotion
and disease prevention programs available in the
communities we serve.
Program discounts are negotiated whenever
possible.
c Educational initiatives designed to encourage members to receive
age/
gender appropriate preventive care services.
c Comprehensive Health Management programs for diabetes and
asthma that
offer:
Valuable information from HealthPlus every three months
Seminars
related to your illness, given by qualified
professionals
Enrollment in a program tailored especially to your needs
c Some
benefits you may expect from participation include:
A healthier, more
active lifestyle
Reduce sysmptons
Fewer emergency room, urgent care
visits, or hospitalizations
Support from qualified professionals to help
you manage
your illness
Nothing
Alternative treatments You Pay
No benefit All
charges
Chiropractic You Pay
Not covered:
c Hypnosis
c Biofeedback
c Acupuncture
All charges
c Spinal Manipulation when provided by, or under the direction of,
your
Primary Care Physician, or provided by a Specialist Physician
to whom you
are appropriately referred.
$10 per office visit 22
22 Page 23 24
2002 HealthPlus
of Michigan 23 Section 5( b)
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Section 5 (b). Surgical and anesthesia services provided by physicians and
other health care professionals
Benefit Description You Pay
Surgical procedures
A
comprehensive range of services, such as:
c Operative procedures
c
Treatment of fractures, including casting
c Normal pre-and post-operative
care by the surgeon
c Correction of amblyopia and strabismus
c Endoscopy
procedures
c Biopsy procedures
c Removal of tumors and cysts
c
Correction of congenital anomalies (see reconstructive surgery)
c 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
c Orthognathic surgery prior to the age of twenty-one (21) for
congenital
defects directly affect the growth, development, and
function of the jaw
c Insertion of internal prosthetic devices. See 5( a) Orthopedic and
prosthetic devices for device coverage information.
Nothing
Here are some important things to keep in mind about these benefits:
c 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.
c Plan physicians must provide or arrange your care.
c We have no
calendar deductible
c 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.
c 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.)
c YOUR PHYSICIAN 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. 23
23 Page 24 25
2002 HealthPlus
of Michigan 24 Section 5( b)
Reconstructive surgery You Pay
c Surgery to correct a functional defect
c 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
c 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.
c All stages of breast reconstruction surgery following a mastectomy,
such as:
surgery to produce a symmetrical appearance on the other
breast;
treatment of any physical complications, such as lymphedemas;
breast
prostheses and surgical bras and replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
Nothing
Not covered:
c 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
c Surgeries related to sex transformation
c Other services and
procedures for Cosmetic purposes, such as
procedures to correct baldness or
wrinkling
c Wigs, prosthetic hair, hair transplants, or other procedures or
supplies to enhance hair growth
All charges
Surgical procedures (Continued) You Pay
Not
covered:
c Reversal of voluntary sterilization
c Routine
treatment of condtions of the foot; see foot care
All charges
c Voluntary sterilization
c Treatment of burns
Note: Generally, we
pay for internal prostheses (devices) according to
where the procedure is
done. For example, we pay Hospital benefits for a
pacemaker and Surgery
benefits for insertion of the pacemaker.
$10 per office visit 24
24 Page 25 26
2002 HealthPlus
of Michigan 25 Section 5( b)
Oral and maxillofacial surgery
(Continued) You Pay
Not covered:
c Oral
implants and transplants
c Procedures that involve the teeth or their
supporting structures
(such as the periodontal membrane, gingiva, and
alveolar bone)
c Dental care and associated supplies, services, and tests, except as
specifically provided in this section.
All charges
Limited to:
c Cornea
c Heart
c Heart/ lung
c Lung (single and
double)
c Pancreas
c Kidney
c Liver
c Allogenetic (donor) bone
marrow transplants
c 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.
c Intestinal transplants (small intestine) and the small intestine with
the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas
Nothing
Organ/ tissue transplants You Pay
Oral surgical procedures, limited to:
c Reduction of fractures of the
jaws or facial bones;
c Surgical correction of cleft lip, cleft palate, or
severe functional
malocclusion;
c Removal of stones from salivary ducts;
c Excision of leukoplakia or
malignancies;
c Excision of cysts and incision of abscesses when done as
independent procedures;
c Orthognathic surgery prior to the age of twenty-one (21) for
congenital
defects directly affecting the growth, development, and
function of the jaw;
c Hospitalization charges for multiple extractions which must be
performed in a Hospital due to a concurrent hazardous medical
condition;
and
c Other surgical procedures that do not involve the teeth or their
supporting structures.
Nothing 25
25 Page
26 27
2002 HealthPlus of Michigan
26 Section 5( b)
All charges
Professional services provided
in
c Hospital (inpatient)
Nothing
Professional services provided in
c Hospital outpatient department
c Skilled Nursing Facility
c Freestanding Emergency Center
c Office
Nothing
Anesthesia You Pay
Organ/ tissue transplants (Continued) You Pay
Not covered:
c Medical expenses incurred by a Member who
donates an organ or
tissue to a non-Member
c Medical expenses incurred by a non-Member who donates an
organ or
tissue to a Member will only be covered if the non-Member
does not have
coverage for these services
c Implants of artificial organs
c Transplants not listed as
covered
c National Transplant Program (NTP) A case manager is assigned
upon
notification of a member needing a transplant. The physician,
member and
case manager develop a treatment plan specific to the
member's medical
needs.
Note: We cover related medical and hospital expenses of the donor when
we
cover the recipient.
Nothing 26
26 Page
27 28
2002 HealthPlus of Michigan
27 Section 5( c)
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Here are some important things to remember about these benefits:
c
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.
c Plan physicians must provide or arrange your care and you must be
hospitalized
in a Plan facility.
c We have no calendar year deductible.
c 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.
c The amounts listed below are for the charges billed by the facility (i. e.,
hospital
or surgical center) or ambulance service for your surgery or care.
Any costs
associated with the professional charge (i. e., physicians, etc.)
are covered in
Sections 5( a) or (b).
c YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL
STAYS.
Please refer to Section 3 to be sure which services require
precertification.
