VANTAGE HEALTH PLAN, INC. http:// www.
vhpla. com
2002
A Health Maintenance Organization
Serving: Northern and Central Louisiana to include the areas
surrounding
Monroe, Shreveport, and Alexandria
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 5 for requirements.
Monroe area
Enrollment codes for this Plan:
AQ1 Self Only
AQ2
Self and Family
Shreveport /Alexandria areas
Enrollment codes for this Plan:
MV1
Self Only
MV2 Self and Family
Special notice: This Plan is offered for the first time under the
Federal Employees
Health Benefits Program during the 2001 Open Season.
RI 73-808
For changes
in benefits
see page 6. 1
1 Page 2 3
2002 Vantage Health Plan, Inc. 2 Table of Contents
Table
of Contents
Introduction………………………………………………………………….
........................................................................................
4
Plain Language
.......................................................................................................................................................................................
4
Inspector General Advisory
....................................................................................................................................................................
4
Section 1. Facts about this HMO plan
...................................................................................................................................................
5
How we pay providers
..........................................................................................................................................................
5
Who provides my health
care?..............................................................................................................................................
5
Your
Rights...........................................................................................................................................................................
5
Service
Area..........................................................................................................................................................................
6
Section 2. We are a new plan
................................................................................................................................................................
6
Section 3. How you get care
...................................................................................................................................................................
6
Identification
cards................................................................................................................................................................
6
Where you get covered
care..................................................................................................................................................
6
. Plan
providers.................................................................................................................................................................
6
. Plan facilities
..................................................................................................................................................................
6
What you must do to get covered care
..................................................................................................................................
6
. Primary
care....................................................................................................................................................................
6
. Specialty
care..................................................................................................................................................................
7
. Hospital care
...................................................................................................................................................................
7
Circumstances beyond our
control........................................................................................................................................
8
Services requiring our prior
approval....................................................................................................................................
8
Section 4. Your costs for covered services
............................................................................................................................................
9
. Copayments
....................................................................................................................................................................
9
.
Deductible.......................................................................................................................................................................
9
. Coinsurance
....................................................................................................................................................................
9
Your catastrophic protection out-of-pocket
maximum.........................................................................................................
9
Section 5. Benefits
...............................................................................................................................................................................
10
Overview.............................................................................................................................................................................
10
(a) Medical services and supplies provided by
physicians and other health care professionals
.................................... 11
(b) Surgical
and anesthesia services provided by physicians and other health care
professionals................................. 20
(c)
Services provided by a hospital or other facility, and ambulance services
.............................................................. 24
(d) Emergency services/ accidents
..................................................................................................................................
27
(e) Mental health and substance abuse benefits
.............................................................................................................
30
(f) Prescription drug
benefits.........................................................................................................................................
32
(g) Special features
.......................................................................................................................................................
35
. Travel benefit
. 70/ 30
reduced benefit option for certain out of network providers with
preauthorization
. Hearing impaired interpreter
expense 2
2 Page 3
4
2002 Vantage Health Plan, Inc. 3 Table of Contents
(h) Dental
benefits..........................................................................................................................................................
36
Section 6. General exclusions --things we don't
cover..........................................................................................................................
37
Section 7. Filing a claim for covered services
.....................................................................................................................................
38
Section 8. The disputed claims process
...............................................................................................................................................
39
Section 9. Coordinating benefits with other coverage
........................................................................................................................
41
When you have…
. Other health
coverage....................................................................................................................................................
41
. Original
Medicare..........................................................................................................................................................
41
. Medicare managed care plan
........................................................................................................................................
43
TRICARE/ Workers' Compensation/
Medicaid....................................................................................................................
43
Other Government
agencies................................................................................................................................................
44
When others are responsible for
injuries.............................................................................................................................
44
Section 10. Definitions of terms we use in this
brochure......................................................................................................................
45
Section 11. FEHB facts
........................................................................................................................................................................
46
Coverage
information........................................................................................................................................................
46
. No pre-existing condition limitation
.........................................................................................................................
46
. Where you get information about enrolling in the FEHB
Program...........................................................................
46
. Types of coverage available for you and your
family
...............................................................................................
46
. When benefits and premiums start
............................................................................................................................
47
. Your medical and claims records are confidential
....................................................................................................
47
. When you
retire........................................................................................................................................................
47
When you lose benefits
.....................................................................................................................................................
47
. When FEHB coverage ends
......................................................................................................................................
47
. Spouse equity
coverage............................................................................................................................................
47
. Temporary Continuation of Coverage (TCC)
..........................................................................................................
47
. Converting to individual coverage
...........................................................................................................................
48
Getting a Certificate of Group Health Plan
Coverage.....................................................................................................
48
Long term care insurance is coming later in 2002
................................................................................................................................
49
Index………..
.......................................................................................................................................................................................
50
Summary of benefits
.............................................................................................................................................................................
51
Rates
.......................................................................................................................................................................................
Back cover 3
3 Page
4 5
2002 Vantage Health Plan, Inc. 4 Introduction/ Plain Language/
Advisory
Introduction
Vantage Health Plan, Inc.
909 North
18 th Street, Suite 201
Monroe, LA 71201
This brochure describes the benefits of Vantage Health Plan, Inc. under our
contract (CS 2851) 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.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002. 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 Vantage Health Plan,
Inc.
. We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
. Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you compare plans.
If you have comments or suggestions about how to
improve the structure of this brochure,
let OPM know. Visit OPM's "Rate
Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the
Office of Personnel Management, Office of Insurance
Planning and Evaluation Division, 1900 E Street, NW, Washington, DC
20415.
Inspector General Advisory
Stop health care fraud! Fraud increases the cost of health care for
everyone. If you suspect that a physician, pharmacy, or hospital has charged you
for services you did not receive, billed you
twice for the same service, or
misrepresented any information, do the following:
. Call the provider and
ask for an explanation. There may be an error. . If the provider does not
resolve the matter, call us at 318/ 361-0900 and explain
the situation.
. If we do not resolve the issue, call or write: THE
HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room
6400
Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for fraud. Also, the Inspector General may
investigate anyone who uses an ID card
if the person tries to obtain
services for someone who is not an eligible family
member, or is no longer
enrolled in the Plan and tries to obtain benefits. Your
agency may also take
administrative action against you. 4
4 Page 5 6
2002 Vantage Health Plan, Inc. 5 Section 1
Section 1.
Facts about this HMO plan
This Plan is a health maintenance organization
(HMO). We require you to see specific physicians, hospitals, and other providers
that
contract with us. These Plan providers coordinate your health care
services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in addition to
treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments
and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit
claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available. You cannot
change plans because a
provider leaves our Plan. We cannot guarantee that any one physician, hospital,
or other provider will
be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers
accept a negotiated payment from us, and you will only be
responsible for your copayments or coinsurance.
Who provides my health care?
