Enrollment codes for this Plan:
5W1 Self Only 5W2 Self and Family
SummaCare Health Plan http:// www. summacare. com
This Plan has
3-year accreditation
from the NCQA. See the 2002 Guide
for more
information on NCQA.
Commercial HMO/ POS
Medicare HMO
2002
RI 73-768
For changes
in benefits
see page 6 1
1 Page 2 3
Table of Contents
Introduction
………………………………………………………………….
.......................................................................................
4
Plain Language
.......................................................................................................................................................................................
4
Inspector General Advisory
....................................................................................................................................................................
4
Section 1. Facts about this HMO plan
...................................................................................................................................................
5
How we pay providers
..........................................................................................................................................................
5
Who provides my health
care?..............................................................................................................................................
5
Your
Rights...........................................................................................................................................................................
5
Service
Area..........................................................................................................................................................................
5
Section 2. How we change for 2002
......................................................................................................................................................
6
Program-wide changes
..........................................................................................................................................................
6
Changes to this
Plan..............................................................................................................................................................
6
Section 3. How you get care
.................................................................................................................................................................
7
Identification
cards................................................................................................................................................................
7
Where you get covered
care..................................................................................................................................................
7
Plan providers
.................................................................................................................................................................
7
Plan facilities
..................................................................................................................................................................
7
What you must do to get covered care
..................................................................................................................................
7
Primary
care....................................................................................................................................................................
7
Specialty
care..................................................................................................................................................................
7
Hospital care
...................................................................................................................................................................
8
Circumstances beyond our
control........................................................................................................................................
9
Services requiring our prior
approval....................................................................................................................................
9
Section 4. Your costs for covered services
..........................................................................................................................................
10
Copayments
..................................................................................................................................................................
10
Deductible.....................................................................................................................................................................
10
Coinsurance
..................................................................................................................................................................
10
Your out-of-pocket
maximum.............................................................................................................................................
10
Section 5. Benefits
...............................................................................................................................................................................
11
Overview.............................................................................................................................................................................
11
(a) Medical services and supplies provided by physicians and other health
care professionals .................................... 12
(b) Surgical and
anesthesia services provided by physicians and other health care
professionals................................. 22
(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.........................................................................................................................................
34
(g) Special features
.......................................................................................................................................................
36
Flexible benefits option 2
2 Page 3 4
Complementary Care
24 Hour Nurse Line
Maternal Care Program
Centers for Excellence
Travel Benefit
Web Site
NCQA Accreditation
(h) Dental
benefits..........................................................................................................................................................
37
(i) Non-FEHB benefits available to Plan
members.......................................................................................................
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…
Other health coverage
....................................................................................................................................................
43
Original
Medicare..........................................................................................................................................................
43
Medicare managed care plan
........................................................................................................................................
45
TRICARE/ Workers' Compensation/ Medicaid
...................................................................................................................
45
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
.......................................................................................................................................................................
48
Coverage
information........................................................................................................................................................
48
No pre-existing condition limitation
.........................................................................................................................
48
Where you get information about enrolling in the FEHB
Program...........................................................................
48
Types of coverage available for you and your
family...............................................................................................
48
When benefits and premiums start
............................................................................................................................
49
Your medical and claims records are confidential
....................................................................................................
49
When you
retire........................................................................................................................................................
49
When you lose benefits
.....................................................................................................................................................
49
When FEHB coverage ends
......................................................................................................................................
49
Spouse equity
coverage............................................................................................................................................
49
Temporary Continuation of Coverage (TCC)
..........................................................................................................
49
Converting to individual coverage
...........................................................................................................................
49
Getting a Certificate of Group Health Plan
Coverage..............................................................................................
50
Long Term Care Insurance is Coming Later in 2002
..........................................................................................................................
51
Index
.........................................................................................................................................................................................
52
Summary of benefits
.............................................................................................................................................................................
53
Rates
.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 SummaCare Health Plan 4
Introduction/ Plain Language
Introduction
SummaCare Health
Plan
10 Main Street
Akron, Ohio 44308
This brochure describes the benefits of SummaCare Health Plan under our
contract (CS 2830) 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 6. Rates
are shown at the end of this brochure.
Plain Language
Teams of Government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family member;
"we" means SummaCare Health Plan.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar
descriptions to help you compare plans.
If you have comments or suggestions
about how to improve the structure of this brochure, let OPM know. Visit OPM's
"Rate
Us" feedback area at www. opm. gov/ insure or e-mail us at
fehbwebcomments@ opm. gov. You may also write to OPM at The
Office of
Personnel Management, Office of Insurance Planning and Evaluation Division, 1900
E Street, Washington, DC,
20415-3650.
Inspector General Advisory
Stop health care fraud! Fraud increases
the cost of health care for everyone. If you suspect that a physician, pharmacy,
or
hospital has charged you for services you did not receive, billed you
twice for the same service, or misrepresented any
information, do the
following:
Call the provider and ask for an explanation. There may be an error. If the
provider does not resolve the matter, call us at 330-996-8700 or 800-996-8701
and explain the situation.
If we do not resolve the issue, call THE
HEALTH CARE FRAUD HOTLINE--202/ 418-3300 or write to: The United States
Office of Personnel Management, Office of the Inspector General Fraud Hotline,
1900 E Street, NW, Room 6400,
Washington, DC 20415.
Penalties for
Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate anyone who
uses an ID card if the person tries to obtain services for someone who is not an
eligible family member, or is no longer enrolled in the Plan and tries to
obtain benefits. Your agency may also take
administrative action against
you. 4
4 Page 5 6
2002 SummaCare Health Plan 5 Section 3
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other providers that
contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to
treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments,
coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may
have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot
change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers
accept a negotiated payment from us, and you will only be
responsible for your copayments or coinsurance.
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.
SummaCare is licensed by the Ohio Department of Insurance and must comply to
their guidelines.
SummaCare has been in business since 1993; offering the
FEBH Plan since 1998.
SummaCare is a for-profit corporation.
If you want
more information about us, call 330-996-8700 or 800-996-8701, or write to
SummaCare Health Plan, 10 Main Street,
Akron, Ohio, 44308. You may also
contact us by fax at 330-996-8415 or visit our website at www. summacare. com.
Service Area
To enroll in this Plan, you must live in or work in
our Service Area. This is where our providers practice. Our service area is the
following counties in Ohio: Ashtabula, Carroll, Cuyahoga, Geauga, Mahoning,
Medina, Lorain, Portage, Stark, Summit, Trumbull,
Tuscarawas and Wayne.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area, we will pay only
for emergency
care benefits. We will not pay for any other health care services out of our
service area unless the services have prior
plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents live out of the
area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO
that has agreements with
affiliates in other areas. If you or a family member move, you do not have to
wait until Open Season to
change plans. Contact your employing or retirement
office. 5
5 Page 6
7
2002 SummaCare Health Plan 6 Section 3
Section 2. How we change for 2002
Program-wide changes
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.
We increased speech therapy benefits by removing the requirement that
services must be required to restore functional speech. (Section 5( a)).
