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Page Navigation PanelRural Carrier Benefit Plan
Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version
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Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families.
In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship.
The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable.
Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure. |
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Sincerely,
Kay Coles James
Director
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Sponsored and administered by: The National Rural Letter Carriers' Association
Who may enroll in this Plan: Only eligible active and retired rural letter carriers of the U. S. Postal Service may enroll in this Plan. To enroll you must
already be, or must immediately become, a member of the National Rural Letter Carriers' Association.
To become a member: For information on how to become a member of the National Rural Letter Carriers' Association, please contact the Secretary for your State Association or the membership office
of the National Rural Letter Carriers' Association.
Membership dues: Active and retired Postal Service membership dues vary by state.
Enrollment codes for this Plan: 381 High Option -Self Only
382 High Option -Self and Family
RI 72-005
Rural Carrier Benefit Plan 2003 http:// www. NRLCA. org
A fee-for-service plan with a preferred provider organization
Mutual of Omaha Insurance Company, the underwriter for the RURAL CARRIER
BENEFIT PLAN has received accreditation from URAC (also known as the American Accreditation
Healthcare Commission), for Health Utilization Manage-ment Standards. See the 2003 Guide for more informa-tion
on accreditation.
For changes
in benefits see page 9.
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Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to give you this notice to tell you
how OPM may use and give out (" disclose") your personal medical information held by OPM.
OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is protected,
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:
To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.
OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission at any time, except if OPM has
already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is
missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any information that you authorized
OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O.
Box instead of your home address). Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to
your request if the information is used to conduct operations in the manner described above. Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.
If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707
Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail within 60 days of the change.
The privacy practices listed in this notice will be effective April 14, 2003.
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Introduction
.............................................................................................................................................................................................. 6
Plain Language
......................................................................................................................................................................................... 6
Stop Health Care Fraud!
......................................................................................................................................................................... 6-7
Section 1. Facts about this fee-for-service plan
..................................................................................................................................... 8
Section 2. How we change for 2003
...................................................................................................................................................... 9
Section 3. How you get care
.............................................................................................................................................................. 10-13
Identification cards
................................................................................................................................................................. 10
Where you get covered care
............................................................................................................................................. 10-11
Covered providers.........................................................................................................................................................
10
Covered facilities
.......................................................................................................................................................... 11
What you must do to get covered care
............................................................................................................................ 11-12
How to get approval for
............................................................................................................................................... 12-13
Your hospital stay (precertification)
....................................................................................................................... 12-13
Other services
............................................................................................................................................................... 13
Section 4. Your costs for covered services
....................................................................................................................................... 14-17
Copayments
.................................................................................................................................................................. 14
Deductible
..................................................................................................................................................................... 14
Coinsurance
.................................................................................................................................................................. 14
Differences between our allowance and the bill
.................................................................................................... 14-15
Your catastrophic protection out-of-pocket maximum
......................................................................................................... 15
When government facilities bill us
........................................................................................................................................ 15
If we overpay you
.................................................................................................................................................................. 15
When you are age 65 or over and you do not have Medicare
............................................................................................ 16
When you have Medicare
...................................................................................................................................................... 17
Section 5. Benefits
.............................................................................................................................................................................. 18-47
Overview
................................................................................................................................................................................ 18
(a) Medical services and supplies provided by physicians and other health care professionals
................................... 19-26
(b) Surgical and anesthesia services provided by physicians and other health care professionals
................................ 27-30
(c) Services provided by a hospital or other facility, and ambulance services
.............................................................. 31-33
(d) Emergency services/ accidents
.......................................................................................................................................... 34
(e) Mental health and substance abuse benefits
.............................................................................................................. 35-39
(f) Prescription drug benefits
........................................................................................................................................... 40-42
(g) Special features
........................................................................................................................................................... 43-44
Flexible benefits option
24 hour nurse line
Cancer treatment benefit
Kidney dialysis benefit
Routine eye exam benefit
Travel benefit/ overseas services
Healthy maternity program
Disease management programs
(h) Dental benefits
............................................................................................................................................................ 45-46
(i) Non-FEHB benefits available to Plan members
............................................................................................................. 47
Table of Contents
2003 Rural Carrier Benefit Plan 4 Table of Contents
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2003 Rural Carrier Benefit Plan 5 Table of Contents
Section 6. General exclusions things we don't cover
................................................................................................................... 48
Section 7. Filing a claim for covered services
............................................................................................................................... 49-50
Section 8. The disputed claims process
......................................................................................................................................... 51-52
Section 9. Coordinating benefits with other coverage
................................................................................................................... 53-57
When you have other health coverage
..................................................................................................................... 53
What is Medicare?