VHP is a Mixed Model Prepayment (MMP)
Plan that contracts with Louisiana Regional Physicians Hospital Organization,
physicians
practicing in 14 different groups, and with individual
physicians, as well. VHP contracts with 23 Hospitals and 5 Referral Centers,
139 Primary Care Physicians (PCPs), 538 Specialists, 16 Chiropractors, and 6
Podiatrists. PCPs are Family Practitioners, General
Practitioners,
Internists, Pediatricians, and those Obstetricians/ Gynecologists (OB/ GYNs) who
have chosen to be PCPs.
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.
. 6 Years in existence
. Profit status -For profit
If you want more
information about us, call 318/ 361-0900, or write to Vantage Health Plan, Inc. – 909 North 18 th Street, Suite 201 –
Monroe,
LA 71201. You may also contact us by fax at 318/ 361-2159 or visit our website
at www. vhpla. 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
includes
the following parishes:
In the Monroe area: Caldwell, East Carroll, Franklin, Jackson,
Lincoln, Madison, Morehouse, Ouachita, Richland, Tensas, Union,
West
Carroll, and Winn.
In the Shreveport/ Alexandria areas: Allen, Avoyelles, Bienville,
Bossier, Caddo, Evangeline, Rapides, Red River, and Webster.
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 Vantage Health Plan, Inc. 6 Section 2/ Section 3
Section 2. We are a new plan
This plan is new to the FEHBP
Program. We are being offered for the first time during the 2001 open season.
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 318/ 361-0900.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments, and/ or coinsurance, and you
will not have to file claims.
. Plan providers Plan providers are physicians and other health care
professionals in our service area that we contract with to provide covered
services to our members. We credential Plan
providers according to national
standards.
We list Plan providers in the provider
directory, which we update periodically. The list is
also on our website
at www. vhpla. com. Primary care physicians may be chosen from the
following specialties: Family Practice, Internal Medicine, Pediatrician, and
select
OB/ GYN physicians. All other specialties are considered specialist
physicians.
. 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.
vhpla. com. Please see the
website for a list of referral centers.
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.
You may select the same primary care
physician for each of your family
members or you may choose a different primary care
physician for each of
your family members. You may change your primary care
physician at any time
by calling us at 318/ 361-0900.
. Primary care Your primary care physician can be a Family
Practitioner, General Practitioner, Internist, Pediatrician, or an Obstetrician/
Gynecologist (call us to see if your OB/ GYN is a primary
care physician).
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.
What you must do
to get covered care 6
6
Page 7 8
2002
Vantage Health Plan, Inc. 7 Section 2/ Section 3
. 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
present the referral form to
the specialist at the time of service. Your
referral is good for two visits within ninety
days. The specialist may call
us at 318/ 361-5998 to get approval for additional visits if
needed. The
primary care physician must provide or authorize all follow-up care.
However, you may see your Vantage gynecologist for your routine annual exam
without
a referral. You may see your Vantage obstetrician when pregnant
without a referral.
You may, also, see a Vantage ophthalmologist once every
two years for a routine eye
exam without a referral.
Here are other things you should know about specialty care:
. If you need
to see a specialist frequently because of a chronic, complex, or serious medical
condition, your primary care physician will give you a referral to a specialist
for two visits. Your primary care physician and specialist will work with
the Plan to
determine the number of additional visits needed.
. 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 member
services department immediately at 318/ 361-0900. 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 7
7 Page 8 9
2002 Vantage Health Plan, Inc. 8 Section 2/
Section 3
. The day your benefits from your former plan run out; or
. The 92 nd day after you become a member of this Plan, whichever happens
first.
These provisions apply only to the benefits of the hospitalized
person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In that case, we will make all
reasonable
efforts to provide you with the necessary care.
Your primary care physician
has authority to refer you for most services. For certain
services, however,
you or 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 preauthorization. Your
physician must obtain
pre-authorization for the following services, such as:
all inpatient admissions, all
outpatient surgeries, endoscopies, MRIs, CT
scans, bone scans, physical therapy,
occupational therapy, speech therapy,
stress tests, home health care, hospice care, cardiac
rehab, DME, nerve
conduction velocity tests, EEGs, bone density studies, prostheses,
infusion
therapy, referrals to non-Plan providers, additional visits to a specialist,
outpatient mental health/ chemical dependency treatment, and Growth Hormone
Therapy
(GHT).
Call the Medical Management Department at 318/ 361-5998 for a complete
listing and
details.
Services requiring our
prior approval 8
8
Page 9 10
2002
Vantage Health Plan, Inc. 9 Section 4
Section 4. Your costs
for covered services
You must share the cost of some services. You are
responsible for:
. Copayments A copayment is a fixed amount of money
you pay to the provider, facility, pharmacy, etc., when you receive services.
Example: When you see your primary care physician you pay a copayment of $15
per
office visit and when you go in the hospital, you pay $250 per
admission.
. Deductible We do not have a deductible.
Note: If you change
plans during open season, you do not have to start a new deductible
under
your old plan between January 1 and the effective date of your new plan. If you
change plans at another time during the year, you must begin a new
deductible under
your new plan.
. Coinsurance Coinsurance is the percentage of our negotiated fee that
you must pay for your care.
Example: In our Plan, you pay 20% of our
allowance for physical, occupational, and
speech therapies, orthopedic &
prosthetic devices, durable medical equipment, allergy
care, and ambulance
services. In our plan, you pay 40% of our allowance for cochlear
implants,
insulin pumps, and infertility services.
Your catastrophic protection We do not have an out-of-pocket maximum.
out-of-pocket maximum
for coinsurance and copayments 9
9 Page 10 11
2002 Vantage Health Plan, Inc. 10 Section 5
Section 5. Benefits --OVERVIEW
(See page 51 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 318/
361-0900 or at our website at
www. vhpla. com.
(a) Medical services and supplies provided by physicians and other health
care professionals........................................................ 11-19
. Diagnostic and treatment services . Lab, X-ray, and other diagnostic tests
. Preventive care, adult . Preventive care, children
. Maternity care
. Family planning . Allergy care
. Treatment therapies . Physical and occupational therapies
. Speech therapy . Hearing services (testing, treatment, and supplies)
.
Vision services (testing, treatment, and supplies) . Foot care
. Orthopedic
and prosthetic devices
. Durable medical equipment (DME) . Home health
services
. Chiropractic . Alternative treatments
. Educational classes and
programs
(b) Surgical and anesthesia services provided by physicians and
other health care professionals ................................................
20-23
. Surgical procedures
. Reconstructive surgery
. Oral and
maxillofacial surgery
. Organ/ tissue transplants . Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
..............................................................................
24-26
. Inpatient hospital . Outpatient hospital or ambulatory surgical
center . Extended care benefits/ skilled nursing care facility benefits .
Hospice care
. Ambulance
(d) Emergency services/ accidents
.................................................................................................................................................
27-29
. Medical emergency . Ambulance
(e) Mental health and substance abuse benefits
............................................................................................................................
30-31
(f) Prescription drug benefits
........................................................................................................................................................
32-34
(g) Special features
.............................................................................................................................................................................