Changes to this Plan
Your share of the non-postal premium will
increase for Self Only by 12.2% and for Self & Family by 12.2%.
Home
Health Care is now covered in full.
The 24 Hour Mental Health Crisis Hotline
has been discontinued. These services can now be received through the SummaCare
24 Hour Nurse Line.
The Plan will cover up to $100 per member, per lifetime for one smoking
cessation program including, therapy and prescription medication.
We will
cover certain intestinal transplants. (Section 5( b)).
We no longer limit
blood cholesterol tests to certain age groups. 6
6
Page 7 8
2002
SummaCare Health Plan 7 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 800-996-8701.
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.
Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our members. We credential Plan
providers according to national
standards. We have contracted with thousands of
healthcare providers to
provide medical services.
We list Plan providers in the provider directory, which we update
periodically. The list is
also on our website at www. summacare. com.
Plan facilities Plan facilities are hospitals and other facilities in
our service area that we contract with to provide covered services to our
members. We list these in the provider directory, which
we update
periodically. The list is also on our website at www. summacare. com.
It
depends on the type of care you need. First, you and each family member must
choose
a primary care physician. This decision is important since your
primary care physician
provides or arranges for most of your health care. A
Primary Care Physician (PCP)
selection card is included with information you
receive during Open Season. You should
fill this card out and send it to up
upon enrollment in the Plan. Be sure to include
information regarding each
of your dependents who will be covered under the Plan.
Primary care Your primary care physician can be a family practitioner,
internist, or pediatrician. Your primary care physician will provide most of
your health care, or give you a referral to see
a specialist.
If you
want to change primary care physicians or if your primary care physician leaves
the Plan, call us. We will help you select a new one.
Specialty care Your primary care physician will refer you to a
specialist for needed care. When you receive a referral from your primary care
physician, you must return to the primary care
physician after the
consultation, unless your primary care physician authorized a certain
number
of visits without additional referrals. The primary care physician must provide
or
authorize all follow-up care. Do not go to the specialist for return
visits unless your
primary care physician gives you a referral. However, you
may see the following
specialists without a referral from your primary care
physician:
-a female may visit a Plan gynecologist for a routine gynecological services;
-a female may visit a Plan OB/ GYN for maternity services;
-a female may
visit a Plan provider for routine mammograms;
-you may visit a Plan
ophthalmologist if you are a diabetic for a annual retinal eye
exam;
-you may visit a Plan ophthalmologist once every 24 months for a routine eye
exam;
What you must do
to get covered care 7
7
Page 8 9
2002
SummaCare Health Plan 8 Section 3
-you may visit a Plan mental
health provider (your provider is responsible for
submitting a treatment
plan to the Plan after the initial visits); and
-visits to an emergency room
or urgent care center for emergency/ urgent care
situations.
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician will develop a treatment
plan that
allows you to see your specialist for a certain number of visits
without additional
referrals. Your primary care physician will use our
criteria when creating your
treatment plan (the physician may have to get an
authorization or approval
beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to your
primary care physician. Your primary care physician will decide what treatment
you need. If he or
she decides to refer you to a specialist, ask if you can
see your current specialist. If
your current specialist does not participate
with us, you must receive treatment from a
specialist who does. Generally,
we will not pay for you to see a specialist who does
not participate with
our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your
primary care physician, who will arrange for you to see another specialist. You
may receive
services from your current specialist until we can make
arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than cause; or
drop
out of the Federal Employees Health Benefits (FEHB) Program and you enroll in
another FEHB Plan; or
reduce our service area and you enroll in another FEHB Plan,
you may be
able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us or, if we drop out of the Program, contact
your new
plan.
If you are in the second or third trimester of pregnancy and you lose access
to your
specialist based on the above circumstances, you can continue to see
your specialist until
the end of your postpartum care, even if it is beyond
the 90 days.
Hospital care Your Plan primary care physician or specialist will make
necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of
facility.
If you are in the
hospital when your enrollment in our Plan begins, call our customer
service
department immediately at 330-996-8700 or 800-996-8701. If you are new to the
FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital
stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day
after you become a member of this Plan, whichever happens first. 8
8 Page 9 10
2002 SummaCare Health Plan 9 Section 3
These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable
efforts to provide you with the necessary care.
Your primary care physician
has authority to refer you for most services. 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.
We call this review and approval process pre-authorization. Your physician
must obtain
approval from us. Before giving approval, we consider if a
service is covered, medically
necessary, and follows generally accepted
medical practice.
We call this review and approval process pre-authorization. Your physician
must obtain
pre-authorization for services such as inpatient stays, surgical
procedures and certain
diagnostic procedures such as an MRI.
Your physician must get our approval before sending you to a hospital,
referring you to a
specialist, or recommending follow-up care. Before giving
approval, we consider if the
service is medically necessary, and if it
follows generally accepted medical practice. You
and your physician will
receive a letter which informs you if the services requested have
been
pre-authorized and the number of visits that have been approved, if applicable.
This
letter will also contain information on how to contact us if you
disagree about a decision
regarding pre-authorization.
Services requiring our
prior approval 9
9
Page 10 11
2002
SummaCare Health Plan 10 Section 4
Section 4. Your
costs for covered services
You must share the cost of some services. You
are responsible for:
Copayments A copayment is a fixed amount of
money you pay to the provider, facility, pharmacy, etc., when you receive
services.
Example: When you see your primary care physician you pay a copayment of $10
per
office visit.
Deductible We do not have a deductible
Coinsurance We do
not have coinsurance.
We do not have an out-of-pocket maximum. Your
out-of-pocket maximum 10
10 Page 11 12
2002 SummaCare
Health Plan 11 Section 5
Section 5. Benefits – OVERVIEW
(See page 6 for how our benefits changed this year and page 53 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 330-996-8700 or
800-996-8701 or at our
website at www. summacare. com.
(a) Medical
services and supplies provided by physicians and other health care
professionals........................................................ 12-21
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family
planning
Infertility services Allergy care
Treatment therapies Physical
and occupational therapies
Speech therapy Hearing services (testing, treatment, and supplies)
Vision
services (testing, treatment, and supplies) Foot care
Orthopedic and
prosthetic devices Durable medical equipment (DME)
Home health services
Chiropractic
Alternative treatments Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................................ 22-26
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital
or other facility, and ambulance services
..............................................................................
27-29
Inpatient hospital Outpatient hospital or ambulatory surgical center Extended
care benefits/ skilled nursing care facility benefits
Hospice care Ambulance
(d) Emergency services/ accidents
.................................................................................................................................................
30-31
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
............................................................................................................................
32-33
(f) Prescription drug benefits
..............................................................................................................................................................
34
(g) Special features
.............................................................................................................................................................................
36
Flexible benefits option Complementary Care 24 Hour Nurse Line Maternal
Care Program
Centers for Excellence Travel Benefit Web site NCQA Accreditation
(h)
Dental benefits
...............................................................................................................................................................................
37
(i) Non-FEHB benefits available to Plan members
............................................................................................................................