............................................................................................................................................... 53-55
Medicare managed care plan
.................................................................................................................................... 56
TRICARE and CHAMPVA
..................................................................................................................................... 56
Workers Compensation
............................................................................................................................................. 57
Medicaid
.................................................................................................................................................................... 57
When other Government agencies are responsible for your care
........................................................................... 57
When others are responsible for injuries
................................................................................................................. 57
Section 10. Definitions of terms we use in this brochure
............................................................................................................... 58-60
Section 11. FEHB facts
.................................................................................................................................................................... 61-63
Coverage information
.................................................................................................................................................... 61-62
No pre-existing condition limitation
........................................................................................................................ 61
Where you get information about enrolling in the FEHB Program
....................................................................... 61
Types of coverage available for you and your family
............................................................................................ 61
Children's Equity Act
.......................................................................................................................................... 61-62
When benefits and premiums start
........................................................................................................................... 62
When you retire
........................................................................................................................................................ 62
When you lose benefits
................................................................................................................................................. 62-63
When FEHB coverage ends
..................................................................................................................................... 62
Spouse equity coverage
............................................................................................................................................ 62
Temporary Continuation of Coverage (TCC)
..................................................................................................... 62-63
Converting to individual coverage
........................................................................................................................... 63
Getting a Certificate of Group Health Plan Coverage
............................................................................................ 63
Long term care insurance is still available
............................................................................................................................................. 64
Index
......................................................................................................................................................................................................... 65
Summary of benefits
........................................................................................................................................................................... 66-67
Rates
........................................................................................................................................................................................... Back cover
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2003 Rural Carrier Benefit Plan 6 Introduction/ Plain Language/ Stop Health Care Fraud
Introduction
This brochure describes the benefits of the Rural Carrier Benefit Plan under our contract (CS 1073) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law.
This plan is underwritten by the Mutual of Omaha Insurance Company, Omaha, Nebraska. The address for the Rural Carrier Benefit Plan administrative office is:
Rural Carrier Benefit Plan 1630 Duke Street, First Floor
Alexandria, VA 22314-3466
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled for Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available
before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 9. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. "You" means the enrollee or family member; "we" means the Rural Carrier Benefit Plan
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure
or e-mail us at fehbwebcomments@ opm. gov.
You may also write to OPM at the Office of
Personnel Management, Office of Insurance
Planning and Evaluation Division, 1900
E Street, NW, Washington, DC 20415-3650.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services.
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
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2003 Rural Carrier Benefit Plan 7 Stop Health Care Fraud
Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
If you suspect that a provider 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 1-800/ 638-8432 and explain the situation.
If we do not resolve the issue:
CALL THE HEALTH CARE FRAUD HOTLINE 1-202/ 418-3300
OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415
Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or
your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
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2003 Rural Carrier Benefit Plan 8 Section 1
Section 1. Facts about this fee-for-service plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers.
We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.
We also have Preferred Provider Organizations (PPO):
Our fee-for-service plan offers services through a PPO. When you live in a PPO network area and use our PPO providers, you will receive covered services at reduced cost. Contact us at 1-800/ 638-8432 or the Mutual of Omaha website,
www. mutualofomaha. com
for the names of PPO providers and to verify their continued participation. You can also go to our web page, which you can reach
through the FEHB web site, www. opm. gov/ insure.