35
. Travel benefit
. 70/ 30 reduced benefit option for certain out of network providers with
preauthorzation
. Hearing impaired interpreter expense
(h) Dental
benefits
..............................................................................................................................................................................
36
Summary of benefits
.............................................................................................................................................................................
51 10
10 Page 11
12
2002 Vantage Health Plan, Inc. 11 Section
5( a)
Section 5( a). Medical services and supplies provided by
physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care.
. We have no
calendar year deductible.
. Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office
.
Office medical consultations
. Second surgical opinion
$15 per office visit
Professional services of physicians
. In an urgent care center
.
During a hospital stay
. In a skilled nursing facility
Nothing
At home $15 per visit
Lab, X-ray and other diagnostic tests
Tests, such as:
. Blood tests
. Urinalysis
. Non-routine pap
tests
. Pathology
. X-rays
. Non-routine Mammograms
. Cat Scans/
MRI
. Ultrasound
. Electrocardiogram and EEG
Nothing 11
11 Page
12 13
2002 Vantage Health Plan, Inc.
12 Section 5( a)
Preventive care, adult You pay
Routine screenings, such as:
. Total Blood Cholesterol – once every
three years
. Colorectal Cancer Screening, including
. Fecal occult blood test
. Sigmoidoscopy, screening – every five years
starting at age 50 Prostate Specific Antigen (PSA test) – one annually for men
age 40 and older
Routine pap test
$15 per office visit
Routine mammogram –covered for women age 35 and older, as
follows:
. From age 35 through 39, one during this five year period
. From age 40
and older, one every calendar year
Nothing
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All
charges.
Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster –
once every 10 years, ages19 and over (except as provided for under Childhood
immunizations)
. Influenza/ Pneumococcal vaccines, annually, age 65 and over
$15 per office visit
Preventive care, children
. Childhood immunizations recommended by
the American Academy of Pediatrics $15 per office visit
. Well-child care charges for routine examinations, immunizations and care
(up to age 22)
. Examinations, such as:
. Eye exams through age 17 to
determine the need for vision correction performed by a pediatrician
. Ear exams through age 17 to determine the need for hearing correction
performed by a pediatrician
. Examinations done on the day of immunizations
( up to age 22)
$15 per office visit 12
12 Page 13 14
2002 Vantage
Health Plan, Inc. 13 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 need to precertify your normal delivery; see page 8 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).
$15 for the first office visit only
$250 per hospital admission
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
. Injectable contraceptive drugs (such as Depo provera)
. Intrauterine
devices (IUDs)
NOTE: We cover oral contraceptives under the prescription drug
benefit.
$15 per office visit or
$250 if outpatient surgery
$35 copay per
34-day supply
$15 per office visit
See pharmacy copays
. Not covered: reversal of voluntary surgical
sterilization, genetic counseling, diaphragms, surgically implanted
contraceptives (such
as Norplant)
All charges. 13
13 Page 14 15
2002 Vantage Health Plan, Inc. 14 Section 5(
a)
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
. Artificial insemination:
. intravaginal
insemination (IVI) Note: We do not cover fertility drugs under
medical benefits or under the
prescription drug benefit.
40% coinsurance
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
.
Fertility drugs
. Intracervical insemination (ICI)
.
Intrauterine insemination (IUI)
All charges.
Allergy care
Testing and treatment
Allergy injection
20%
coinsurance
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges. 14
14 Page 15 16
2002 Vantage Health Plan, Inc. 15 Section 5(
a)
Treatment therapies You pay
. Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/
Tissue Transplants on page 22.
. Respiratory and inhalation therapy
. Dialysis – Hemodialysis and
peritoneal dialysis
. Intravenous (IV)/ Infusion Therapy – Home IV and
antibiotic therapy
. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the
prescription drug benefit.
Note: – We will only cover GHT when we
pre-authorize the treatment.
Call 318/ 361-5998 for pre-authorization. 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 pre-authorization in Section 3.
$15 per office visit
$250 per hospital admission
Not covered: any service not approved by us All charges.
Physical and occupational therapies
. 20 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 18 sessions
20% coinsurance
Not covered:
. long-term rehabilitative therapy
.
exercise programs
All charges. 15
15 Page 16 17
2002 Vantage
Health Plan, Inc. 16 Section 5( a)
Speech therapy You pay
. 20 visits per condition for the services of qualified speech
therapists 20% coinsurance
Not covered:
. Services provided by a family member All
charges.
Hearing services (testing, treatment, and supplies)
. First
hearing aid and testing only when necessitated by accidental injury
. Hearing testing for children through age 17 (see Preventive care,
children)
$15 per office visit
Not covered:
. all other hearing testing . hearing aids,
testing and examinations for them All charges.
Vision services (testing, treatment, and supplies)
. Routine eye
exam, with refraction, by a Vantage ophthalmologist once every two years with no
referral.
. One pair of eyeglasses or contact lenses to correct an impairment directly
caused by accidental ocular injury or intraocular surgery
(such as for
cataracts)
. Eye exam to determine the need for vision correction for
children through age 17 (see Preventive care, children)
Note: See Preventive care, children for eye exams for children
$15 per office visit
Not covered:
. Eyeglasses or contact lenses, except as above,
and, after age 17, examinations for them except as outlined in "Preventive care,
adult"
. Eye exercises and orthoptics
. Radial
keratotomy and other refractive surgery
All chrges. 16
16 Page 17 18
2002 Vantage
Health Plan, Inc. 17 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric shoe
inserts.
$15 per office visit
Not covered:
. Cutting, trimming or removal of corns, calluses,
or the free edge of toenails, and similar routine treatment of conditions of the
foot,
except as stated above
. Treatment of weak, strained or flat feet or bunions or spurs; and of any
instability, imbalance or subluxation of the foot (unless the
treatment is
by open cutting surgery)
All charges.
Orthopedic and prosthetic devices
. Artificial limbs and eyes;
stump hose; limited to the initial issue only
. Externally worn breast prostheses and surgical bras, including necessary
replacements, following a mastectomy
. Corrective orthopedic appliances for
non-dental treatment of tempormandibular joint (TMJ) pain dysfunction.
.
Internal prosthetic devices, such as artificial joints, pacemakers and
surgically implanted breast implant following mastectomy. Note:
We pay
internal prosthetic devices as hospital benefits: See section
5( c) for
payment information. See 5( b) for coverage of surgery to
insert the device.
20% coinsurance
. Cochlear implants that are preauthorized, including training and other
services specific to the cochlear implant
Note: To be eligible for this
benefit, member must be covered by VHP
for 18 consecutive months.
Replacements are not covered, and the
benefit is limited to one (1) cochlear
implant per member per lifetime.
40% coinsurance 17
17 Page
18 19
2002 Vantage Health Plan, Inc.
18 Section 5( a)
Orthopedic and prosthetic devices
(Continued) You pay
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
All charges
Durable medical equipment (DME)
Rental or purchase, at our option,
including repair and adjustment, of
durable medical equipment prescribed by
your Plan physician, such as
oxygen and dialysis equipment. Under this
benefit, we also cover:
. hospital beds;
. non-motorized wheelchairs;
. crutches;
.
walkers; and
. blood glucose monitors.