38
Summary of benefits
.............................................................................................................................................................................
53 11
11 Page 12
13
2002 SummaCare Health Plan 12 Section 5(
a)
Section 5 (a). Medical services and supplies provided by
physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
The calendar year
deductible is: We have no calendar year deductible.
Be sure to read Section
4, Your costs for covered services, for valuable information about how
cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office $10 per
office visit
Professional services of physicians
In an urgent care center
During a
hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
Home visits
$25
Nothing
Nothing
$10 per office visit
$10 per office visit
$10 per visit 12
12 Page
13 14
2002 SummaCare Health Plan
13 Section 5( a)
Lab, X-ray and other diagnostic tests You Pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Nothing if you receive these services during
your office visit;
otherwise, $10 per office visit
Preventive care, adult
Routine screenings, such as:
Total
Blood Cholesterol – once every three years
Colorectal Cancer Screening,
including
Fecal occult blood test
Sigmoidoscopy, screening – every five
years starting at age 50
Prostate Specific Antigen (PSA test) – one annually
for men age 40 and older
Routine pap test
Note: The office visit is covered if pap test is
received on the same day;
see Diagnosis and Treatment, above.
$10 per office visit
Preventive Care -Adult --continued on next page 13
13 Page 14 15
2002 SummaCare Health Plan 14 Section 5( a)
Preventive care, adult (continued) You pay
Routine mammogram –covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40
through 64, one every calendar year
At age 65 and older, one every two
consecutive calendar years
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster – once
every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Preventive care, children
Childhood immunizations recommended by
the American Academy of Pediatrics
Well-child care charges for routine examinations, immunizations and care
(under age 22)
Examinations, such as: Eye exams through age 17 to determine
the need for vision correction.
Ear exams through age 17 to determine the
need for hearing correction
Examinations done on the day of immunizations
(under age 22)
$10 per office visit 14
14 Page 15 16
2002 SummaCare
Health Plan 15 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 22 for other
circumstances, such as extended stays for you or your baby.
You may remain in the hospital up to 48 hours after a regular delivery and 96
hours after a cesarean delivery. We will extend your inpatient
stay if
medically necessary.
We cover routine nursery care of the newborn child
during the covered portion of the mother's maternity stay. We will cover other
care of an
infant who requires non-routine treatment only if we cover the infant
under a Self and Family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for
illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
$10 for initial office visit only. You pay
nothing for additional office
visits.
Not covered: Routine sonograms to determine fetal age, size or sex All
charges.
Family planning
A broad range of voluntary family
planning services, limited to:
Voluntary sterilization
Surgically
implanted contraceptives (such as Norplant)
Injectable contraceptive drugs
(such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
NOTE:
We cover oral contraceptives under the prescription drug benefit.
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, voluntary abortions,
All charges.
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
Artificial insemination: intravaginal insemination
(IVI)
intracervical insemination (ICI) intrauterine insemination (IUI)
$10 per office visit 15
15 Page 16 17
2002 SummaCare
Health Plan 16 Section 5( a)
Not covered:
Assisted
reproductive technology (ART) procedures, such as:
in vitro
fertilization embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer Services and supplies related to excluded ART
procedures
Cost of donor sperm
Cost of donor egg
All charges.
Allergy care
Testing and treatment
Allergy injection
$10
per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 16
16 Page 17 18
2002 SummaCare Health Plan 17 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under Organ/
Tissue
Transplants on page 25.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal
dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
preauthorize the treatment. Call
the Plan at 800-996-8701 for
preauthorization. We will ask you to submit
information that establishes
that the GHT is medically necessary. 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 17
17 Page 18 19
2002 SummaCare
Health Plan 18 Section 5( a)
Physical and occupational
therapies You pay
60 visits per condition for the services of each of
the following:
qualified physical therapists and occupational therapists.
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.
Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction, is provided for up to 36 sessions. We must
approve these services.
$10 per office visit or per outpatient visit
Nothing during a covered
inpatient admission.
Not covered:
long-term rehabilitative therapy
exercise programs
All charges.
Speech therapy
Unlimited visits per condition $10 per visit
Hearing services (testing, treatment, and supplies)
First hearing
aid and testing only when necessitated by accidental injury
Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered:
all other hearing testing hearing aids,
testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies)
One pair of
eyeglasses or contact lenses to correct an impairment directly caused by
accidental ocular injury or intraocular surgery (such as for
cataracts)
$10 per office visit.
Eye exam to determine the need for vision correction for children through age
17 (see Preventive care, children)
Routine eye exam every 24 months.
$10 per office visit
$10 per office visit.
Not covered:
Eyeglasses or contact
lenses and, after age 17, examinations for them
Eye exercises and
orthoptics
Radial keratotomy and other refractive surgery
All charges. 18
18 Page 19 20
2002 SummaCare
Health Plan 19 Section 5( a)
Foot care You pay
Routine
foot care when you are under active treatment for a metabolic or
peripheral
vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$10 per office visit
Not covered:
Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot, except
as stated above
Treatment of weak, strained or flat feet or
bunions or spurs; and of any instability, imbalance or subluxation of the foot
(unless the treatment is
by open cutting surgery)
All charges.
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump
hose; deluxe models not covered unless medically necessary.
Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as
artificial joints, pacemakers, cochlear implants, and surgically implanted
breast implant following
mastectomy. Note: See 5( b) for coverage of the
surgery to insert the
device.
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
$10 per office visit
Not covered:
Orthopedic and corrective shoes
Arch
supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings,
support hose, and other supportive devices
Prosthetic replacements (covered only if pre-authorized by the SummaCare
Health Services Management program)
All charges. 19
19 Page 20 21
2002 SummaCare
Health Plan 20 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
standard
versions of the following:
hospital beds;
wheelchairs; non-motorized;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.
$10 per office visit
Not covered:
Motorized wheel chairs All charges.
Home health services
Home health care ordered by a Plan physician
and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.),
licensed
vocational nurse (L. V. N.), or home health aide
Nothing.
Not covered:
nursing care requested by, or for the convenience
of, the patient or the patient's family;
home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic or rehabilitative.
All charges.
Chiropractic
Not covered All charges. 20
20 Page 21 22
2002 SummaCare Health Plan 21 Section 5( a)
Alternative treatments You pay
Not covered:
acupuncture naturopathic services
hypnotherapy biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
Smoking Cessation – Up to $100 for one smoking cessation program per member
per lifetime, including all related expenses such as drugs.
Diabetes self-management
Nothing, except if services are provided in
doctor's office, then you pay
$10 per office
visit. 21
21 Page 22 23
2002 SummaCare
Health Plan 22 Section 5( b)
Section 5 (b). Surgical and
anesthesia services provided by physicians
and other health care
professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care.
Be sure to read
Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e. hospital, surgical center, etc.).