Contact the Rural Carrier Benefit Plan to request a
PPO directory.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If
no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply. When you use a PPO hospital, keep in mind that the health care professionals who provide services to you in the hospital, such as radiologists,
emergency room physicians, anesthesiologists, and pathologists, may not all be preferred providers. If they are not, we will pay them as non-PPO providers.
The Plan has PPO networks in all states except for Hawaii, Vermont and Wyoming.
How we pay providers
We generally reimburse participating providers according to an agreed-upon fee schedule and we do not offer additional financial incentives based on care provided or not provided to you. Our standard provider agreements do not contain any incentives to
restrict a provider's ability to communicate with or advise you of any appropriate treatment options. In addition, we have no compensation agreement, ownership, or other influential interests that are likely to affect provider advice or treatment decisions.
Call the telephone number on your identification (ID) card to locate health care providers who may offer discounts.
We may apply a discount to covered services you receive from other providers through our negotiated arrangements with those providers.
Your Rights
OPM requires all FEHB Plans provide certain information to their FEHB members. You may get information about networks, our providers, facilities, and us. 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.
Years in existence
Profit status
If you want more information about us, call 1-800/ 638-8432 or write to Rural Carrier Benefit Plan, 1630 Duke Street, First Floor, Alexandria, VA 22314-3466. You may also contact us by fax at 1-703/ 684-9627 or visit our website at www. nrlca. org.
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2003 Rural Carrier Benefit Plan 9 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that
does not change benefits.
Program-wide changes A Notice of the Office of Personnel Management's Privacy Practices is included.
A section on the Children's Equity Act describes when an employee is required to maintain Self and Family coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.
Program information on Medicare is revised.
The Medically Underserved section is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.
Changes to this Plan Your share of the non-Postal premium will increase by 17.5% for Self Only or 18.8% for Self and Family.
We clarified the brochure to better explain that a copayment of $20 applies for each different doctor visit when a Plan member sees more than one PPO doctor in the same day.
We clarified the Durable medical equipment (DME) benefit by adding a list of equipment that the Plan does not pay for, Section 5( a).
We clarified Allergy care to show that the Plan pays for allergy serum under Prescription drug benefits, Section 5( f).
We clarified the brochure language to show that freestanding alcohol or drug abuse facilities with accreditation from the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) are included as covered facilities under the Plan,
Section 3.
We clarified the brochure to show that sonograms are covered under Lab, X-ray and other diagnostic tests, Section 5( a).
We clarified the brochure language to show that during the calendar year the Plan covers two preventive care visits per person under Dental benefits, Section 5( h).
We clarified the Extended care benefits/ Skilled nursing care facility benefits to better explain how the Plan pays for care received in a skilled nursing facility, Section 5( c).
We clarified the brochure to better explain how the Plan pays for care received as a result of a medical emergency like a heart attack or stroke under Emergency services/ accidents, Section 5( d).
We added four exclusions to General exclusions things we don't cover, Section 6.
We increased the Plan's copayment for doctor office visits from $15 per visit to $20 per visit when you use a PPO doctor.
We changed the benefits for a stay in a non-PPO hospital from 100% for room and board, after a $200 deductible, and 80% of other hospital charges to 85% of room and board and other hospital charges after a copayment of $200 for the first day of each
hospital stay.
We changed the benefits for the outpatient hospital facility charge when surgery is done from 100% for a PPO and non-PPO facility to 85% for a PPO facility and 75% for a non-PPO facility after the calendar year deductible.
We increased the copayment for prescription drugs ordered through our mail order prescription program from $13 generic or $18 brand name to $15 generic or $25 brand name and for Plan members with Medicare Part B coverage from $3 generic or $6
brand name to $6 generic or $12 brand name.
We now provide benefits for one routine colonoscopy every ten years beginning at age 50.
We eliminated our benefit exclusion for acts of war and terrorism.