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Benefit Description You Pay
Inpatient hospital
Other hospital services and supplies, such as:
c Operating, recovery,
maternity, and other treatment rooms
c Prescribed drugs and medicines
c
Diagnostic laboratory tests and X-rays
c Administration of blood and blood
products
c Blood or blood plasma, if not donated or replaced
c
Dressings, splints, casts, and sterile tray services
c Medical supplies and
equipment, including oxygen
c Anesthetics, including nurse anesthetist
services
c Take-home drugs
c Medical supplies, appliances, medical
equipment, and any covered
items billed by a hospital for use at home
Nothing
Room and board, such as:
c ward, semiprivate, or intensive
care accommodations
c general nursing care; and
c meals and special
diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.
Nothing
Section 5 (c). Services provided by a hospital or other
facility, and
ambulance services
Inpatient hospital -Continued on next page 27
27 Page 28 29
2002 HealthPlus of Michigan 28 Section 5( c)
Inpatient hospital (Continued) You Pay
c
Operating, recovery, and other treatment rooms
c Prescribed drugs and
medicines
c Diagnostic laboratory tests, X-rays, and pathology services
c Administration of blood, blood plasma, and other biologicals
c Blood
and blood plasma, if not donated or replaced
c Pre-surgical testing
c
Dressing, casts, and sterile tray services
c Medical supplies, including
oxygen
c Anesthetic 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
c Custodial or domiciliary care, basic care, or
housekeeping
c Non-covered facilities, such as nursing homes, schools
c Services or products provided by Convalescent Homes, Homes for
the Aged, or Adult Foster Care Facilities
c Personal comfort items such as telephone, television, barber
services, guest meals and beds
c Private duty nursing, unless medically necessary
c Blood and
blood derivatives not replaced by the Member
All charges
Outpatient hospital or ambulatory surgical center You Pay
Not covered:
c Custodial or domiciliary care, basic care, or
housekeeping
c Personal comfort or convenience items such as
television and
telephone services
c Blood and blood derivatives not replaced by the member
c
Private duty nursing
All charges 28
28 Page 29 30
2002 HealthPlus
of Michigan 29 Section 5( c)
Extended care benefits/ skilled
nursing care facility benefits You Pay
Benefits for care in a Skilled
Nursing Facility shall be limited to a
maximum of one hundred (100) days per
Member 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 doctor
and approved by the Plan.
Nothing
Hospice services provided by a Hospice under the direction of a Plan
doctor who certifies that the member is in the terminal stages of illness,
with a life expectancy of approximately six months or less. Services must
be ordered by your Primary Care Physician and authorized in advance by
us. Services are limited to:
c Room and board charges
c Medical supplies, drugs and medicines
c
Medical-social services
Nothing
Not covered:
c Custodial or domiciliary care, basic care
c Independent nursing, homemaker services
c Personal
comfort or convenience items such as television and
telephone services
c Private duty nursing services
c Skilled Nursing Services
provided on a twenty-four (24) hour basis
in the home
All charges
Hospice care You Pay
Ambulance You Pay
Local professional ambulance service when
medically appropriate Nothing
Not covered:
c Custodial or domiciliary care, basic care, or
housekeeping
c Personal comfort or convenience items such as
television and
telephone services
c Private duty nursing services
c Blood and blood derivatives
not replaced by the member
All charges 29
29 Page 30 31
2002 HealthPlus
of Michigan 30 Section 5( d)
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Section 5 (d). Emergency services/ accidents
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some problems are
emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes,
poisonings, gunshot
wounds, or sudden inability to breathe. There are many other acute conditions
that we may
determine are medical emergencies what they all have in common
is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
Members are covered for treatment when a true emergency exists. If you are
in doubt of the seriousness of the medical condition and have time to call your
Primary Care Physician, you
should do so. If your physician feels that the
problem requires immediate attention, he or she will direct your
treatment.
Please note: Emergency health services rendered by a participating provider
within our service area are
covered. Also, services will be covered if they
are rendered by a non-affiliated provider because an emergency
prevents you
from receiving services from a participating provider.
Emergencies outside our service area: In case of an emergency when you
are out of the HealthPlus service area, we provide coverage for necessary care.
If your problem is too serious to wait until you return to the HealthPlus
service area, go to a physician, after-hours care center, or the hospital
nearest you for treatment. Emergency
admissions require notification of
HealthPlus within 24 hours, or as soon thereafter as possible. You may call
HealthPlus 24 hours a day at the Emergency Services number on the back of
your HealthPlus identification card.
Please call promptly after an emergency
in order to confirm coverage, ensure proper follow-up care and assure
payment for covered services you receive.
Note: We reserve the right not to pay for non-emergency treatment received at
emergency facilities. If you are
hospitalized at Non-Affiliated Hospital,
you may be transferred to an Affiliated Hospital upon request of your
Primary Care Physician as soon as it is medically appropriate in the opinion
of the attending physician. Should
you, or your designee, refuse a transfer
to an Affiliated Hospital, continued care provided to you at a Non-Affiliated
Hospital shall not constitute covered services and shall no longer be the
financial responsibility of us.
Follow-up Visits to Non-Affiliated Providers
of Emergency Health Services within the Service Area shall be
limited to two
(2) Visits within thirty (30) days of the emergency. Follow-up Visits to
Non-Affiliated Providers of
Emergency Health Services outside the Service
Area shall be limited to two (2) Visits within thirty (30) days of the
emergency, or the number of Visits specified in a treatment plan approved by
us.
Here are some important things to keep in mind about these benefits:
c Please remember that all benefits are subject to the definitions,
limitations, and
exclusions in this brochure.
c We have no calendar year deductible.
c 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. 30
30
Page 31 32
2002
HealthPlus of Michigan 31 Section 5( d)
You Pay
Not
covered:
c Elective care or non-emergency care
c Emergency
care provided outside the service area if the need for
care could have been
foreseen before leaving the service area
c Medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area
c Blood and blood derivatives not replaced by the member
All charges
c Emergency care at a doctor's office
c Emergency care at an urgent care
center
c Emergency care as an outpatient or inpatient at a hospital,
including
doctor's services
NOTE: Emergency care urgent care center and hospital copay waived if
you
are admitted to a hospital.
$10 per office visit
$25 per visit
$25 per visit
Emergency outside our service area You Pay
c Emergency care at a
doctor's office
c Emergency care at an urgent care center
c Emergency
care as an outpatient or inpatient at a hospital, including
doctor's
services
NOTE: Emergency care urgent care center and hospital copay waived if
you
are admitted to a hospital.