YOUR 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.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
A
comprehensive range of services, such as:
Operative procedures Treatment of
fractures, including casting
Normal pre-and post-operative care by the surgeon Correction of amblyopia and
strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and
cysts Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual
weighs 100 pounds or 100% over his or her normal weight
according to current
underwriting standards; eligible members must be
age 18 or over
Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
$10 per office visit
Surgical procedures continued on next page. 22
22 Page 23 24
2002 SummaCare Health Plan 23 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per office visit
Not covered:
Reversal of voluntary sterilization Routine
treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital
anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth
marks; webbed fingers; and webbed toes.
$10 per office visit
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast; treatment
of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.
$10 per office visit.
Not covered:
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to improve physical appearance
through
change in bodily form, except repair of accidental injury
Surgeries related to sex transformation
All charges. 23
23 Page 24 25
2002 SummaCare
Health Plan 24 Section 5( b)
Oral and maxillofacial surgery
You Pay
Oral surgical procedures, limited to:
Reduction of fractures
of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or
severe functional
malocclusion;
Removal of stones from salivary ducts; Excision of
leukoplakia or malignancies;
Excision of cysts and incision of abscesses when done as independent
procedures; and
Other surgical procedures that do not involve the teeth or
their supporting structures.
Temporomandibular Joint disfunction (TMJ)
$10 per office visit
Not covered:
Oral implants and transplants Procedures
that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone)
All charges. 24
24 Page 25 26
2002 SummaCare
Health Plan 25 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/
Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor)
bone marrow transplants
Autologous bone marrow transplants (autologous stem
cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell
tumors
Intestinal transplants
(small intestine) and the small intestine with the
liver or small intestine
with multiple organs such as the liver, stomach,
and pancreas
National
Transplant Program (NTP) – The Plan contracts with a national network of
transplant providers. Pre-authorization must be
obtained for all transplants.
Limited Benefits -Treatment for breast
cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in
an NCI-or NIH-approved
clinical trial at a Plan-designated center of
excellence and if approved by
the Plan's medical director in accordance with
the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when
we
cover the recipient.
Nothing
Not covered:
Donor screening tests and donor search expenses,
except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered
All charges 25
25 Page 26 27
2002 SummaCare
Health Plan 26 Section 5( b)
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)
Nothing
Professional services provided in –
Hospital outpatient department
Skilled nursing facility
Ambulatory surgical center Office
$10 per office visit 26
26 Page 27 28
2002 SummaCare
Health Plan 27 Section 5( c)
Section 5 (c). Services provided
by a hospital or other facility,
and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
Be sure to read Section 4, Your costs
for covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with
Medicare.
The amounts listed below are for the charges billed by the
facility (i. e., hospital or surgical center) or ambulance service for your
surgery or care. Any costs associated with the professional charge
(i. e., physicians, etc.) are covered in Sections 5( a) or (b).
YOUR
PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require precertification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
ward, semiprivate, or intensive care accommodations; general nursing
care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.
Nothing
Inpatient hospital continued on next page. 27
27 Page 28 29
2002 SummaCare Health Plan 28 Section 5( c)
Inpatient hospital (continued) You pay
Other
hospital services and supplies, such as:
Operating, recovery, maternity, and
other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced Dressings,
splints, casts, and sterile tray services
Medical supplies and equipment,
including oxygen Anesthetics, including nurse anesthetist services
Take-home
items Medical supplies, appliances, medical equipment, and any covered
items
billed by a hospital for use at home
Nothing
Not covered:
Custodial care Non-covered facilities, such
as nursing homes, schools
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating,
recovery, and other treatment rooms Prescribed drugs and medicines
Diagnostic laboratory tests, X-rays, and pathology services Administration of
blood, blood plasma, and other biologicals
Blood and blood plasma, if not
donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray
services Medical supplies, including oxygen
Anesthetics and anesthesia
service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We do
not cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/ skilled nursing care facility
benefits
Extended care/ Skilled nursing facility:
The Plan covers a comprehensive range of benefits for up to 100 days of
skilled care after hospitalization when full-time 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.
You
pay nothing. All medically necessary services are covered.
Nothing
Not covered: custodial care All charges. 28
28 Page 29 30
2002 SummaCare Health Plan 29 Section 5( c)
Hospice care You Pay
Supportive and palliative care for a
terminally ill member is covered in the
home or a hospice facility. Services
include inpatient and outpatient care,
and family counseling; these services
are provided under the direction of a
Plan doctor who certifies that the
patient is in the terminal stages of illness,
with a life expectancy of
approximately six months or less.
Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
Local professional ambulance service when medically
appropriate Nothing 29
29 Page
30 31
2002 SummaCare Health Plan
30 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
Be sure to read Section 4,
Your costs for covered services, for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A
medical emergency is the sudden and unexpected onset of a condition or an injury
that you believe endangers your life or
could result in serious injury or
disability, and requires immediate medical or surgical care. Some problems are
emergencies
because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are
emergencies
because they are potentially life-threatening, such as heart attacks, strokes,
poisonings, gunshot wounds, or sudden
inability to breathe. There are many
other acute conditions that we may determine are medical emergencies – what they
all have
in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
local emergency system (e. g., the 911 telephone
System) or go to the
nearest hospital emergency room or approved urgent care center. Be sure to tell
the emergency room
personnel that you are a Plan member so they can notify
the Plan. You or a family member should notify the Plan within 48
hours
unless it was not reasonably possible to do so. It is your responsibility to
ensure that the Plan has been timely notified.
If you need to be hospitalized in a non-Plan facility, the Plan must be
notified within 48 hours or on the first working day
following your
admission, unless it was not reasonably possible to notify the Plan within that
time. If you are hospitalized in
non-Plan facilities and a Plan doctor
believes care can be better provided in a Plan hospital, you will be transferred
when
medically feasible with any ambulance charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a Plan provider would
result in death,
disability or significant jeopardy to your condition.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided
by Plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 48 hours or
on the first working day following your admission,
unless it was not
reasonably possible to notify the Plan within that time. If a Plan doctor
believes care can be better provided in a
Plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan
providers must be approved by the Plan or provided
by Plan providers. 30
30 Page 31 32
2002 SummaCare Health Plan 31 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care
center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$10 per office visit
$25 per visit
$50 per visit – waived if admitted
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$10 per office visit
$25 per visit
$50 per visit – waived if admitted
Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
All charges.
Ambulance
Professional ambulance service when medically
appropriate.
See 5( c) for non-emergency service.
$50 per occurrence –
waived if admitted
Not covered: air ambulance All charges. 31
31 Page 32 33
2002 SummaCare Health Plan 32 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T
When you get our approval for services and follow a treatment plan we
approve, cost sharing and limitations
for Plan mental health and substance
abuse benefits will be no greater for similar benefits than for other
illnesses and conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions
in this brochure.