We changed our Accidental injury benefit from 100% up to a maximum benefit of $400 to 100% of the emergency room visit charges and 100% of the initial doctor's office visit. This benefit change does not apply to reimbursement of charges for x-rays
or laboratory tests.
We changed our smoking cessation benefit from benefits received during twelve consecutive months to benefits received during a calendar year.
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2003 Rural Carrier Benefit Plan 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800/ 638-8432.
Where you get covered care You can get care from any "covered provider" or "covered facility." How much we pay and you pay depends on the type of covered provider or facility you use. If
you live in the PPO network area and use our preferred providers, you will pay less.
Covered providers We consider the following to be covered providers when they perform services within the scope of their license or certification:
Physician: A doctor of medicine (M. D.), osteopathy (D. O.), dental surgery (D. D. S.), medical dentistry (D. M. D.), podiatric medicine (D. P. M.), chiropractic (D. C.), and
optometry (O. D.), when acting within the scope of his/ her license or certification.
Qualified Clinical Psychologist: An individual who has earned either a doctoral or Masters Clinical Degree in psychology or an allied discipline and who is licensed or
certified in the state where services are performed. This presumes a licensed individual has demonstrated to the satisfaction of state licensing officials that he/ she by virtue of
academic and clinical experience is qualified to provide psychological services in that state.
Nurse Midwife: A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure or
certification.
Nurse Practitioner/ Clinical Specialist: A person who: 1) has an active R. N. license in the United States; 2) has a baccalaureate or higher degree in nursing; and 3) is licensed
or certified as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification.
Clinical Social Worker: A social worker who: 1) has a master's or doctoral degree in social work; 2) has at least two years of clinical social work practice; and 3) in states
requiring licensure, certification, or registration, is licensed, certified, or registered as a social worker where the services are rendered.
Nursing School Administered Clinic: A clinic that is: 1) licensed or certified in the state where the services are performed; and 2) provides ambulatory care in an
outpatient setting primarily in rural or inner-city areas where there is a shortage of physicians. Services billed for by these clinics are considered outpatient 'office'
services rather than facility charges.
Physician Assistant: A person who is licensed, registered, or certified in the state where services are performed.
Licensed Professional Counselor or Master's Level Counselor: A person who is licensed, registered, or certified in the state where services are performed.
Audiologist: A person who is licensed, registered, or certified in the state where services are performed.
Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in states OPM determines are "medically underserved."
For 2003, the states are: Alabama, Idaho, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas,
Utah, West Virginia, and Wyoming.
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2003 Rural Carrier Benefit Plan 11 Section 3
Covered facilities Covered facilities include:
Hospital:
1) An institution that is accredited as a hospital under the hospital accreditation program of the JCAHO; or
2) Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service, and that is primarily
engaged in providing:
a) General inpatient care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which facilities must
be provided on it premises or under its control; or
b) Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities (including x-ray and laboratory) on
its premises, under its control, or through a written agreement with a hospital (as defined above) or with a specialized provider of those facilities.
For treatment of alcoholism and drug abuse, hospital also includes a freestanding alcohol and drug abuse treatment facility approved by the JCAHO.
In no event shall the term hospital include a convalescent nursing home or institution or part thereof that:
1) Is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged;
2) Furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or
3) Is operated as a school.
Skilled Nursing Facility: An institution or that part of an institution that provides convalescent skilled nursing care 24 hours a day and is certified (or is qualified and
could be certified) as a skilled nursing facility under Medicare.
Birthing Center: A licensed facility that is equipped and operated solely to provide prenatal care, to perform uncomplicated spontaneous deliveries, and to provide
immediate post-partum care.
Hospice: A public or private agency or organization that:
1) Administers and provides hospice care; and
2) Meets one of the following requirements:
Is licensed or certified as a hospice by the State in which it is located;
Is certified (or is qualified and could be certified) to participate as a hospice under Medicare;
Is accredited as a hospice by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO); or
Meets the standards established by the National Hospice Organization.