20% coinsurance
. Insulin pumps that are preauthorized, including training, supplies, and
other services specific to the insulin pump.
Note: To be eligible for this
benefit, member must be covered by VHP
for 18 consecutive months.
Replacements are not covered, and the
benefit is limited to one (1) pump per
member per lifetime.
40% coinsurance
Not covered:
. Motorized wheel chairs . Exercise
equipment, including pools and hot tubs All charges. 18
18 Page 19 20
2002 Vantage Health Plan, Inc. 19 Section 5(
a)
Home health services You pay
. Home health care ordered by
a Plan physician and provided by a registered nurse (R. N.), licensed practical
nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
. Services include oxygen therapy, intravenous therapy and medications.
Nothing
Not covered:
. nursing care requested by, or for the
convenience of, the patient or the patient's family;
. home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges.
Chiropractic
. Manipulation of the spine and extremities
.
Adjunctive procedures such as ultrasound, electrical muscle stimulation,
vibratory therapy, and cold pack application
Services require a referral from your primary care physician.
$15 per office visit
Alternative treatments
Not covered:
. acupuncture
. naturopathic services
. hypnotherapy . biofeedback
All charges.
Educational classes and programs
Coverage is limited to:
.
Diabetes self-management
. Nutritional Counseling
Nothing for a one-time evaluation and training
program per person when
medically necessary
up to a maximum of $500.
Nothing for up to four (4) visits per diagnosis
per calendar year with
preauthorization. 19
19 Page
20 21
2002 Vantage Health Plan, Inc.
20 Section 5( b)
Section 5( b). Surgical and anesthesia
services provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. Plan physicians must provide or arrange your care.
. We have no
calendar year deductible.
. Be sure to read Section 4, Your costs for
covered services, for valuable information about how cost sharing works.
Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
. The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e., hospital, surgical center, etc.).
. YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF SOME SURGICAL PROCEDURES.
Please refer to the preauthorization information shown in Section 3 to be sure
which services require preauthorization and
identify which surgeries require
preauthorization.
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 and meets
medically necessary criteria
including failed medical treatment;
eligible members must be age 18 or over
. Insertion of internal prosthetic devices. See 5( a) – Orthopedic and
prosthetic devices for device coverage information.
. Voluntary sterilization
. Treatment of burns
Note: Generally, we
pay for internal prostheses (devices) according to
where the procedure is
done. For example, we pay Hospital benefits for
a pacemaker and Surgery
benefits for insertion of the pacemaker.
$15 per office visit; nothing for hospital
visits. 20
20 Page 21 22
2002 Vantage Health Plan, Inc. 21 Section 5(
b)
Surgical procedures (Continued) You pay
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.
Nothing
. All stages of breast reconstruction surgery following a mastectomy, such
as:
. surgery to produce a symmetrical appearance on the other breast;
.
treatment of any physical complications, such as lymphedemas;
. breast
prostheses and surgical bras and replacements (see Prosthetic devices)
Note:
If you need a mastectomy, you may choose to have the procedure
performed on
an inpatient basis and remain in the hospital up to 48
hours after the
procedure.
See above.
Not covered:
. Cosmetic surgery – any surgical procedure (or
any portion of a procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
. Surgeries related to sex transformation
All charges. 21
21 Page 22 23
2002 Vantage
Health Plan, Inc. 22 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.
Nothing
Not covered:
. Oral implants and transplants .
Procedures that involve the teeth or their supporting structures (such as
the periodontal membrane, gingiva, and alveolar bone)
All charges.
Organ/ tissue transplants
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
Note: Transplants are covered if approved by the Plan's medical
director
in accordance with the Plan's protocols, and the transplants
must be
performed in a VHP approved facility.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Nothing 22
22 Page
23 24
2002 Vantage Health Plan, Inc.
23 Section 5( b)
Organ/ tissue transplants (Continued)
You pay
Not covered:
. Donor screening tests and
donor search expenses, except those performed for the actual donor
. Implants of artificial organs
. Transplants not listed as
covered
All charges.
Anesthesia
Professional services provided in –
. Hospital
(inpatient) . Hospital outpatient department
. Skilled nursing facility . Ambulatory surgical center
Nothing
Professional services provided in –
. Office
$15 per office visit 23
23 Page 24 25
2002 Vantage Health Plan, Inc. 24 Section 5(
c)
Section 5( c). Services provided by a hospital or other facility,
and ambulance services
I M
P O
R T
A N
T
Here are some important things to remember about these benefits:
.
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they are
medically necessary.
. Plan physicians must provide or arrange your care and you must be
hospitalized in a Plan facility.
. We have no deductible.
. Be sure to
read Section 4, Your costs for covered services, for valuable information
about how cost sharing works. Also read Section 9 about coordinating benefits
with other coverage, including with
Medicare.
. The amounts listed below are for the charges billed by 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 PREAUTHORIZATION OF HOSPITAL STAYS. Please refer to
Section 3 to be sure which services require pre-authorization.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
. ward, semiprivate, or intensive care accommodations; . general
nursing care; and
. meals and special diets.
NOTE: If you want a private room when it is
not medically necessary,
you pay the additional charge above the semiprivate
room rate.
Other hospital services and supplies, such as:
. Operating, recovery,
maternity, and other treatment rooms . Prescribed drugs and medicines
. Diagnostic laboratory tests and X-rays . Administration of blood and blood
products
. Blood or blood plasma, if not donated or replaced . Dressings,
splints, casts, and sterile tray services
. Medical supplies and equipment,
including oxygen . Anesthetics, including nurse anesthetist services
.
Take-home items . Medical supplies, appliances, medical equipment, and any
covered
items billed by a hospital for use at home
$250 per admission
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. 24
24 Page 25 26
2002 Vantage
Health Plan, Inc. 25 Section 5( c)
Outpatient hospital or
ambulatory surgical center You pay
. Operating, recovery, and other
treatment rooms . Prescribed drugs and medicines
. Diagnostic laboratory tests, X-rays, and pathology services .
Administration of blood, blood plasma, and other biologicals
. Blood and
blood plasma, if not donated or replaced . Pre-surgical testing
. Dressings,
casts, and sterile tray services . Medical supplies, including oxygen
.
Anesthetics and anesthesia service
NOTE: – We cover hospital services and
supplies related to dental
procedures when necessitated by a non-dental
physical impairment. We
do not cover the dental procedures.
$250 per admission
Not covered: blood and blood derivatives not replaced by the member All
charges.
Extended care benefits/ skilled nursing care facility
benefits/ Rehabilitation care facility benefits
Extended care benefit:
A comprehensive range of benefits for up to 100
days per calendar year
when full-time skilled nursing care is necessary and
confinement in a
skilled nursing facility is medically appropriate as
determined by a Plan
doctor and approved by the Plan.
. Bed, board and general nursing care
. Drugs, biologicals, supplies, and
equipment ordinarily provided or arranged by the skilled nursing facility when
prescribed by a Plan
doctor.