Nothing
Nothing
Nothing
Not covered:
c Elective care or non-emergency care
c
Emergency care provided outside the service area if the need for
care
could have been foreseen before leaving the service area
c Medical and hospital costs resulting from a normal full term
delivery of a baby outside the service area
c Blood and blood derivative not replaced by the member
All charges
Ambulance You Pay
Professional ambulance service when medically
appropriate Nothing
Benefit Description
Emergency within our service area 31
31 Page 32 33
Section 5 (e). Mental health and substance abuse
benefits
2002 HealthPlus of Michigan 32 Section 5( e)
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Benefit Description You Pay
Mental health and substance abuse benefits
c Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
c Medication management
$10 per visit
All diagnostic and treatment services recommended by a Plan provider
and
contained in a treatment plan that we approve. The treatment plan
may
include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing responsibilities
are no greater than for other illness
or conditions.
Mental health and substance abuse benefits -Continued on next page
c Diagnostic tests Nothing
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:
c All benefits are subject to the definitions, limitations, and
exclusions in this
brochure.
c We have no calendar year deductible.
c 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.
c YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See
the
instructions after the benefits description below. 32
32 Page 33 34
2002 HealthPlus of Michigan 33 Section 5( e)
Mental health and substance abuse benefits (Continued)
You Pay
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
c Services provided by a hospital or other facility
c Services in
approved alternative care settings such as partial
hospitalization, half-way
house, residential treatment, full-day
hospitalization, facility based
intensive outpatient treatment
Nothing
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of the following authorization processes:
We have designated Mental Health/ Substance Abuse providers throughout
our service area. The program's Preferred Provider Panel is comprised of a
select group of psychiatrists, psychologists, social workers and substance
abuse providers. You may obtain Mental Health/ Substance Abuse services
from our Preferred Providers without a referral from your Primary Care
Physician. Services from Mental Health/ Substance Abuse providers not on
our Preferred Provider panel require prior authorization from us.
For coverage of mental health and substance abuse services, you may access
your benefits in any of the following ways:
1. Call the HealthPlus Behavioral Service department at 1-800-555-5025.
2. Contact a panel provider from the HealthPlus Provider Directory and
schedule an appointment. The provider you select will obtain the
referral.
3. Contact your Primary Care Physician to coordinate your care.
Because
our preferred panel of providers changes periodically, you may
want to
obtain an updated list by calling our Behavioral Services department
at
1-800-555-5025.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 33
33 Page
34 35
2002 HealthPlus of Michigan
34 Section 5( f)
Section 5 (f). Prescription drug benefits
There are important features you should be aware of. These include:
c Who can write your prescription. Prescriptions for covered drugs
must be written by your
Primary Care Physician or by a specialist to whom
you have been appropriately referred.
c Where you can obtain them. You must fill the prescription at a
participating pharmacy. A list
of participating pharmacies may be found in
our Provider Directory.
c We use a formulary. Drugs are prescribed by Plan doctors and
dispensed in accordance with
the Plan's drug formulary. The Plan's drug
formulary is based on the effectiveness and costs of
drugs. Non-formulary
drugs will be covered when prescribed by a Plan doctor. 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.
c These are the dispensing limitations. Prescription drugs covered by
a Plan or referral doctor
and obtained at a Plan pharmacy will be dispensed
for up to a 34-day supply. You pay a $5
copay per prescription unit or
refill for generic drugs or for name brand drugs when generic
substitution
is not permissible.
c Why use generic drugs? Generic drugs are lower-priced drugs that are
the therapeutic
equivalent to more expensive brand-name drugs. They must
contain the same active ingredients
and must be equivalent in strength and
dosage to the original brand-name product. Generics cost
less than the
equivalent brand-name product. The U. S. Food and Drug Administration sets
quality standards for generic drugs to ensure that these drugs meet the same
standards of quality
and strength as brand-name drugs. Using the most
cost-effective medication saves money.
However, you and your physician have
the option to request a name-brand even if a generic
option is available.
You will have to pay the difference between the cost of the generic and the
name-brand drug.
c When you have to file a claim. Our members may occasionally receive
bills for health care
services. This could occur for a number of reasons,
such as computer errors or out-of-area
emergency treatment. If you receive a
bill or statement, or are requesting reimbursement, mail
the bills to us
within 90 days of the date of service. Please be sure that the bill contains the
following information:
Patient name
Subscriber number and the
patient's two-digit relationship code as shown on your
identification card
(for example: 345123789-01)
Amount billed
Amount paid
Description of service and procedure codes
Diagnosis and diagnosis codes
Location of service
Date of service
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Here are some important things to keep in mind about these benefits:
c We cover prescribed drugs and medications, as described in the chart
beginning
on the next page.
c All benefits are subject to the definitions, limitations and exclusions in
this
brochure and are payable only when we determine they are medically
necessary.
c We have no calendar year deductible.
c 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.
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Prescription drug benefits begin on next page 34
34 Page 35 36
2002 HealthPlus of Michigan 35 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:
c Drugs and medicines that by Federal law of the United States
require a
physician's prescription for their purchase, except as
excluded below.
c Full range of FDA-approved drugs, prescriptions, and devices for
birth
control
c Insulin and insulin syringes
c Diabetic testing reagents and supplies,
including glucose test strips,
test tape, and alcohol swabs
c Smoking cessation drugs and medications; limited to one course of
therapy every two years when prescribed by the Plan doctor or
psychiatrist and accompanied by enrollment in a smoking cessation
program approved by the Plan doctor or psychiatrist
c Disposable needles and syringes for the administration of covered
medications
c Drugs for sexual dysfunction (see next page)
c Intravenous fluids and
medication for home use, and some injectable
drugs are covered under medical
and surgical benefits.
c Fertility drugs (when used in conjunction with prior authorized
treatment plan)
$5 per unit or refill
Covered medications and supplies -Continued on next page
c When you have to file a claim. (Continued)
Address the envelope
as follows:
HealthPlus of Michigan
Attention: Claims Department
P.