What you must do to It depends on the kind of care you want to receive. You can go to any get covered care provider you want, but we must approve some care in advance.
Transitional care: Specialty care: If you have a chronic or disabling condition and
lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or
lose access to your PPO specialist because we terminate our contract with your specialist for other than cause
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2003 Rural Carrier Benefit Plan 12 Section 3
you may be able to continue seeing your specialist and receiving any PPO benefits 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
and any PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.
Hospital care: We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer
service department immediately at 1-800/ 638-8432.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.
How to Get Approval for
Your hospital stay Precertification is the process by which prior to your inpatient hospital admission we evaluate the medical necessity of your proposed stay and the number of days
required to treat your condition. Unless we are misled by the information given to us, we won't change our decision on medical necessity.
In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your care, you
should always ask your physician or hospital whether they have contacted us.
Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any
benefits.
How to precertify an admission: You, your representative, your physician, or your hospital must call us at 1-800/ 638-8432 at least seven days before admission.
If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your
representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been
discharged from the hospital.
Provide the following information:
Enrollee's name and Plan identification number;
Patient's name, birth date, and phone number;
Reason for hospitalization, proposed treatment, or surgery;
Name and phone number of admitting physician;
Name of hospital or facility; and
Number of planned days of the hospital stay.
We will then tell your physician and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your physician,
and the hospital.
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2003 Rural Carrier Benefit Plan 13 Section 3
Maternity care You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery
or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are
discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.
If your hospital stay If your hospital stay including for maternity care needs to be extended, you, needs to be extended: your representative, your physician or the hospital must ask us to approve the
additional days.
What happens when you If no one contacted us, we will decide whether the hospital stay was medically do not follow the necessary.
precertification rules If we determine that the stay was medically necessary, we will pay the inpatient
charges, less the $500 penalty.
If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered
medical supplies and services that are otherwise payable on an outpatient basis.
If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise
payable on an outpatient basis.
When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then:
for the part of the admission that was medically necessary, we will pay inpatient benefits, but
for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will
not pay inpatient benefits.
Exceptions: You do not need precertification in these cases:
You are admitted to a hospital outside the United States.
You have another group health insurance policy that is the primary payer for the hospital stay.
Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare
lifetime reserve days, then we will become the primary payer and you do need precertification.
Other services Some services require a referral, precertification, or prior authorization.
Home health care (see Section 5( a))
Hospice care (see Section 5( c))
Organ/ Tissue transplants (see Section 5( b))
Skilled nursing care (see Section 5( c))
Mental Health and Substance abuse treatment (see Section 5( e))
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Page 14
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2003 Rural Carrier Benefit Plan 14 Section 4
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
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 PPO physician you pay a copayment of $20 per day. If you see more than one PPO physician on the same day, you pay one copayment for each
different physician seen on that day. When you have a stay in a non-PPO hospital, you pay $200 for the first day of your hospital stay.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count
toward any deductible.
The calendar year deductible is $350 per person. Under a family enrollment, the deductible is satisfied for all family members when the combined covered expenses
applied to the calendar year deductible for family members reach $700.
We also have a separate deductible for dental care$ 50 per person each calendar year.
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 allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible.
Example: You pay 25% of our allowance for physician office visits under our non-PPO benefit.
Note: If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the
law. In this case, when we calculate our share, we will reduce the provider's fee by the amount waived.
For example, if your physician ordinarily charges $100 for a service but routinely waives your 25% coinsurance, the actual charge is $75. We will pay $56.25 (75% of
the actual charge of $75).
Differences between Our "Plan allowance" is the amount we use to calculate our payment for covered our allowance and services. Fee-for-service plans arrive at their allowances in different ways, so their
the bill allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10.
Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on
the provider you use.
When you live in the Plan's PPO area, you should use a PPO provider, whenever possible. The following two examples explain how we will handle your bill when you
go to a PPO provider and when you go to a non-PPO provider. When you use a PPO provider, the amount you pay will usually be much less.
PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your
deductible and coinsurance or copayment. Here is an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have
met your deductible, you are only responsible for your coinsurance. That is, you pay just 10% of our $100 allowance ($ 10). Because of the agreement, your PPO
physician will not bill you for the $50 difference between our allowance and his bill.
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2003 Rural Carrier Benefit Plan 15 Section 4
Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and
coinsurance plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our
allowance is again $100. Because you've met your deductible, you are responsible for your coinsurance, so you pay 25% of our $100 allowance ($ 25). Plus, because
there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance and his bill.
The following table illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician versus a non-PPO physician when you live
in a PPO network area. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table shows the amount you
pay if you have met your calendar year deductible.
EXAMPLE PPO physician Non-PPO physician
Physician's charge $150 $150
Our allowance We set it at: $100 We set it at: $100
We pay 85% of our allowance: $85 75% of our allowance: $75
You owe: Coinsurance 10% of our allowance: $15 25% of our allowance: $25
+Difference up to charge? No: $0 Yes: $50
TOTAL YOU PAY $15 $75
Your catastrophic protection For those benefits where coinsurance or deductibles applies, we pay 100% of the Plan out-of-pocket maximum allowance for the rest of the calendar year after your expenses total to:
for deductibles, coinsurance, and copayments $2,500 per person or $3,000 per family when you use PPO providers/ facilities, or
$3,000 per person or $3,500 per family when you use PPO and non-PPO providers/ facilities combined
$8,000 per person for out-of-network Mental Health/ Substance Abuse care
Your out-of-pocket maximum does not include the following:
Copayments, except the hospital stay copayment
Expenses for prescription medications you order from our mail order drug program
Expenses for dental care
Expenses in excess of our allowances or maximum benefit limits
Expenses for a stay in a skilled nursing facility
Any penalty you pay for failing to get approval for a hospital stay
Any amount you pay for failing to get approval for additional days in the hospital after the initial length of a hospital stay is approved
Any amount you pay for failing to get approval for outpatient mental health/ substance abuse care
Any amount you pay for not following an approved mental health/ substance abuse care treatment program
Expenses you pay for services, supplies and drugs not covered by us
When government facilities Facilities of the Department of Veterans Affairs, the Department of Defense and the bill us Indian Health Service are entitled to seek reimbursement from us for certain services
and supplies they provide to you or a family member. They may not seek more than their governing laws allow.
If we overpay you If your claim has been paid in error for any reason, we will make a diligent effort to recover the overpayment from you or your provider. We may also reduce subsequent
benefit payments to you or to a provider to offset overpayments made in error.
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2003 Rural Carrier Benefit Plan 16 Section 4
When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for those benefits you would be entitled to if you had Medicare. And, your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. The
following chart has more information about the limits.
If you
are age 65 or over, and
do not have Medicare Part A, Part B, or both; and
have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)
Then, for your inpatient hospital care,
the law requires us to base our payment on an amount the "equivalent Medicare amount" set by Medicare's rules for what Medicare would pay, not on the actual charge;
you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;
you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and
the law prohibits a hospital from collecting more than the Medicare equivalent amount.
And, for your physician care, the law requires us to base our payment and your coinsurance on
an amount set by Medicare and called the "Medicare approved amount," or
the actual charge if it is lower than the Medicare approved amount.
If your physician Then you are responsible for
Participates with Medicare or accepts your deductibles, coinsurance, and copayments and any Medicare assignment for the claim and is balance up to the Medicare approved amount;
a member of our PPO network,
Participates with Medicare and is not in your deductibles, coinsurance, copayments, and any our PPO network, balance up to the Medicare approved amount;
Does not participate with Medicare, your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount
It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more
than allowed, ask for a refund. If you need further assistance, call us.
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2003 Rural Carrier Benefit Plan 17 Section 4
When you have the Original We limit our payment to an amount that supplements the benefits that Medicare would Medicare Plan (Part A, Part B, pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical
or both) insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not
participate with Medicare and is not reimbursed by Medicare.