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
NO PREAUTHORIZATION IS NEEDED FOR THESE SERVICES. However, your
provider is required to submit a treatment plan to the Plan after your first two
initial visits.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan may
include services, drugs, and supplies described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive the
care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
Professional services, including individual or group therapy by providers
such as psychiatrists, psychologists, or clinical social workers
Medication management
$10 per visit
Mental health and substance abuse benefits -continued on next page 32
32 Page 33 34
2002 SummaCare Health Plan 33 Section 5( e)
Mental health and substance abuse benefits (continued)
You pay
Diagnostic tests $10 per visit or test
Services provided by a hospital or other facility
Services in approved
alternative care settings such as partial
hospitalization, half-way house,
residential treatment, full-day
hospitalization, facility based intensive
outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment plans on the
treatment plan's clinical
appropriateness. OPM will generally not order us
to pay or provide one
clinically appropriate treatment plan in favor of
another.
All charges.
Preauthorization To be eligible to receive these benefits you must
follow your treatment plan and all the following authorization processes:
You may self-refer to a Plan mental health provider. Your Plan provider will
submit a
treatment plan to the Plan for authorization for continued
treatment. Refer to your
Provider Directory for a listing of Plan providers.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 33
33 Page
34 35
2002 SummaCare Health Plan
34 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions,
limitations and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the
prescription – or – A plan physician or licensed dentist must write the
prescription.
Where you can obtain them. You may fill the prescription at a
SummaCare network pharmacy, a non-network pharmacy, or by mail. We pay a higher
level of benefits when you use a network pharmacy.
These are the
dispensing limitations.
A generic equivalent will be dispensed if it is
available, unless your physician specifically requires a name brand.
If you
receive a name brand drug when a Federally-approved generic drug is available,
and your physician has
not specified Dispense as Written for the name brand
drug, you have to pay the difference in cost between the
name brand drug and
the generic.
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.
You can save money by using generic drugs. However, you and your physician
have the option to request a
name-brand if a generic option is available.
Using the most cost-effective medication saves money.
When you have to file a claim. In an emergency situation, you may have
a prescription filled at a non-Plan pharmacy. You will have to the pay for the
prescription at the time it is filled and submit a claim form to the
Plan
for reimbursement. To obtain a prescription drug claim form, call us at
330-996-8700 or 800-996-8701.
Mail claim forms to SummaCare Health Plan, 10
North Main Street, Akron, Ohio, 44308. 34
34
Page 35 36
2002
SummaCare Health Plan 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 or through our mail order
program:
Drugs and medicines that by Federal law of the United States require a
physician's prescription for their purchase, except those listed as Not
covered.
Insulin Disposable needles and syringes for the
administration of covered
medications
Drugs for sexual dysfunction (see Prior authorization below)
Contraceptive drugs and devices
Intravenous fluids and medications for home use, implantable drugss, such as
Norplant, some injectible drugs, such as Depo Provera, are
covered under
medical benefits.
$5 per generic/$ 10 per brand name prescription
for a 30 day supply
$10per generic/$ 20 per prescription for a 90
day supply through mail
service
Note: If there is no generic equivalent
available, you will still have to
pay the brand
name copay.
Note: You will pay 50% of the cost for growth
hormones.
Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs.
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
Nonprescription medicines
2002 SummaCare Health Plan 36 Section 5( g)
Section 5
(g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we
determine the most effective way to provide services.
We may identify
medically appropriate alternatives to traditional care and coordinate other
benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an
alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may
withdraw it at any time and resume regular contract benefits.
Our decision
to offer or withdraw alternative benefits is not subject to OPM review under the
disputed claims process.
Complementary care As a SummaCare member, you are automatically
enrolled in The Alternative Choice Program which offers discounts to alternative
medicine services such as chiropractic,
acupuncture and massage therapy
services. Also, members can purchase health-related
items online at www. healthyroads. com at a discount and
with free shipping.
For more information, call Customer Service at
800-996-8701.
24 hour nurse line For any of your health concerns, 24 hours a day, 7
days a week, you may call 800-379-5001 and talk with a registered nurse who will
discuss treatment options and answer
your health questions.
Maternal care program The Maternal Care program offers all expectant
members access to a registered nurse who will offer guidance throughout
pregnancy. Information, aid in scheduling
appointments and a post-delivery
visit are included in the program.
Centers of excellence for
transplants/ heart surgery,
etc.
SummaCare Health Plan's network of hospitals includes many Centers of
Excellence
for many types of covered services. Refer to your Provider
Directory for more
information about the hospitals included in the Plan's
network.
Travel benefit/ services
overseas
You are covered for emergency and urgent care services anywhere in the world.
Any
follow-up care should be coordinated through your Primary Care
Physician.
Web site At www. summacare. com
you can view and search through the most updated listing of network
providers, change your PCP, request plan information and learn more about
how SummaCare is working to keep you healthy. You can also contact Customer
Service at any time through our Web site.
NCQA accreditation SummaCare received accreditation through the
National Committee for Quality Assurance (NCQA) in June of 2001. The Plan
received Excellent accreditation for our
Commercial HMO/ POS and Medicare
plans as well as a Commendable accreditation
for our Medicaid HMO plan. The
NCQA measures health plans against over 60
quality measures. SummaCare is
the only plan in northeast Ohio to receive an
Excellent accreditation on
more than one product line. 36
36 Page 37 38
2002 SummaCare
Health Plan 37 Section 5( i)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization
for dental procedures only when a nondental physical impairment exists which
makes hospitalization necessary to safeguard the health of the patient; we do
not cover the dental procedure unless it is
described below..
Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.
$10 per office visit
Dental benefits
We have no other dental benefits. 37
37 Page 38 39
2002 SummaCare Health Plan 38 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium,
and you cannot file an FEHB disputed claim about them.
Fees you pay
for these services do not count toward FEHB deductibles or out-of-pocket
maximums.
Medicare prepaid plan enrollment -This Plan offers Medicare recipients the
opportunity to enroll in the Plan through Medicare. As
indicated on page 45,
annuitants and former spouses with FEHB coverage and Medicare Part B may elect
to drop their FEHB
coverage and enroll in a Medicare prepaid plan when one
is available in their area. They may then later reenroll in the FEHB
Program. Most Federal annuitants have Medicare Part A. Those without
Medicare Part A may join this Medicare prepaid plan but
will probably have
to pay for hospital coverage in addition to the Part B premium. Before you join
the plan, ask whether the plan
covers hospital benefits and, if so, what you
will have to pay. Contact your retirement system for information on dropping
your FEHB
enrollment and changing to a Medicare prepaid plan. Contact us at
888-464-8440 for information on the Medicare prepaid plan and
the cost of
that enrollment.
If you are Medicare eligible and are interested in enrolling in a Medicare
HMO sponsored by this Plan without dropping your
enrollment in this Plan's
FEHB plan, call 888-464-8440 for information on the benefits available under the
Medicare HMO. 38
38 Page
39 40
2002 SummaCare Health Plan
39 Section 6
Section 6. General exclusions --things we don't
cover
The exclusions in this section apply to all benefits. Although
we may list a specific service as a benefit, we will not cover it
unless
your Plan doctor determines it is medically necessary to prevent, diagnose, or
treat your illness, disease, injury, or
condition and we agree, as discussed
under What Services Require Our Prior Approval on page 9.