O. Box 1700
Flint, MI 48501-1700
If you need further assistance, or have questions, please call our Customer
Service Department at
(800) 332-9161. 35
35
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2002
HealthPlus of Michigan 36 Section 5( f)
Covered medications
and supplies (Continued) You Pay
Not covered:
c
Drugs and supplies for cosmetic purposes
c Vitamins, nutrients and
food supplements even if a physician
prescribes or administers them
c Nonprescription medicines (or their Prescription Drug
equivalents)
c Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies
c Medical supplies as dressings and antiseptics
c Drugs to
enhance athletic performance
c Replacement of lost, stolen, or
destroyed medication.
All charges
Here are some things to keep in mind about our prescription drug
program:
c Benefits for Prescription Drugs in our formulary will be limited to
the
reasonable cost of generically available products, unless no
generically
equivalent product exists or a Member-specific review
for medical necessity
by us determines the need for brand name
medication. We reserve the right to
determine generic equivalency
of products available to HPM Members. We
reserve the right to
review Prescription Drug products and procedures for
medical
necessity, efficacy of use, and quality to determine if they should
be
available to HPM Members.
c Prescription Drugs for Treatment of Sexual Dysfunction:
Coverage is
limited to fifty percent (50%) of covered charges and
shall not
exceed six (6) doses per thirty (30) day period and shall be
limited to the
original prescription and up to two (2) refills prior to
follow up with the
treating physician.
50% per unit or refill 36
36 Page 37 38
2002 HealthPlus
of Michigan 37 Section 5( g)
Section 5 (g). Special features
NCQA "Excellent
Accreditation"
We have been awarded "Excellent Accreditation" status for our Commercial
HMO the highest level possible for the third year in a row by the
National
Committee for Quality Assurance (NCQA). NCQA is an independent,
not-for-profit
organization dedicated to measuring the quality of America's
health care.
High risk pregnancies A case manager is assigned upon notification of
a high risk pregnancy. The physician, member, and case manager develop a
treatment plan specific to the
member's medical needs.
Centers of excellence for
transplants/ heart
surgery/ etc
The following are Centers of excellence available when appropriately
referred:
Cleveland Clinic Foundation
University of Michigan
HealthQuest Health
Resource Library
The Health Resource Library is a service dedicated to providing our members
with a wide range of health information. Our library is stocked with over
200
books, videos, audiocassettes, and pamphlets that can be checked out
just like
at a public library, but in the comfort of your home. This is a
free service; we
even pay for all the postage. To learn more about the
Health Resource Library,
call the HealthQuest Program at (800) 345-9956,
extension 1943 and select
option 5.
College Students Eligible college students are covered for emergency
illnesses or injuries that occur when they are out of the service area. Contact
us at 1-800-332-9161 for
eligibility requirements.
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
c We may identify
medically appropriate alternatives to traditional care and
coordinate other
benefits as a less costly alternative benefit.
c Alternative benefits are subject to our ongoing review.
c By approving
an alternative benefit, we cannot guarantee you will get it
in the future.
c The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
c Our decision to offer or withdraw alternative benefits is not subject to
OPM review under the disputed claims process. 37
37 Page 38 39
2002 HealthPlus of Michigan 38 Section 5( g)
Section 5 (h). Dental benefits
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Here are some important things to keep in mind about these benefits:
c 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.
c Plan physicians or dentists must provide or arrange your care.
c We
have no calendar year deductible.
c 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.
c 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.
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Accidental injury benefit You Pay
We have no other dental benefits.
Nothing
Dental benefits 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. 38
38 Page 39 40
Section 6.
General exclusions things we don't cover
The exclusions in this
section apply to all benefits. Although we may list a specific service as a
benefit, we will
not cover it unless your Plan doctor determines it is
medically necessary to prevent, diagnose, or treat your
illness, disease,
injury, or condition.
We do not cover the following:
c Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
c Services,
drugs, or supplies you receive while you are not enrolled in this plan;
c
Services, drugs, or supplies that are not medically necessary;
c Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric
practice;
c Experimental or investigational procedures, treatments, drugs or devices;
c 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;
c Services, drugs, or supplies related to sex transformations; or
c
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program.
2002 HealthPlus of Michigan 39 Section 6 39
39 Page 40 41
2002 HealthPlus of Michigan 40 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or obtain
your prescription drugs at
Plan pharmacies, you will not have to file
claims. Just present your identification card and pay your copayment.
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, and In most cases, providers and facilities file
claims for you. Physicians must drug benefits file on the form HCFA-1500,
Health Insurance Claim Form. Facilities will
file on the UB-92 form. For
claims questions and assistance, call us at
(800) 332-9161.
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:
c Covered member's name and ID number;
c Name and address of the
physician or facility that provided the service or
supply;
c Dates you received the services or supplies;
c Diagnosis;
c Type of
each service or supply;
c The charge for each service or supply;
c A
copy of the explanation of benefits, payments, or denial from any
primary
payer such as the Medicare Summary Notice (MSN); and
c Receipts, if you paid for your services.
Submit your claims to: HealthPlus of Michigan
Attn: Claims
2050 S.
Linden Rd.
P. O. Box 1700
Flint, MI 48501-1700
Important Note: Charges for the completion of claim forms, interest on late
payments, or charges for failure to keep scheduled appointments are not
covered.
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. 40
40 Page
41 42
2002 HealthPlus of Michigan
41 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: 2050 South Linden Road, P. O.
Box 1700, Flint, MI 48501-1700; and
(c) Include a statement about why you
believe our initial decision was wrong, based on specific benefit
provisions
in this brochure; and
(d) Include copies 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:
c 90 days after the date of our letter
upholding our initial decision; or
c 120 days after you first wrote to us
if we did not answer that request in some way within 30 days;
or
c 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
1900 E Street, NW, Washington, D. C.
20415-3630.