Rehabilitation facility care benefit:
Benefits for up to 45 days per calendar year in a rehabilitation care
facility, when medically indicated and approved by the Plan, for
rehabilitative care following a post-acute illness or injury.
. Semiprivate room accommodations
. Medically necessary services and
supplies
$250 per admission
Not covered: custodial care All charges. 25
25 Page 26 27
2002 Vantage Health Plan, Inc. 26 Section 5(
c)
Hospice care You pay
. Medically necessary services and
supplies provided by a Vantage provider in the home setting Nothing
Not covered: Independent nursing, homemaker services All charges.
Ambulance
. Local professional ambulance service when
medically appropriate 20% coinsurance 26
26 Page 27 28
2002 Vantage
Health Plan, Inc. 27 Section 5( d)
Section 5( d). Emergency
services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
.
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure.
. We have no calendar year deductible.
. Be sure to read Section 4, Your costs for covered services, for
valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or
could result in serious
injury or disability, and requires immediate medical or surgical care. Some
problems are emergencies
because, if not treated promptly, they might become
more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or
sudden inability to
breathe. There are many other acute conditions that we may determine are medical
emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an 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. , call 911) or go to the nearest
hospital emergency room. Be
sure to tell the emergency room personnel that
you are a Plan member so they can notify the Plan. You should follow-up with
your primary care doctor as soon as possible.
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 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 recommended by non-Plan providers
must be approved by 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. You may notify the Plan
by calling
318/ 361-0900. If a Plan doctor believes care can be better
provided in a Plan hospital, you will be transferred when medically
feasible
with any ambulance charges covered in full.
To be covered by this plan, any follow-up care recommended by non-Plan
Providers must be approved by the Plan or
provided by Plan providers. 27
27 Page 28 29
2002 Vantage Health Plan, Inc. 28 Section 5(
d)
Benefit Description You pay
Emergency within our service area
. Emergency care at a doctor's office
. Emergency care at an urgent
care center
. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$15 per office visit
$20 per urgent care center visit
$50 per
emergency room visit. If the
emergency results in admission to a
hospital, the copay is waived.
Not covered: Elective care or non-emergency care, follow-up care All
charges.
Emergency outside our service area
. Emergency care
at a doctor's office . Emergency care at an urgent care center
. Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$15 per office visit
$20 per urgent care center visit
$50 per emergency room visit. If the
emergency results in admission to a
hospital, the copay is waived.
Not covered:
. Elective care or non-emergency care, follow-up
care
. Emergency care provided outside the service area if the need
for care could have been foreseen before leaving the service area
. Medical and hospital costs resulting from a normal full-term delivery of
a baby outside the service area
All charges. 28
28 Page 29 30
2002 Vantage
Health Plan, Inc. 29 Section 5( d)
Ambulance You pay
Professional ambulance service (ground or air) when medically
appropriate.
See 5( c) for non-emergency service.
20% coinsurance
Ambulance service (ground or air) when we are moving you from one
facility to another.
Nothing 29
29 Page 30 31
2002 Vantage
Health Plan, Inc. 30 Section 5( e)
Section 5( e). Mental
health and substance abuse benefits
I M
P O
R T
A N
T
When you receive care, you must get our approval for services and follow a
treatment plan we approve. If
you do, cost-sharing and limitations for
mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
. All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
. 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.
. YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See
the instructions after the benefits description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other
illnesses or
conditions.
. Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers
Medication management
$15 per outpatient or office visit
. Diagnostic tests Nothing
. Services provided by a hospital or other
facility
. Services in approved alternative care settings such as partial
hospitalization, residential treatment, full-day hospitalization, facility
based intensive outpatient treatment
$250 per inpatient admission
$15 per outpatient admission 30
30 Page 31 32
2002 Vantage Health Plan, Inc. 31 Section 5(
e)
Mental health and substance abuse benefits (Continued)
You pay
Not covered: Services we have not approved
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not order
us to pay or provide one clinically appropriate treatment plan in favor of
another.
All charges.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all the authorization processes:
Mental
health and substance abuse requires preauthorization. Call us at 318/ 361-5998
before receiving these services.
Limitation We may limit your benefits if you do not obtain a treatment
plan. 31
31 Page
32 33
2002 Vantage Health Plan, Inc.
32 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.
. We have no calendar year deductible.
. See below for preauthorization
requirements.
. Be sure to read Section 4, Your costs for covered
services, for valuable information about how cost sharing works. Also read
Section 9 about coordinating benefits with other coverage, including with
Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
. Who can write your prescription. A plan physician or licensed
dentist must write the prescription
. Where you can obtain them. You
must fill the prescription at a plan pharmacy, or by mail.
. We use a
preferred formulary. There are three categories for this benefit. Generic
drugs -$10 copay; Preferred (formulary) name brand drugs -$20 copay; and
Non-preferred (Non-formulary) name brand drugs -$
35 copay. Prescriptions are covered for up to a 34-day supply. Maintenance
drugs may be covered for up to
a 90-day supply. Copays apply to each 34-day
supply. All prescriptions are available through mail order.
. These are the dispensing limitations. A generic equivalent will be
dispensed if it is available, unless you choose a name brand. If you receive a
name brand drug when a Federally-approved generic drug is available,
you have to pay the generic copay of $10, plus the difference in cost between
the name brand drug and the
generic. Some drugs have a limit and some drugs
require preauthorization. Please call us at 318/ 361-5998 for
details or
questions.
. Why use generic drugs? Generic drugs offer a safe and economic way
to meet your prescription drug needs. The generic name of a drug is its chemical
name; the name brand is the name under which the manufacturer advertises
and
sells a drug. Under Federal law, generic and name brand drugs must meet the same
standards for safety, purity,
strength, and effectiveness. A generic
prescription costs you --and us --less than a name brand prescription.
. When you have to file a claim. Upon enrollment, if you need a
prescription before you receive your ID card, you may have to pay for the
prescription and file a claim with us. Please call us at 318/ 361-5998 for
details. You will need to send us your receipt with the NDC number of the
drug purchased. We will submit
that information to our pharmacy benefit
company who will reimburse you by mail. 32
32
Page 33 34
2002
Vantage Health Plan, Inc. 33 Section 5( f)
Benefit Description
You pay
Covered medications and supplies
We cover the following
medications and supplies prescribed by a Plan
physician, or licensed
dentist, and obtained from a Plan pharmacy:
. Drugs and medicines (including injectibles) 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
. Diabetic supplies, including needles, syringes, lancets, urine and blood
glucose testing reagents; a copay charge applies per item per each 34-day
supply
. Oral and injectible contraceptive drugs
. Migraine drugs
are subject to dosage limits set by the Plan. Contact Medical Management at 318/
361-5998 for details.
. Certain pain medications and certain medications for treatment of
conditions, such as acne and insomnia, are limited by the Plan. Contact Medical
Management at 318/ 361-5998 for details.