We do not cover the following:
Care by non-Plan providers except for authorized referrals or emergencies
(see Emergency Benefits);
Services, drugs, or supplies you receive while you
are not enrolled in this Plan;
Services, drugs, or supplies that are not
medically necessary;
Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice;
Experimental
or investigational procedures, treatments, drugs or devices;
Services,
drugs, or supplies related to abortions, except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is
the result of an act of rape or incest ;
Services, drugs, or supplies related to sex transformations; or
Services,
drugs, or supplies you receive from a provider or facility barred from the FEHB
Program. 39
39 Page
40 41
2002 SummaCare Health Plan
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:
In most cases, providers and facilities file claims for you. Physicians must
file on the
form HCFA-1500, Health Insurance Claim Form. Facilities will
file on the UB-92 form.
For claims questions and assistance, call us at
330-996-8700 or 800-996-8701.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500
or a claim form that includes the information shown below. Bills
and receipts should be
itemized and show:
Covered member's name and ID number;
Name and address of the physician or
facility that provided the service or supply;
Dates you received the
services or supplies;
Diagnosis;
Type of each service or supply;
The
charge for each service or supply;
A copy of the explanation of benefits,
payments, or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and
Receipts, if you paid for your services.
Submit your claims to:
SummaCare Health Plan, 10 North Main Street, Akron,
Ohio, 44308
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.
Medical, hospital and drug
benefits 40
40 Page 41 42
2002 SummaCare Health Plan 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:
Write to us within 6 months from the date of our decision; and
Send your
request to us at: {Plan address}; and
Include a statement about why you
believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and
Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical
records, and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: Pay the
claim (or, if applicable, arrange for the health care provider to give you the
care); or
Write to you and maintain our denial --go to step 4; or
Ask
you or your provider for more information. If we ask your provider, we will send
you a copy of our request—
go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information was due. We
will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us --if
we did not answer that request in some way within 30 days; or
120 days after
we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW,
Washington, DC
20415-3630. 41
41 Page
42 43
2002 SummaCare Health Plan
42 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
A statement about why you
believe our decision was wrong, based on specific benefit provisions in this
brochure;
Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms;
Copies of all letters you sent to us about the claim;
Copies of all
letters we sent to you about the claim; and
Your daytime phone number and
the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim.
Note: You are the only person who has
a right to file a disputed claim with OPM. Parties acting as your
representative, such
as medical providers, must include a copy of your
specific written consent with the review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of reasons
beyond your control.
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 330-996-8700 or
800-996-8701 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that
they can give your claim expedited treatment too, or
You can call OPM's Health Benefits Contracts Division III at 202-606-0737
between 8 a. m. and 5 p. m. eastern time. 42
42
Page 43 44
2002
SummaCare Health Plan 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.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under
65 years of age.
People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you
should be able to qualify for premium-free
Part A insurance. (Someone who was a
Federal employee on January 1, 1983 or
since automatically qualifies.) Otherwise, if
you are age 65 or older, you
may be able to buy it. Contact 1-800-MEDICARE for
more information.
Part B (Medical Insurance). Most people pay monthly for Part B. Generally,
Part B premiums are withheld from your monthly Social Security check or your
retirement
check.
If you are eligible for Medicare, you may have choices in how you get your
health care.
Medicare + Choice is the term used to describe the various
health plan choices available
to Medicare beneficiaries. The information in
the next few pages shows how we
coordinate benefits with Medicare, depending
on the type of Medicare managed care plan
you have.
The Original Medicare Plan (Original Medicare) is available everywhere in the
United
States. It is the way everyone used to get Medicare benefits and is
the way most people
get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist,
or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay
your share. Some things
are not covered under Original Medicare, like prescription
drugs.
When you are enrolled in Original Medicare along with this Plan, you still
need to follow
the rules in this brochure for us to cover your care. Your
care must continue to be
authorized by your Plan PCP, or precertified as
required.
We will not waive any of our copayments.
The Original Medicare Plan (Part A or Part B) 43
43 Page 44 45
2002 SummaCare Health Plan 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… A. When either you --or
your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or a
family member are eligible for
Medicare solely because of a disability), !
2) Are an annuitant, !
3) Are a reemployed annuitant with the Federal
government when…
a) The position is excluded from FEHB, or !
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you..)
!
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge who retired under Section 7447 of title 26, U. S. C. (or if your
covered
spouse is this type of judge), !
5) Are enrolled in Part B only, regardless of your employment status, ! (for
Part B services) ! (for other services)
6) Are a former Federal employee
receiving Workers' Compensation and the
Office of Workers' Compensation
Programs has determined that you are
unable to return to duty,
!
(except for claims
related to Workers'
Compensation.)
B. When you --or a covered family member --have Medicare based on
end
stage renal disease (ESRD) and…
1) Are within the first 30 months of eligibility to receive Part A
benefits solely
because of ESRD, !
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD, !
3) Become eligible for Medicare due to ESRD after Medicare became
primary
for you under another provision, !
C. When you or a covered family member have FEHB and…
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or !
b) Are an active employee !
c) Are a former spouse of an annuitant !
d) Are a former spouse of an active employee ! 44
44 Page 45 46
2002 SummaCare Health Plan 45 Section 9
You probably will never have to file a claim form when you have both our
Plan and the
Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original
Medicare is the primary payer, Medicare processes your claim first.
In most
cases, your claims will be coordinated automatically and we will pay the
balance of covered charges. You will not need to do anything. To find out if
you
need to do something about filing your claims, call us at 330-996-8700
or 800-996-
8701 or www. summacare. com.
We do not waive any costs when you have Medicare.
Medicare managed
care plan If you are eligible for Medicare, you may choose to enroll in and
get your Medicare
benefits from another type of Medicare+ Choice plan --a
Medicare managed care plan.
These are health care choices (like HMOs) in
some areas of the country. In most
Medicare managed care plans, you can only
go to doctors, specialists, or hospitals that
are part of the plan. Medicare
managed care plans provide all the benefits that Original
Medicare covers.
Some cover extras, like prescription drugs. To learn more about
enrolling in
a Medicare managed care plan, contact Medicare at 1-800-MEDICARE
(1-
800-633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options are
available to you:
This Plan and our Medicare managed care plan: You
may enroll in our Medicare
managed care plan and also remain enrolled in our
FEHB plan. In this case, we do/ do not
waive any of our copayments,
coinsurance, or deductibles for your FEHB coverage.
This Plan and another plan's Medicare managed care plan: You may
enroll in
another plan's Medicare managed care plan and also remain enrolled
in our FEHB plan.
We will still provide benefits when your Medicare managed
care plan is primary, even
out of the managed care plan's network and/ or
service area (if you use our Plan
providers), but we will not waive any of
our copayments.. If you enroll in a Medicare
managed care plan, tell us. We
will need to know whether you are in the Original
Medicare Plan or in a
Medicare managed care plan so we can correctly coordinate
benefits with
Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an
annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your
Medicare managed care plan premium.) For
information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB
Program, generally you
may do so only at the next open season unless you involuntarily
lose
coverage or move out of the Medicare managed care plan's service area.