Send OPM the following information:
c A statement about why you believe
our decision was wrong, based on specific benefit provisions in this
brochure;
c Copies of documents that support your claim, such as physicians' letters,
operative reports, bills,
medical records, and explanation of benefits (EOB)
forms;
c Copies of all letters you sent to us about the claim;
c Copies of all
letters we sent to you about the claim; and
c 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. 41
41
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2002
HealthPlus of Michigan 42 Section 8
Note: You are the only person
who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your
specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because
of reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
6 If you do not agree with OPM's
decision, your only recourse is to sue. If you decide to sue, you must file the
suit against OPM in Federal court by December 31 of the third year after the
year in which you received the
disputed services, drugs or supplies, or from the year in which you were
denied 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
(800) 332-9161 and we will
expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
c If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim
expedited treatment too, or
c You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0737
between 8 a. m. and 5 p. m.
eastern time. 42
42
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2002
HealthPlus of Michigan 43 Section 9
Section 9. Coordinating
benefits with other coverage
When you have other health coverage You
must tell us if you are covered or a family member is covered under
another
group health plan or have automobile insurance that pays health
care
expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as
the primary payer and the other plan pays a reduced benefit as the secondary
payer. We, like other insurers, determine which coverage is primary
according
to the National Association of Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance. After
the primary plan pays, we will pay what is left of our allowance, up to our
regular benefit. We will not pay more than our allowance.
c What is
Medicare? Medicare is a Health Insurance Program for:
c People 65 years of age and older.
c Some people with disabilities,
under 65 years of age.
c People with End-Stage Renal Disease (permanent
kidney failure
requiring dialysis or a transplant).
Medicare has two parts:
c 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.
c Part B (Medical Insurance). Most people pay monthly for Part B.
Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various
health plan choices available to Medicare beneficiaries. The information in
the next few pages shows how we coordinate benefits with Medicare,
depending on the type of Medicare managed care plan you have.
c 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, or precertified as
required.
We will not waive any of our out-of-pocket costs.
(Primary payer chart
begins on next page.) 43
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2002 HealthPlus
of Michigan 44 Section 9
The following chart illustrates whether
the Original Medicare Plan or this Plan should be the primary payer for
you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if
you or a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is
Original Medicare
This Plan
1) Are an active employee with the Federal government (including
when you
or a family member are eligible for Medicare solely
because of a
disability),
3
3
3
3
(for Part B services)
6) Are a former Federal employee receiving Workers' Compensation
and the
Office of Workers' Compensation Programs has determined
that you are unable
to return to duty,
3
(for other services)
3
3
3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, 3
3
3
3
3
A. When either you or your covered spouse
are age 65 or over and
2) Are an annuitant,
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,
3
(except for claims related to Workers'
Compensation.)
B. When you or a covered family member have
Medicare
based on end stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,
2) Have completed the 30-month ESRD coordination period and are
still
eligible for Medicare due to ESRD,
C. When you or a covered family member have FEHB and
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare.
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
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.)
3
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2002 HealthPlus of Michigan
45 Section 9
Claims process when you have the Original
Medicare Plan You
probably will never have to file a claim form when
you have both our Plan
and the Original Medicare Plan.
c When we are the primary payer, we process the claim first.
c When
Original Medicare is the primary payer, Medicare processes your
claim first.
In most cases, your claims will be coordinated automatically
and we will pay
the balance of covered charges. You will not need to do
anything. To find
out if you need to do something about filing your
claims, call us at (800)
332-9161 or visit our website at
www. healthplus. com.
We waive some costs when you have the Original Medicare Plan
When Original Medicare is the primary payer, we will waive some
out-of-pocket
costs, as follows:
c Medical services and supplies provided by physicians and other health
care professionals. If you are enrolled in Medicare Part B, we will waive
after member copayment Part B deductible, 20% of Medicare approved
amounts and Part B excess charges.
c Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get your
Medicare benefits from another type of
Medicare+ Choice plan a
Medicare managed care plan. These are health care
choices (like HMOs) in
some areas of the country. In most Medicare managed
care plans, you can
only go to doctors, specialists, or hospitals that are
part of the plan.
Medicare managed care plans provide all the Benefits that
Original
Medicare covers. Some cover extras, like prescription drugs. To
learn more
about enrolling in a Medicare managed care plan, contact Medicare
at 1-
800-MEDICARE (1-800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You may enroll in our
Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments, coinsurance, or
deductibles for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your
Medicare managed care plan is primary, even out of the managed care plan's
network and/ or service area (if you use our Plan providers), but we will
not
waive any of our out-of-pocket costs. 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 manager care plan so we can
correctly
coordinate benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan:
If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan. 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. 45
45 Page 46 47
2002 HealthPlus of Michigan 46 Section 9
c If you do not enroll in If you do not have one or both Parts of
Medicare, you can still be covered
Medicare Part A or Part B under
the FEHB Program. We will not require you to enroll in Medicare
Part B and,
if you can't get premium-free Part A, we will not ask you to
enroll in it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage.
Workers' Compensation We do not cover services that:
c you need
because of a workplace-related illness or injury that the Office
of Workers'
Compensation Programs (OWCP) or a similar Federal or
State agency determines
they must provide; or
c OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment,
we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for for injuries medical or hospital care for injuries or illness caused
by another person,
you must reimburse us for any expenses we paid. However,
we will cover
the cost of treatment that exceeds the amount you received in
the settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our subrogation
procedures. 46
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2002 HealthPlus of Michigan
47 Section 10
Section 10. Definitions of terms we use in this
brochure
Acute Care Service The provision of highly concentrated care to
patients requiring comprehensive observation, continuous monitoring, and
treatment with
immediate Physician intervention when necessary due to the
seriousness or
unstable nature of the illness or injury.
Affiliated Provider A provider who has agreed in writing to provide
services to Members.
Appropriately Referred That situation when a
referral is issued on behalf of a Member from that Member's Primary Care
Physician to another Provider, or from a Physician
to whom a Member is
referred to another Provider, if such referrals are
consistent with HPM's
referral policy.
Calendar year January 1 through December 31 of the same year.
Copayment When expressed as a dollar sum, the amount each Member must
pay per Visit to a treating Provider in connection with Health Care Benefits.
Copayment, when expressed as a percentage, means the portion of
Reasonable Charge which each Member must pay per Visit to a treating
Provider.
Covered services Care we provide benefits for, as described in this
brochure.
Day Treatment Mental Health Generally accepted therapeutic
services and/ or ancillary services which And/ or Substance Abuse Services
last four (4) or more consecutive hours.
Dental Care Services or procedures which concern maintenance or repair
of the teeth and/ or gums or are performed to prepare the mouth for dentures.
Dentist An individual licensed under the Act or any licensing statute
or law of the applicable governing state or governmental unit to engage in the
practice of
dentistry.