Retail pharmacy for up to a 34-day supply:
A $10 copay for generic drugs;
A $20 copay for preferred (formulary)
name brand drugs; and
A $35 copay for non-preferred (non-formulary)
name brand drugs.
Mail order for up to a 90-day supply:
A $30 copay for generic drugs;
A $60 copay for preferred (formulary)
name brand drugs; and
A $105 copay for non-preferred (non-formulary)
name brand drugs.
Copays are required per prescription unit or
refill for up to a 34-day
supply or 100 unit
supply, whichever is less; or one
commercially
prepared unit (i. e., one
inhaler, one vial ophthalmic medication or
insulin)
Note: Maintenance medications may be
obtained for up to a 90-day supply
from
either the retail pharmacy or through mail
order, subject to a
copay for each 34-day
supply, i. e., 3 copays.
Mandatory generic when available. If you
choose the name brand, you will
pay the
generic copay of $10, plus the cost
difference between the name
brand drug
and the generic.
Sexual dysfunction drugs are subject to dosage limits set by the Plan.
Contact Medical Management at 318/ 361-5998 for details.
A $35 copay for
non-preferred (non-formulary)
name brand drugs 33
33 Page 34 35
2002 Vantage Health Plan, Inc. 34 Section 5(
f)
Covered medications and supplies (Continued) You pay
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
. Smoking
cessation drugs and medication
. Drugs prescribed for weight loss and
appetite suppressants, except for treatment of morbid obesity
All charges. 34
34 Page 35 36
2002 Vantage
Health Plan, Inc. 35 Section 5( g)
Section 5( g). Special
features
Feature Description
Travel benefit We may cover certain travel arrangements, if and only
if, we are requiring you to travel outside our service area to obtain treatment
that could be provided
locally, but out of network. Call Medical Management
at 318/ 361-5998 for
details.
70% reduced benefit
option for certain out of
network providers
with
preauthorization
We may offer you 70% coverage, based on the Plan allowable, for certain out
of network providers with preauthorization. Call Medical Management at
318/ 361-5998 for details.
Hearing impaired
interpreter expense
100% less any applicable copayment for expenses incurred by any hearing
impaired member for services performed by a qualified interpreter/
transliterator
(other than a family member) when such services are used by
the member in
connection with medical treatment or diagnostic consultations
performed by a
health care provider. 35
35
Page 36 37
2002
Vantage Health Plan, Inc. 36 Section 5( h)
Section 5( h).
Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure and are payable only when we
determine they are medically necessary.
. We cover hospitalization for dental procedures only when a non-dental
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.
20% coinsurance
Dental benefits
We have no other dental benefits. 36
36 Page 37 38
2002 Vantage Health Plan, Inc. 37 Section 6
Section 6. General exclusions --things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will not cover it
unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury,
or condition and we agree, as discussed under
What Services Require Our Prior Approval on page 8.
We do not cover the following:
. Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
. Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
.
Services, drugs, or supplies that are not medically necessary;
. Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or psychiatric practice;
. Experimental or investigational
procedures, treatments, drugs or devices;
. Services, drugs, or supplies
related to abortions, except when the life of the mother would be endangered if
the fetus were carried to term;
. Services, drugs, or supplies related to sex transformations; or
.
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program.
. 37
37 Page 38 39
2002 Vantage
Health Plan, Inc. 38 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will, generally, not have to file claims. Just present your
identification card and pay your copayment or coinsurance.
You will need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us
directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital and In most cases, providers and facilities file
claims for you. Physicians must file on the
prescription drug benefits
form HCFA-1500, Health Insurance Claim Form. Facilities will file on the
UB-92 form. For claims questions and assistance, call us at 318/ 361-0900 or
888/ 823-1910.
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:
Vantage Health Plan, Inc. – 909 North 18 th Street,
Suite 201 – Monroe, LA
71201
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you received the service, unless timely
filing was prevented
by administrative operations of Government or legal incapacity,
provided the
claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 38
38 Page
39 40
2002 Vantage Health Plan, Inc.
39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or
request for
services, drugs, or supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Vantage Health Plan, Inc. – 909 North 18 th Street, Suite
201-Monroe, LA 71201; and
(c) Include a statement about why you believe our
initial decision was wrong, based on specific benefit provisions in this
brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records,
and explanation of
benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to
step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the information was due. We
will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
. 90 days after the date of our letter
upholding our initial decision; or
. 120 days after you first wrote to us
--if we did not answer that request in some way within 30 days; or
. 120
days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3, 1900 E Street, NW,
Washington, DC
20415-3630. 39
39 Page
40 41
2002 Vantage Health Plan, Inc.
40 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 318/ 361-0900 and
we will
expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
. If we expedite our review and maintain our denial, we will
inform OPM so that they can give your claim expedited treatment too, or
. You can call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755
between 8 a. m. and 5 p. m. eastern time. 40
40
Page 41 42
2002 Vantage Health Plan, Inc. 41 Section 9
Section 9.
Coordinating benefits with other coverage
When you have other health
coverage You must tell us if you are covered or a family member is covered
under another group health plan or have automobile insurance that pays health
care 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 or the
balance, whichever is less. 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.
However, we do not require referrals
to in-Plan specialists, nor do we
require preauthorization for in-Plan services.
. The Original Medicare Plan (Part A or Part B)
(Primary payer chart begins on next page.) 41
41 Page 42 43
2002 Vantage Health Plan, Inc. 42 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 re-employed 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, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
Please note, if your Plan
physician does not participate in Medicare, you will have to file a claim with
Medicare. 42
42 Page
43 44
2002 Vantage Health Plan, Inc.
43 Section 9
Claims process when you have the Original
Medicare Plan --You probably will never
have to file a claim form when
you have both our Plan and the Original Medicare Plan.
. 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 up to our allowance. You will not need to do
anything
and you should not be billed. To find out if you need to do
something about filing
your claims, call us at 318/ 361-0900 or 888/
823-1910.
We waive some costs when you have the Original Medicare Plan--When
Original
Medicare is the primary payer, we will waive some out-of-pocket
costs, as follows:
Medical services and supplies provided by physicians and other health care
professionals.
If you are enrolled in Medicare Part B, we will waive your
office visit copay, inpatient
copay, emergency room copay and outpatient
surgery copay.
. 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 another plan's Medicare managed care plan: You may
enroll in
another plan's Medicare managed care plan and also remain enrolled
in our FEHB plan.
We will still provide benefits when your Medicare managed
care plan is primary, even
out of the managed care plan's network and/ or
service area (if you use our Plan
providers), but we will not waive any of
our copayments or coinsurance. If you enroll in a
Medicare managed care
plan, tell us. We will need to know whether you are in the
Original Medicare
Plan or in a Medicare managed care plan so we can correctly
coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed care plan: If
you are an
annuitant or former spouse, you can suspend your FEHB coverage to
enroll in a Medicare
managed care plan, eliminating your FEHB premium. (OPM
does not contribute to your
Medicare managed care plan premium.) For
information on suspending your FEHB
enrollment, contact your retirement
office. If you later want to re-enroll in the FEHB
Program, generally you
may do so only at the next open season unless you involuntarily
lose
coverage or move out of the Medicare managed care plan'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 43
43 Page 44 45
2002 Vantage Health Plan, Inc. 44 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. 44
44 Page 45 46
2002 Vantage Health Plan, Inc. 45 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar
year January 1 through December 31 of the same year. For new enrollees, the
calendar year begins on the effective date of their enrollment and ends on
December 31 of the same
year.