If you do not have one or both Parts of Medicare, you can still be covered
under the
FEHB Program. We will not require you to enroll in Medicare Part B
and, if you can't
get premium-free Part A, we will not ask you to enroll in
it.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE
and this Plan cover you, we pay first. See your
TRICARE Health Benefits Advisor if you
have questions about TRICARE
coverage.
If you do not enroll in
Medicare Part A or Part B
Claims process when you have the
Original Medicare Plan -- 45
45 Page 46 47
2002 SummaCare Health Plan 46 Section 9
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the Office of Workers'
Compensation Programs (OWCP) or a similar Federal or State agency determines
they
must provide; or
OWCP or a similar agency pays for through a third party
injury settlement or other similar proceeding that is based on a claim you filed
under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we
will
cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government 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
46 Page 47 48
2002 SummaCare Health Plan 47 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same
year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 10.
Covered services Care we provide benefits for, as described in this
brochure.
Custodial care Care comprised of services and supplies,
including room and board and other institutional services, that is provided to
an individual, whether disabled or not, primarily to assist in
the
activities of daily living.
In determining is a service is experimental or investigational, the
Planresearches the
safety and effectiveness of medical treatment. The Plan's
Utilization Review Committee,
which consists of physicians, may also be
consulted to assist in determinations. In the
course of the determination
process, numerous medical and healthcare industry journals
and healthcare
databases may be used. For many procedures, the Plan follows guidelines
set
by the Health Care Financing Administration (HCFA).
Medical necessity A service or supply must be necessary and
appropriate for the diagnosis and treatment of an illness or injury as
determined by the Plan based on generally accepted current
medical practice.
Us/ We Us and we refer to SummaCare Health Plan.
You You
refers to the enrollee and each covered family member.
Experimental or
investigational services 47
47 Page 48 49
2002 SummaCare Health Plan 48 Section 11
Section 11. FEHB facts
No pre-existing condition We will not
refuse to cover the treatment of a condition that you had
limitation
before you enrolled in this Plan solely because you had the condition before
you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or
about enrolling in the retirement office can answer your
questions, and give you a Guide to Federal Employees
FEHB Program
Health Benefits Plans, brochures for other plans, and other materials
you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment
begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your
enrollment status without information from your employing
or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for
for you and your family you, your spouse,
and your unmarried dependent children under age 22, including any foster
children or stepchildren your employing or retirement office authorizes coverage
for. Under certain circumstances, you may also continue coverage for a
disabled child 22
years of age or older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and Family
enrollment if
you marry, give birth, or add a child to your family. You may
change your enrollment 31
days before to 60 days after that event. The Self
and Family enrollment begins on the
first day of the pay period in which the
child is born or becomes an eligible family
member. When you change to Self
and Family because you marry, the change is effective
on the first day of
the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you
marry.
Your employing or retirement office will not notify you when a family
member is no
longer eligible to receive health benefits, nor will we. Please
tell us immediately when
you add or remove family members from your coverage
for any reason, including
divorce, or when your child under age 22 marries
or turns 22.
If you or one of your family members is enrolled in one FEHB plan, that
person may not
be enrolled in or covered as a family member by another FEHB
plan. 48
48 Page
49 50
2002 SummaCare Health Plan
49 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you first join this Plan during
premiums start open season, your coverage begins on the first day of
your pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on January 1. If you join at
any other time during the year, your employing office will tell you the
effective date of
coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only
records are confidential the following
will have access to it:
OPM, this Plan, and subcontractors when they administer this contract;
This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
Law enforcement officials when investigating and/ or
prosecuting alleged civil or criminal actions;
OPM and the General Accounting Office when conducting audits;
Individuals
involved in bona fide medical research or education that does not disclose your
identity; or
OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as
temporary continuation
of coverage (TCC).
When you lose benefits
When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
Your enrollment ends, unless you cancel your enrollment, or
You are a
family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may not coverage continue to get benefits under your
former spouse's enrollment. But, you may be eligible
for your own FEHB coverage under the spouse equity law. If you are recently
divorced
or are anticipating a divorce, contact your ex-spouse's employing
or retirement office to
get RI 70-5, the Guide to Federal Employees
Health Benefits Plans for Temporary
Continuation of Coverage and Former
Spouse Enrollees, or other information about your
coverage choices.
Temporary Continuation of Coverage (TCC) If you leave Federal service,
or if you lose coverage because you no longer qualify as a
family member,
you may be eligible for Temporary Continuation of Coverage (TCC).
For
example, you can receive TCC if you are not able to continue your FEHB
enrollment
after you retire, if you lose your job, if you are a covered
dependent child and you turn 22
or marry, etc.
You may not elect TCC if you are fired from your Federal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC,
and the RI 70-5, the Guide
to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage
and Former Spouse Enrollees, from
your employing or retirement office or from
www. opm. gov/ insure. It
explains what you have to do to enroll. 49
49
Page 50 51
2002 SummaCare Health Plan 50 Section 11
Converting to
You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends (If you canceled
your coverage or did not pay your premium, you cannot convert);
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If
you leave Federal service, your employing office will notify you of your right
to
convert. You must apply in writing to us within 31 days after you receive
this notice.
However, if you are a family member who is losing coverage, the
employing or
retirement office will not notify you. You must apply in
writing to us within 31 days
after you are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you
will not have to answer questions about your health, and we
will not impose a waiting
period or limit your coverage due to pre-existing
conditions.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a
Federal
law that offers limited Federal protections for health coverage
availability and continuity
to people who lose employer group coverage. If
you leave the FEHB Program, we will
give you a Certificate of Group Health
Plan Coverage that indicates how long you have
been enrolled with us. You
can use this certificate when getting health insurance or other
health care
coverage. Your new plan must reduce or eliminate waiting periods,
limitations, or exclusions for health related conditions based on the
information in the
certificate, as long as you enroll within 63 days of
losing coverage under this Plan. If you
have been enrolled with us for less
than 12 months, but were previously enrolled in other
FEHB plans, you may
also request a certificate from those plans.
For more information, get OPM
pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB
Program. See also the FEHB Web site
(www. opm. gov/ insure/ helath);
refer to the "TCC and HIPAA frequently asked
questions". These highlight
HIPAA rules, such as the requirement that Federal
employees must exhaust
any TCC eligibility as one condition for guaranteed access to
individual
health coverage under HIPAA, and have information about Federal and State
agencies you can contact for more information.
Getting a Certificate of
Group Health Plan
Coverage 50
50 Page 51 52
2002 SummaCare Health Plan 51 Section 11
Long Term Care Insurance Is Coming Later in 2002
The Office
of Personnel Management (OPM) will sponsor a high-quality long term care
insurance program effective in October 2002.
As part of its educational
effort, OPM asks you to consider these questions:
It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease such as
Alzheimer's.
LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice care, and more. LTC
insurance can supplement care provided by family members, reducing the burden
you
place on them.