Durable Medical Equipment Equipment of the
type approved by HPM which is able to withstand repeated use, is primarily and
customarily used to serve a medical purpose,
and is not generally useful to
a person in the absence of illness or injury.
Experimental or A
service that is of doubtful medical usefulness or effectiveness to the
investigational services Member, as assessed by local medical community
standards.
Freestanding Emergency Center A Facility which is licensed, certified,
or otherwise authorized pursuant to the Act or any similar licensing statute or
law of its governing state or
governmental unit to provide services in
emergencies or after hours.
Hearing Aid An electronic device of the
type approved by HPM worn on the person for the purpose of amplifying sound and
assisting the physiologic process of
hearing, and includes an ear mold, if
medically necessary.
Home Health Agency A facility or program which
is licensed, certified, or otherwise authorized pursuant to the Act or other
similar licensing statute of its governing state or
governmental unit and is
approved to provide home health services. 47
47
Page 48 49
2002
HealthPlus of Michigan 48 Section 10
Hospice A Provider
which is licensed, certified, or otherwise authorized pursuant to the Act or
other similar licensing statute of its governing state or
governmental unit
to supply pain relief, symptom management, and
supportive services to
individuals suffering from a disease or condition with
a terminal prognosis.
Hospital An acute care general facility which: (1) provides inpatient
diagnostic and therapeutic facilities for surgical or medical diagnosis,
treatment, and care of
injured and sick persons by or under the supervision
of a staff of duly
licensed Physicians; (2) is licensed, certified, or
otherwise authorized
pursuant to the Act or other similar licensing statute
of its governing state or
governmental unit; and (3) which is not, other
than incidentally, a place of
rest, a place for the aged, a nursing home, or
a facility for the treatment of
substance abuse or pulmonary tuberculosis.
In-Network Benefits The provision of Covered Services by: (A) The
Member's Primary Care Phsycian; (B) A Provider to whom the Member is
Appropriately Referred;
or (C) An Affiliated Provider when a referral or
other authorization is not
required by HPM.
Intermediate Care As it applies to Mental Health and Substance Abuse
Services, the use of a full or partial residential therapy setting (also known
as Residential and Day
Treatment programs), and shall include generally
accepted therapeutic
techniques and other therapeutic and ancillary
services.
Intermittent Skilled Nursing Care Services provided by a licensed
nurse to a Member who has a medically predictable recurring need for skilled
care at least once in every sixty (60)
day period.
Medical Necessity
The health care associated with the Member is consistent with and called for
in relationship to the intensity of service, severity of illness, and
appropriateness of services provided.
Medicare Title XVIII of the
Social Security Act and all amendments thereto.
Members The
Subscriber and his/ her Dependents covered under this Contract.
Non-Affiliated Provider A Provider who has not agreed in writing to
provide services to Members.
Non-Plan Physician A Physician who has
not entered into a written contract to provide services to Members.
Non-Preferred Mental Health An Affiliated Provider specializing in the
treatment of mental illness Provider who is not designated by HPM as a
Preferred Provider.
Non-Preferred Substance Abuse An Affiliated
Provider specializing in the treatment of substance abuse Provider who is
not designated by HPM as a Preferred Provider.
Orthotic Appliance An
apparatus of the type approved by HPM which is used to support, align, prevent,
or correct deformities, or to improve the function of movable parts
of the
body. 48
48 Page
49 50
2002 HealthPlus of Michigan
49 Section 10
Out-of-Network Benefits The provision of
Covered Services by: (A) A Non-Affiliated Provider, unless Appropriately
Referred; (B) An Affiliated Provider (other than the
Member's Primary Care
Physician) to whom the Member was not
Appropriately Referred; or (C) A
Provider under any other circumstances
which does not meet the definition of
an In-Network Benefit.
Outpatient Mental Health Therapeutic services which last less than (4)
consecutive hours. And/ or Substance Abuse Services
Pharmacy A business licensed under the Act or similar licensing
statute or law of its governing state or governmental unit to engage in the
practice of pharmacy.
Physician An individual licensed under the Act
or other similar licensing statute or law of the applicable governing state or
governmental unit to engage in the
practice of allopathic medicine,
osteopathic medicine, chiropractic, or
podiatric medicine and surgery.
Plan Physician Any Physician who has entered into a written contract
to provide services to Members.
Preferred Mental Health An Affiliated Provider specializing in the
treatment of mental illness who is Provider both selected by a Member for
his/ her care and is designated by HPM as a
Preferred Mental Health
Provider.
Preferred Substance Abuse An Affiliated Provider
specializing in the treatment of substance abuse Provider who is both
selected by a Member for his/ her care and is designated by
HPM as a
Preferred Substance Abuse Provider.
Prosthetic Device A device that
replaces all or a part of an internal body organ or external body member, or
that replaces all or a part of the function of a permanently
inoperative or
malfunctioning internal body organ or external body member.
Provider
A health professional, facility, or agency complying with the Act or other
similar licensing statute of the applicable governing state or governmental
unit. The following services are not covered: Services which are provided
by individuals who are not licensed/ certified under the Michigan Public
Health Code (or other similar code/ statute of any other state or government
unit) or services which are beyond the treating individual's licensing.
Reasonable Charge The lesser of the treating Provider's charge or the
amount determined to be a fair charge by HPM in comparison to charges of other
Providers in the
same geographic region.
Residential Substance Abuse A course of treatment which requires
twenty-four (24) hour on-site Program presence coupled with the
continuous availability of intense drug and
alcohol therapy.
Semi-Private Room A room containing two (2) or more patient beds in
an inpatient facility.
Short-Term Service for a condition which HPM
determines can be expected to significantly improve within a period of sixty
(60) days. 49
49 Page
50 51
2002 HealthPlus of Michigan
50 Section 10
Skilled Care Service Concentrated
observation, monitoring, evaluation, and intervention by licensed and trained
personnel under the direction of a Physician and usually
does not require
daily intervention for conditions that are stable or
stabilizing.
Skilled Nursing Facility A facility licensed to provide Skilled
Nursing Care in accordance with the Act or other similar licensing statute of
its governing state or governmental
unit.
Specialist Physician A
Plan or Non-Plan Physician to whom a Member is Appropriately Referred.