If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician
accepts Medicare assignment for the claim.
If your physician accepts Medicare assignment, then you pay nothing for covered charges.
If your physician does not accept Medicare assignment, then you pay the difference between our payment combined with Medicare's payment and the charge.
Note: The physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the "limiting
charge." The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than
allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to your Medicare carrier who sent you the MSN form. Call us if
you need further assistance.
Please see Section 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare.
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2003 Rural Carrier Benefit Plan 18 Section 5
Section 5. Benefits OVERVIEW
(See page 9 for how our benefits changed this year and pages 66-67 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 1-800/ 638-8432 or at our website at www. nrlca. org
(a) Medical services and supplies provided by physicians and other health care professionals .................................................... 19-26
Diagnostic and treatment services Vision services (testing, treatment, and supplies) Lab, X-ray, and other diagnostic tests Foot care
Preventive care, adult Orthopedic and prosthetic devices Preventive care, children Durable medical equipment (DME)
Maternity care Home health services Family planning Chiropractic
Infertility services Alternative treatments Allergy care Educational classes and programs
Treatment therapies Physical, occupational and speech therapies
Hearing services (testing, treatment, and supplies)
(b) Surgical and anesthesia services provided by physicians and other health care professionals ................................................ 27-30
Surgical procedures Organ/ tissue transplants Reconstructive surgery Anesthesia
Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services ............................................................................... 31-33
Inpatient hospital Hospice care Outpatient hospital or ambulatory surgical center Ambulance
Extended care benefits/ Skilled nursing care facility benefits
(d) Emergency services/ Accidents .......................................................................................................................................................... 34
Accidental injury Ambulance Medical emergency
(e) Mental health and substance abuse benefits ............................................................................................................................... 35-39
(f) Prescription drug benefits ............................................................................................................................................................ 40-42
(g) Special features ............................................................................................................................................................................ 43-44
Flexible benefits option Kidney dialysis benefit 24 hour nurse line Routine eye exam benefit
Cancer treatment benefit Healthy maternity program Travel benefit/ overseas services Disease management programs
(h) Dental benefits ............................................................................................................................................................................ 45-46
(i) Non-FEHB benefits available to Plan members .............................................................................................................................. 47
SUMMARY OF BENEFITS................................................................................................................................................................ 66-67
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2003 Rural Carrier Benefit Plan 19 Section 5( a)
Here are some important things you should 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.
The calendar year deductible is: $350 per person ($ 700 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to
show when the calendar year deductible does not apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.
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Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "( No deductible)" when it does not apply.
Diagnostic and treatment services
Professional services of physicians (not including surgery)
In a physician's office, including but not limited to:
Medical consultations
Injections, except specialty pharmacy drugs
One routine physical exam per person each calendar year
Note: We pay for surgery services by a physician under Surgical services, Section 5( b).
Office surgery, office visits on the same day as surgery and office visits up to 90 days following surgery are covered under Surgical services, Section
5( b).
Supplies provided by a physician during an office visit are covered under Section 5( a) of the brochure.
Drugs supplied by a physician are covered under Section 5( f) of the brochure, as drugs from other sources.
Outpatient physical therapy, occupational therapy, and speech therapy are covered under Section 5( a).
Treatment for Mental and Nervous Disorders, Alcoholism and Substance Abuse is covered under Section 5( e).
Professional services of physicians (not including surgery)
During a hospital stay
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment
In your home
In an urgent care center
Note: We pay for surgery services by a physician under Surgical services, Section 5( b).
Not covered: All charges
Telephone consultations, mailing, faxes, emails or any other
communications to or from a physician, hospital or other medical provider.