Welcome to the club! 76% of Americans believe they will never need long term
care, but the facts are that
about half them will. And it's not just the old
folks. About 40% of people needing long
term care are under age 65. They may
need chronic care due to a serious accident, a
stroke, or developing
multiple sclerosis, etc.
We hope you will never need long term care, but everyone should have a plan
just in case. Many people now consider long term care insurance to be vital to
their financial
and retirement planning.
Yes, it can be very expensive. A year in a nursing home can exceed $50,000.
Home care for only three 8-hour shifts a week can exceed $20,000 a year. And
that's before
inflation!
Long term care can easily exhaust your savings.
Long term care insurance can protect your savings!
Not FEHB. Look at the "Not Covered" blocks in sections 5( a) and 5( c)
of your FEHB brochure. Health plans don't cover custodial care or a stay in an
assisted living facility or
a continuing need for a home health aide to help
you get in and out of bed and with other
activities of daily living. Limited
stays in skilled nursing facilities can be covered in
some circumstances.
Medicare only covers skilled nursing care home care (the highest level of
nursing care) after a hospitalization for those who are blind, age 65 or older,
or fully disabled. It also
has a 100 day limit.
Medicare only covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term care
insurance can provide choices of care and preserve your independence.
Employees will get more information from their agencies during the LTC open
enrollment period in the late summer/ early fall of 2002.
Retirees will
receive information at home.
Our toll-free teleservice center will being in
mid-2002. In the meantime, you can learn more about the program on our web site
at www. opm. gov/ insure/ ltc.
Many FEHB enrollees think that their health plan and/ or Medicare will cover
their long-term care needs. Unfortunately, they are WRONG!
How are YOU
planning to pay for the future custodial or chronic care you may need?
You
should consider buying long-term care insurance.
What is long term care
(LTC) insurance?
I'm healthy, I won't need
long term care. Or, will I?
Is long term care expensive?
But won't my FEHB plan,
Medicare or
Medicaid
cover my long term care?
When will I get more
information on how to apply
for this new
insurance
How can I find out more about
the program NOW? 51
51 Page 52 53
2002 SummaCare Health Plan 52 Index
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury
30 Allergy tests 16
Alternative treatment 21
Ambulance 29
Anesthesia
26
Autologous bone marrow transplant 25
Biopsies 22 Blood and
blood plasma 28
Breast cancer screening 13
Casts 22 Changes for 2002 6
Chemotherapy 17
Childbirth 15
Chiropractor 20
Cholesterol tests
13
Claims 40
Colorectal cancer screening 13
Congenital anomalies 23
Contraceptive devices and drugs 35
Coordination of benefits 43
Covered charges 10
Covered providers 5
Crutches 20
Deductible
10
Definitions 47
Dental care 37
Diagnostic services 13
Disputed claims review 41
Donor expenses (transplants) 25
Durable
medical equipment (DME) 20
Educational classes and programs 21
Effective date of enrollment 49
Emergency 30
Experimental or
investigational 47
Eyeglasses 18
Family planning 15
Fecal
occult blood test 13
General Exclusions 39
Hearing services 18 Home health services 20
Hospice care 29
Hospital 27
Immunizations 14
Infertility 15
Inhospital
physician care 12
Inpatient Hospital Benefits 27
Insulin 35
Laboratory and pathological services 13
Long term care 51
Machine diagnostic tests 13 Magnetic Resonance
Imagings
(MRIs) 13
Mail Order Prescription Drugs 35
Mammograms 14
Maternity Benefits 15
Medicaid 46
Medically necessary 47
Medicare 43
Mental Conditions/ Substance
Abuse Benefits 32
Neurological testing 13
Newborn care 15
Non-FEHB Benefits 38
Nursery charges 15
Obstetrical care 15 Occupational therapy 18
Office visits 12 Oral and maxillofacial surgery 24
Orthopedic devices 19
Ostomy and catheter supplies 20
Out-of-pocket expenses 10 Outpatient
facility care 28
Oxygen 20 Pap test 13
Physical examination 12
Physical therapy 18 Physician 12
Pre-admission testing 28
Preauthorization 9
Preventive care, adult 13 Preventive care, children 14
Prescription drugs 34 Preventive services 13
Prostate cancer screening
13 Prosthetic devices 19
Psychologist 32 Psychotherapy 32
Radiation
therapy 17 Renal dialysis 17
Room and board 27 Second surgical
opinion 12
Skilled nursing facility care 28 Smoking cessation 21
Speech
therapy 18 Splints 22
Sterilization procedures 15 Subrogation 43
Substance abuse 32 Surgery 22
Anesthesia 26 Oral 24
Outpatient 28
Reconstructive 23
Syringes 35 Temporary continuation of
coverage
49 Transplants 25
Vision services 18 Well child care 14
Wheelchairs 20 Workers' compensation 46
X-rays 13 52
52 Page 53 54
2002 SummaCare Health Plan 53 Summary
Summary of benefits for SummaCare Health Plan 2002
Do not
rely on this chart alone. All benefits are provided in full unless indicated
and are subject to the definitions,
limitations, and exclusions in this
brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.
If you want to enroll or change your enrollment in this Plan, be sure to put
the correct enrollment code from the cover
on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office.................
Office visit copay: $10 for both primary care and specialist 12
Services provided by a hospital:
Inpatient............................................................................................
Outpatient
.........................................................................................
Nothing 27
28
Emergency benefits:
In-area..............................................................................................
Out-of-area
......................................................................................
Same for both in-and out-of-area
$10 per office visit; $25 per urgent
care center
visit; $50 per emergency room visit (waived if
admitted)
30
30
Mental health and substance abuse
treatment...................................... $10 per office visit 32
Prescription drugs
.................................................................................
$5 per generic/$ 10 per brand name prescription
for 30 day supply; $10 per
generic/$ 20 per
brand name prescription for 90 day supply
through mail
service
34
Dental Care
.......................................................................................
Nothing for preventive services; accidental
injuries covered under medical
benefits –
subject to either office visit copay of $10 or
emergency room
copay of $50
37
Vision Care
.......................................................................................
You pay $10 for one routine eye exam every 24
months; hardware benefit only
after surgery 18
Special features: Flexible benefits option, Complementary care; 24 hour nurse
line; Maternal care program; Centers of
excellence for transplants/ heart
surgery, etc.; Travel benefit/ services overseas; Web site; NCQA accreditation
36 53
53 Page
54
2002 SummaCare Health Plan 54
2002 Rate
Information for
SummaCare Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment
category, refer to the FEHB Guide for that category or
contact the agency that maintains
your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to
the FEHB Guide for United States Postal Service Employees,
RI 70-2. Different postal
rates apply and special FEHB guides are published
for Postal Service Nurses, RI 70-2B;
and for Postal Service Inspectors and
Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate
members of any postal employee organization who are not career
postal employees.
Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share
Standard Option
Self Only 5W1 $75.43 $25.14 $163. 43 $54.47 $89.26
$11.31
Standard Option
Self and Family
5W2
$207. 43 $69.14 $449. 43
$149. 81 $245. 46 $31.11 54