Coinsurance Coinsurance is the
percentage of our allowance that you must pay for your care. See page 9.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 9.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Care furnished for the purpose of meeting non-medically necessary personal
needs which could be provided by persons without professional skills or
training, such as assistance in
mobility, dressing, bathing, eating,
preparation of special diets, and taking medication.
Custodial care is not
covered by the Medicare managed care plan, or Medicare, unless
provided in
conjunction with skilled nursing care and/ or skilled rehabilitation services.
The Plan makes its determination of experimental or investigational
treatment, including
medical and surgical services, drugs, devices and
biological products upon review of
evidence provided by evaluations of
national medical associations, consensus panels,
and/ or other technological
evaluations, including the scientific quality of such supporting
evidence
and rationale. The information it reviews comes from the U. S. Food and Drug
Administration, and from scientific evidence in published medical
literature, as well as in
published peer-reviewed medical literature.
Group health coverage Coverage offered by an employer.
Medical
necessity Medical services or hospital services which are determined by the
Plan Medical Director or designee to be:
a) Rendered for the treatment or diagnosis of an injury or illness; and
b) Appropriate for the symptoms, consistent with diagnosis, and otherwise in
accordance
with sufficient scientific evidence and professionally recognized
standards; and
c) Not furnished primarily for the convenience of the member, the attending
physician,
or other provider of service.
Whether there is "sufficient scientific evidence" shall be determined by the
Plan based on
the following: peer-reviewed medical literature; publications,
reports, evaluations, and
regulations issued by State and Federal government
agencies; Medicare local carriers, and
intermediaries; and such other
authoritative medical sources as deemed necessary by the
Plan.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Plans determine their
allowances in different ways. We determine our
allowance as follows: the
charges are consistent with those normally charged by the
provider or
organization for the same services or supplies.
Us/ We Us and we refer to Vantage Health Plan, Inc.
You You
refers to the enrollee and each covered family member.
Experimental or
investigational services 45
45 Page 46 47
2002 Vantage Health Plan, Inc. 46 Section 11
Section 11.
FEHB facts
No pre-existing condition We will not refuse to cover the
treatment of a condition that you had
limitation before you enrolled
in this Plan solely because you had the condition before you enrolled.
Where you can get information See www.
opm. gov/ insure. Also, your employing or
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. 46
46 Page
47 48
2002 Vantage Health Plan, Inc. 47 Section 11
When
benefits and The benefits in this brochure are effective on January 1. If
you joined this Plan
premiums start during Open Season, your coverage
begins on the first day of your first pay period that starts on or after January
1. Annuitants' coverage and premiums begin on January 1. If
you joined at any other time during the year, your employing office will tell
you the
effective date of coverage.
Your medical and claims We will keep your medical and claims
information confidential. Only the following
records are confidential
will have access to it:
. OPM, this Plan, and subcontractors when they administer this contract;
. This Plan and appropriate third parties, such as other insurance plans and
the Office of Workers' Compensation Programs (OWCP), when coordinating benefit
payments and
subrogating claims;
. Law enforcement officials when investigating and/
or prosecuting alleged civil or criminal actions;
. OPM and the General Accounting Office when conducting audits;
.
Individuals involved in bona fide medical research or education that does not
disclose your identity; or
. OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your Federal service. If you
do not meet this requirement, you
may be eligible for other forms of coverage, such as
temporary continuation
of coverage (TCC).
When you lose benefits
. When FEHB coverage ends You will
receive an additional 31 days of coverage, for no additional premium, when:
. Your enrollment ends, unless you cancel your enrollment, or
. You are
a family member no longer eligible for coverage.
You may be eligible for
spouse equity coverage or Temporary Continuation of Coverage.
. Spouse
equity 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 If you leave Federal service, or
if you lose coverage because you no longer qualify as a
(TCC) 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. 47
47 Page
48 49
2002 Vantage Health Plan, Inc. 48 Section 11
.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage
. Your coverage under TCC or the spouse equity
law ends (If you canceled your coverage or did not pay your premium, you cannot
convert);
. You decided not to receive coverage under TCC or the spouse equity law; or
. You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of your
right to
convert. You must apply in writing to us within 31 days after you
receive this notice.
However, if you are a family member who is losing
coverage, the employing or
retirement office will not notify you. You
must apply in writing to us within 31 days
after you are no longer eligible
for coverage.
Your benefits and rates will differ from those under the FEHB Program;
however, you
will not have to answer questions about your health, and we
will not impose a waiting
period or limit your coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) is a Federal
Group Health Plan
Coverage law that offers limited Federal protections for health coverage
availability and continuity to people who lose employer group coverage. If you
leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long
you have
been enrolled with us. You can use this certificate when getting
health insurance or other
health care coverage. Your new plan must reduce or
eliminate waiting periods,
limitations, or exclusions for health related
conditions based on the information in the
certificate, as long as you
enroll within 63 days of losing coverage under this Plan. If you
have been
enrolled with us for less than 12 months, but were previously enrolled in other
FEHB plans, you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary Continuation of
Coverage (TCC) under the FEHB
Program. See also the FEHB web site
(www. opm. gov/ insure/ health):
refer to the "TCC and HIPAA" frequently asked
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. 48
48
Page 49 50
2002 Vantage Health Plan, Inc. 49 Long Term Care Insurance
Long Term Care Insurance Is Coming Later in 2002!
The Office
of Personnel Management (OPM) will sponsor a high-quality long-term care
insurance program effective in October
2002. As part of its educational
effort, OPM asks you to consider these questions:
. It's insurance to help pay for long term care services you may need if you
can't take care of yourself because of an extended illness or injury, or an
age-related disease
such as Alzheimer's.
. LTC insurance can provide
broad, flexible benefits for nursing home care, care in an assisted living
facility, care in your home, adult day care, hospice care, and more.
LTC insurance can supplement care provided by family members, reducing the
burden you place on them.
. Welcome to the club! . 76% of Americans believe they will never need long
term care, but the facts are that
about half of them will. And it's not just
the old folks. About 40% of people
needing long-term care are under age 65.
They may need chronic care due to a
serious accident, a stroke, or
developing multiple sclerosis, etc.
. We hope you will never need long term
care, but everyone should have a plan just in case. Many people now consider
long term care insurance to be vital to their
financial and retirement planning.
. Yes, it can be very
expensive. A year in a nursing home can exceed $50,000. Home care for only three
8-hour shifts a week can exceed $20,000 a year. And that's
before inflation!
. Long term care can easily exhaust your savings. Long-term care
insurance can protect your savings.