Us/ We Us and we refers to HealthPlus of Michigan
Visit
A meeting between a Member and Provider for the purpose of rendering Covered
Services, without regard to the frequency of meetings if each such
meeting
is separated by any period of time.
You You refers to the enrollee
and each covered family member. 50
50 Page 51 52
2002 HealthPlus
of Michigan 51 Section 11
Section 11. FEHB facts
No
pre-existing condition We will not refuse to cover the treatment of a
condition that you had before limitation you enrolled in this Plan solely
because you had the condition before you
enrolled.
Where you can get
information See www. opm. gov/ insure. Also, your employing or retirement
office can about enrolling in the answer your questions, and give you a
Guide to Federal Employees Health
FEHB Program Benefits
Plans, brochures for other plans, and other materials you need to make an
informed decision about:
c When you may change your enrollment;
c How you can cover your family
members;
c What happens when you transfer to another Federal agency, go on
leave
without pay, enter military service, or retire;
c When your enrollment ends; and
c When the next open season for
enrollment begins.
We don't determine who is eligible for coverage and, in most cases, cannot
change your enrollment status without information from your employing or
retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for you, for you and your family your spouse, and
your unmarried dependent children under age 22,
including any foster
children or stepchildren your employing or retirement
office authorizes
coverage for. Under certain circumstances, you may also
continue coverage
for a disabled child 22 years of age or older who is
incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You may
change your enrollment 31 days before to 60 days after that event. The Self
and Family enrollment begins on the first day of the pay period in which the
child is born or becomes an eligible family member. When you change to
Self and Family because you marry, the change is effective on the first day
of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we. Please
tell us immediately when you add or remove family members from your
coverage for any reason, including divorce, or when your child under age 22
marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan.
When benefits and The benefits in this brochure are effective on
January 1. If you joined this premiums start Plan during Open Season,
your coverage begins on the first day of your first
pay period that starts
on or after January 1. Annuitants' coverage and
premiums begin on January 1.
If you joined at any other time during the
year, your employing office will
tell you the effective date of coverage. 51
51
Page 52 53
2002
HealthPlus of Michigan 52 Section 11
Your medical and claims
We will keep your medical and claims information confidential. Only the
records are confidential following will have access to it:
c OPM,
this Plan, and subcontractors when they administer this contract;
c 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;
c Law enforcement officials when investigating and/ or prosecuting alleged
civil or criminal actions;
c OPM and the General Accounting Office when conducting audits;
c
Individuals involved in bona fide medical research or education that does
not disclose your identity; or
c OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of
your Federal service. If you do not meet this requirement, you
may be
eligible for other forms of coverage, such as Temporary Continuation
of
Coverage (TCC).
When you lose benefits
c When FEHB coverage ends You will receive an additional 31 days of
coverage, for no additional
premium, when:
c Your enrollment ends, unless you cancel your enrollment, or
c You are a
family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation
of Coverage.
c Spouse equity coverage If you are divorced from a Federal employee
or annuitant, you may not
continue to get benefits under your former
spouse's enrollment. But, you
may be eligible for your own FEHB coverage
under the spouse equity law.
If you are recently divorced or are
anticipating a divorce, contact your ex-spouse's
employing or retirement
office to get RI 70-5, the Guide to Federal
Employees Health Benefits
Plans for Temporary Continuation of Coverage
and Former Spouse Enrollees,
or other information about your coverage
choices.
c Temporary Continuation If you leave Federal service, or if you lose
coverage because you no longer
of Coverage (TCC) qualify as a family
member, you may be eligible for Temporary
Continuation of Coverage (TCC).
For example, you can receive TCC if you
are not able to continue your FEHB
enrollment after you retire, if you lose
your job, if you are a covered
dependent child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, from
your employing or retirement office or from www. opm. gov/ insure. It
explains what you have to do to enroll. 52
52
Page 53 54
c
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
c Your coverage under TCC or the spouse equity law ends (If you canceled
your coverage or did not pay your premium, you cannot convert);
c You decided not to receive coverage under TCC or the spouse equity law;
or
c You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to convert. You must apply in writing to us within 31 days after you
receive this notice. However, if you are a family member who is losing
coverage, the employing or retirement office will not notify you. You
must
apply in writing to us within 31 days after you are no longer eligible
for
coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you will not have to answer questions about your health, and we
will not impose a waiting period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) Group Health Plan Coverage is a
Federal law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If
you leave the FEHB Program, we will give you a Certificate of Group
Health Plan Coverage that indicates how long you have been enrolled with
us. You can use this certificate when getting health insurance or other
health
care coverage. Your new plan must reduce or eliminate waiting
periods,
limitations, or exclusions for health related conditions based on
the
information in the certificate, as long as you enroll within 63 days of
losing
coverage under this Plan. If you have been enrolled with us for less
than 12
months, but were previously enrolled in other FEHB plans, you may
also
request a certificate from those plans.
For more information, get OPM pamphlet RI-79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www.
opm. gov/ insure/ health); refer to the "TCC and
HIPAA" frequently asked
question. These highlight HIPAA rules, such as
the requirement that Federal
employees must exhaust any TCC eligibility as
one condition for guaranteed
access to individual health coverage under
HIPAA, and have information about
Federal and State agencies you can
contact for more information.
2002 HealthPlus of Michigan 53 Section 11 53
53 Page 54 55
2002 HealthPlus of Michigan 54 Long Term
Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office of Personnel Management (OPM) will sponsor a high-quality
long term care insurance program
effective in October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is long term care (LTC) insurance?
c It's insurance to help
pay for long term care services you may need if you can't take care of yourself
because of
an extended illness or injury, or an age-related disease such as
Alzheimer's.
c LTC insurance can provide broad, flexible benefits for care in a nursing
home, in an assisted living facility, 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 need long term care. Or, will I?
c 76% of
Americans believe they will never need long term care, but the facts are that
about half of them will.
And it's not just the old folks. About 40% of
people needing long term care are under age 65. They may need
chronic care
due to a serious accident, a stroke, or developing multiple sclerosis, etc.
c We hope you will never need long term care, but you should have a plan just
in case. LTC insurance may be
vital to your financial and retirement
planning.
Is long term care expensive?
c Yes. A year in a nursing home can
exceed $50,000 and only three 8-hour shifts a week can exceed $20,000 a
year, that's before inflation!
c LTC can easily exhaust your savings but LTC insurance can protect it.
But won't my FEHB plan, Medicare or Medicaid cover my long term care?
c Not FEHB. Look under "Not covered" in sections 5( a) and 5( c)
of your FEHB brochure. Custodial care,
assisted living, or continuing home
health care for activities of daily living are not covered. Limited stays in
skilled nursing facilities can be covered in some circumstances.
c Medicare only covers skilled nursing home care after a hospitalization with
a 100 day limit.
c Medicaid covers LTC for those who meet their state's
guidelines, but restricts covered services and where they
can be received.
LTC insurance can provide choices of care and preserve your independence.
When will I get more information?
c Employees will get more
information from their agencies during the late summer/ early fall of 2002.
c Retirees will receive information at home.
How can I find out more about the program NOW?
c A toll-free
telephone number will begin in mid-2002. You can learn more about the program
now at
www. opm. gov/ insure/ ltc.
c Many FEHB enrollees think their health plan and/ or Medicare covers
long-term care. Unfortunately, they
are WRONG!
c How are YOU planning to pay for the future custodial or chronic care you
may need? Consider buying long
term care insurance. 54
54 Page 55 56
Index
Do not rely on this page; it is for
your convenience and may not show all pages where the terms appear.
Accidental injury 38
Allergy tests 18
Alternative treatment 22
Allogenetic (donor) bone marrow
transplant 25
Ambulance 31
Anesthesia 26
Autologous bone marrow
transplant 25
Blood
and blood plasma 27
Breast cancer screening 15
Changes for
2002 8
Chemotherapy 18
Childbirth 16
Chiropractic 22
Cholesterol
tests 15
Claims 40
Colorectal cancer screening 15
Contraceptive
devices and drugs 35
Coordination of benefits 43
Covered charges 12
Covered providers 9
Definitions 47
Dental care 38
Diagnostic services 14
Disputed claims review 41
Donor expenses
(transplants) 25
Durable medical equipment
(DME) 21
Educational
classes and
programs 22
Effective date of enrollment 51
Emergency 30
Experimental or investigational 47
Eyeglasses 20
Family planning 17
Fecal occult blood test 15
General
Exclusions 39
Hearing services 19
Home health services 21
Hospice care 29
Home nursing care 21
Hospital 27
Immunizations 16
Infertility 17
Inhospital physician care 14
Inpatient Hospital Benefits 27
Insulin 35
Laboratory and
pathological
services 15
Machine diagnostic tests 15
Magnetic
Resonance Imagings
(MRIs) 15
Mammograms 15
Maternity Benefits 16
Medicaid 46
Medically necessary 48
Medicare 43
Members 48
Mental Conditions/ Substance
Abuse Benefits 32
Newborn care
16
Nursery charges 16
Obstetrical care 16
Occupational
therapy 19
Ocular injury 19
Office visits 14
Oral 25
Oral and
maxillofacial surgery 25
Orthopedic devices 20
Out-of-pocket expenses 12
Outpatient facility care 28
Oxygen 21
Pap test 15
Physical examination 15
Physical therapy 19
Physician 49
Precertification 11
Preventive care, adult 15
Preventive care, children 16
Prescription drugs 34
Preventive
services 15
Prior approval 11
Prostate cancer screening 15
Prosthetic devices 20
Psychologist 32
Psychotherapy 32
Radiation therapy 18
Reconstructive 24
Room and board 27
Second surgical opinion 14
Skilled nursing facility care 29
Smoking cessation 22
Speech therapy 19
Sterilization procedures 17
Substance abuse 32
Surgery 23
Temporary continuation of
coverage 52
Transplants 25
Treatment therapies 18
Vision
services 20
Well child care 16
Workers' compensation 46
X-rays 15
2002 HealthPlus of Michigan 55 Index 55
55 Page 56 57
2002 HealthPlus of Michigan 56 Notes
NOTES: 56
56 Page 57 58
2002 HealthPlus
of Michigan 57 Notes
NOTES: 57
57 Page 58 59
2002 HealthPlus of Michigan 58 Notes
NOTES: 58
58 Page 59 60
2002 HealthPlus
of Michigan 59
Summary of benefits for the HealthPlus of Michigan
-2002
c 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.
c 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.
c We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
c Diagnostic and treatment services provided in the office........ Office
visit copay: $10
primary care; $10 specialist 14
Services provided by a hospital:
c
Inpatient....................................................................................
Nothing 27
c
Outpatient.................................................................................
Nothing 28
Emergency benefits:
c In-area
.......................................................................................
$25 per visit 31
c Out-of-area
................................................................................
Nothing 31
Mental health and substance abuse treatment ...............................
Regular cost sharing. 32
Prescription drugs
.......................................................................... $5
copay per unit or refill 34
Dental Care (Accidental injury benefit only)
............................... Nothing 38
Vision Care
....................................................................................
No benefit. 20
Special features: 37
c NCQA "Excellent" Accreditation c
High risk pregnancies c Centers of Excellence for
transplants/ heart
surgery, etc. c HealthQuest and Health Resource Library c College Students
c Flexible benefits option
We have no out-of-pocket
Protection against catastrophic costs maximum.
Your out-of-pocket
(your out-of-pocket maximum)
..................................................... expenses covered under
this 12
plan are limited to stated
copayments that are required
for
a few benefits.
Summary of Benefits 59
59 Page 60
2002 HealthPlus of Michigan 60
2002 Rate Information for
HealthPlus of Michigan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment
category, refer to the FEHB Guide for that category or
contact the agency that maintains your
health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the
FEHB Guide for United States Postal Service Employees,
RI 70-2. Different postal rates apply
and special FEHB guides are published
for Postal Service Nurses and Tool & Die employees
(see RI 70-2B); and
for Postal Service Inspectors and Office of Inspector General (OIG)
employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members
of any postal employee organization. Refer to the
applicable FEHB Guide.
Type of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share
Postal Premium Non-Postal Premium
Biweekly Monthly Biweekly
Self Only X51 $93.20 $31.06 $201.92 $67.31 $110.28 $13.98
Self and
Family X52 $223.41 $81.23 $484.86 $175.99 $263.75 $40.89
GREATER FLINT AND SAGINAW AREAS 60