. Not FEHB. Look at the "Not covered" blocks in sections 5( a) and 5(
c) of your FEHB brochure. Health plans don't cover custodial care or a stay in
an assisted
living facility or a continuing need for a home health aide to
help you get in and out
of bed and with other activities of daily living.
Limited stays in skilled nursing
facilities can be covered in some
circumstances.
. Medicare only covers skilled nursing home care (the highest
level of nursing care) after a hospitalization for those who are blind, age 65
or older or fully disabled. It
also has a 100-day limit.
. Medicaid covers long term care for those who
meet their state's poverty guidelines, but has restrictions on covered services
and where they can be received. Long term
care insurance can provide choices of care and preserve your independence.
. Employees will get more information from their agencies during the LTC
open enrollment period in the late summer/ early fall of 2002.
. Retirees
will receive information at home.
. Our toll-free teleservice center will
begin in mid-2002. In the meantime, you can
learn more about the program on our web site at www. opm. gov/ insure/ ltc.
. 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 coverage?
How can I find out more about the
program NOW? 49
49 Page 50 51
2002 Vantage Health Plan, Inc. 50 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 16, 21, 36 Allergy tests 14
Allogeneic (donor)
bone marrow
transplant 22
Alternative treatment 19
Ambulance 9, 24,
26, 27, 29
Anesthesia 20, 23, 25
Autologous bone marrow transplant 15,
22
Blood and blood plasma 11, 24, 25, 33 Biopsies 20
Casts 24, 25 Chemotherapy 15
Chiropractic 19
Cholesterol tests
12
Claims 6, 10, 38, 39, 40, 43, 47
Coinsurance 5, 6, 9, 38, 43
Colorectal cancer screening 12
Congenital anomalies 20, 21
Coordination of benefits 41, 43
Covered charges 43
Deductible 9, 11, 20, 24, 27, 30, 32 Definitions 45
Dental care 36
Diagnostic services 11, 19, 24, 30
Dialysis 15, 18
Disputed claims review 39, 40
Donor expenses (transplants) 22, 23
Durable medical equipment (DME) 8, 18
Educational classes and programs 19 Effective date of enrollment 6, 9,
45, 47
Emergency 5, 27
Experimental or investigational 37, 45
Eyeglasses 16
Family planning 13 Fecal occult blood test 12
General Exclusions 10, 37
Hearing services 16
Home health services 19
Hospice care 7, 25, 47
Hospital 26
Immunizations 5, 12 Infertility 9, 14
Inhospital physician care 11
Inpatient hospital benefits 7, 24
Insulin 9, 18, 33
Laboratory services 11, 24, 25
Magnetic Resonance Imaging (MRIs) 8, 11
Mammograms 12
Maternity benefits 13
Medicaid 44, 49
Medically necessary 8, 11, 13,
15,
20, 24, 25, 27, 32, 36, 37
Medicare 11, 20, 24, 27, 30, 32,
36,
38, 41, 42, 43
Members 5, 6, 20
Mental Conditions/ Substance
Abuse
Benefits 30, 31
Newborn care 13 Nurse 19, 24
Nursery charges 13
Obstetrical care 13 Occupational therapy 8,
9,15
Ocular injury 16
Office visits 5, 11
Oral and maxillofacial surgery
22
Orthopedic devices 9, 17, 18, 20
Out-of-pocket expenses 9, 43
Outpatient facility care 25
Oxygen equipment 18, 19
Pap test 11, 12 Physical examination 5, 12
Physical therapy 8, 9,
15
Physician 5, 6, 7, 8, 9, 11, 18, 19,
33, 34, 38, 43, 45
Preauthorization 8, 19, 20, 24, 30,
31, 32, 35, 39, 40
Preventive
care, adult 12
Preventive care, children 12
Prescription drugs 32, 33,
34 38, 41,
43
Prosthetic devices 9, 17, 18, 20, 21
Psychiatrists 30
Psychologists 30
Radiation therapy 15 Renal disease dialysis 15, 41, 42
Room and board 24
Second surgical opinion 11 Skilled nursing
facility care 7, 11, 23, 25,
45, 49
Smoking cessation 34
Speech
therapy 8, 9, 16
Subrogation 44
Substance abuse 30, 31
Surgery
. Anesthesia 20, 23, 25 . Oral 22
. Outpatient 25 . Reconstructive 21
Syringes 33
Temporary
continuation of Coverage (TCC) 47, 48
Transplants 15, 22, 23
Treatment therapies 17, 15
Vision services 16
Well child care 12 Wheelchairs 18
Workers' compensation 42, 44, 47
X-rays 11, 24, 25 50
50 Page 51 52
2002 Vantage Health Plan, Inc. 51 Summary
Summary of benefits for Vantage Health Plan, Inc. -2002
.
Do not rely on this chart alone. All benefits are provided in full unless
indicated and are subject to the definitions,
limitations, and exclusions in
this brochure. On this page, we summarize specific expenses we cover; for more
detail,
look inside.
. If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from the cover on
your enrollment form.
. We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
. Diagnostic and treatment services provided in the office.................
Office visit copay: $15 primary care or specialist 11
Services provided by a hospital:
.
Inpatient............................................................................................
. Outpatient
.........................................................................................
$250 per admission copay
$250 per outpatient surgery copay
24
25
Emergency benefits:
.
In-area..............................................................................................
. Out-of-area
......................................................................................
$50 per visit
$50 per visit
28
28
Mental health and substance abuse
treatment...................................... Regular cost sharing 30
Prescription drugs
.................................................................................
Retail pharmacy for up to a 34-day supply per prescription unit or
refill
Mail order pharmacy for up to a 90-day supply per prescription unit or
refill
Retail Pharmacy: $10 copay for generic
drugs; $20 copay for
preferred (formulary)
name brand drugs; $35 copay for non-preferred
(non-formulary) name brand drugs.
Mail Order Pharmacy: $30 copay for generic
drugs; $60 copay for
preferred (formulary)
name brand drugs; $105 copay for non-preferred
(non-formulary) name brand drugs.
32-34
Dental Care ....................................... Accidental injury benefit
only 20% coinsurance 36
Vision Care One routine eye exam every two years
with no referral $15 per visit 16
Special features: Travel benefit; 70%
reduced benefit option for certain out of network providers with
preauthorization;
hearing impaired interpreter expense
35
Protection against catastrophic costs
(your out-of-pocket
maximum)…………………………
We do not have an out-of-pocket maximum 9 51
51 Page 52
2002
Vantage Health Plan, Inc. 52 Rates
Rates
2002 Rate Information for
VANTAGE HEALTH PLAN, INC.
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
Monroe area
Self Only AQ1 $97.86 $40.16 $212. 03 $87.01 $115. 52
$22.50
Self and Family AQ2 $223. 41 $146. 87 $484. 06 $318. 21 $263. 75 $106. 53
Shreveport/ Alexandria areas
Self Only MV1 $97.86 $48.44 $212. 03
$104. 95 $115. 52 $30.78
Self and Family MV2 $223. 41 $169. 09 $484. 06 $366. 36 $263. 75 $128. 75 52