PPO: $20 copayment (No deductible)
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
Section 5( a). Medical services and supplies provided by physicians and other health care professionals
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2003 Rural Carrier Benefit Plan 20 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG
Sonograms
Preventive care, adult
Routine screenings, limited to:
Sigmoidoscopy, screening every five years starting at age 50
Annual coverage of one fecal occult blood test for members age 40 and older
Routine Prostate Specific Antigen (PSA) test one annually for men age 40 and older
One non-fasting blood cholesterol test every three consecutive calendar years
Chlamydial infection
One routine pap test per calendar year
Routine mammogram one annually for women age 35 and older
One routine colonoscopy exam every 10 years beginning at age 50
Not covered: All charges
Adult immunizations
Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics for dependent children under age 22.
Note: Associated charges for office visits and other services are considered under Diagnostic and treatment services on page 19.
PPO: Nothing (No deductible)
Non-PPO: Nothing up to Plan allowance then any difference between our allowance and the
billed amount (No deductible)
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
Note: If your PPO provider uses a non-PPO lab or radiologist, we will pay non-PPO
benefits for the lab and X-ray charges.
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
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2003 Rural Carrier Benefit Plan 21 Section 5( a)
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Delivery
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see page 13 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 cover an extended stay, if
medically necessary, but you, your representative, your physician or your hospital must precertify the extended stay.
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 if we cover the infant under a Self and Family enrollment.
We cover the initial routine examination of your newborn infant covered under your family enrollment.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits, Section 5( c), and Surgical
services, Section 5( b).
One routine sonogram
Not covered: All charges
Procedures, services, drugs, and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried
to term or when the pregnancy is the result of an act of rape or incest.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures, Section 5( b))
Surgical implant of contraceptive drugs (such as Norplant)
Injection of contraceptive drugs (such as Depo provera)
Fitting, inserting or removing Intrauterine devices (such as diaphragms or IUDs)
Note: We cover contraceptive drugs and devices under Prescription drug benefits, Section 5( f).
Note: We cover surgical procedures under Surgical services in Section 5( b).
Not covered: All charges
Reversal of voluntary surgical sterilization
Genetic counseling
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and the
billed amount
Note: If your child is not covered under a Self and Family enrollment, you pay all of
your child's charges after your discharge from the hospital.
PPO: $20 copayment (No deductible) for non-surgical services.
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount for non-surgical services
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2003 Rural Carrier Benefit Plan 22 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility except as shown in Not covered.
Initial diagnostic tests and procedures done only to identify the cause of infertility
Fertility drugs, hormone therapy and related services
Medical or surgical procedures done to create or enhance fertility
Not covered: All charges
Infertility services after voluntary sterilization
Assisted reproductive technology (ART) procedures, such as: artificial insemination
in vitro fertilization
embryo transfer and GIFT intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Services and supplies related to ART procedures
Cost of donor sperm
Cost of donor egg
Allergy care
Allergy testing, injections and treatment
Note: We cover allergy serum in Prescription drug benefits, Section 5( f).
Not covered: All charges
RAST tests
Food tests
End point titration techniques
Sublingual allergy desensitization
Hair analysis
PPO: 15% of the Plan allowance up to $5,000, then all charges
Non-PPO: 25% of the Plan allowance up to $5,000 and any difference between our
allowance and the billed amount, then all charges.
Note: The Plan will pay up to $5,000 per person per lifetime for covered infertility
services, including prescription drugs.
PPO: Services in a physician's office $20 copayment (No deductible)
Services outside the physician's office 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
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2003 Rural Carrier Benefit Plan 23 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 30.
Dialysis Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy
Respiratory and inhalation therapies
Growth Hormone Therapy (GHT)
Note: Drugs used in treatment therapies are covered under Prescription drug benefits, Section 5( f).
Physical, occupational and speech therapies
Physical therapy, speech therapy and occupational therapy:
90 total combined visits per calendar year for all three listed therapies provided by:
qualified physical therapists;
qualified physicians;
speech therapists; and
occupational therapists
Note: We cover physical and occupational therapy to restore bodily function only when there has been a total or partial loss of bodily functions
because of an illness or injury and when the physician:
1) orders the care;
2) identifies the specific professional skills the patient needs and the medical necessity for the skilled services; and
3) indicates the length of time the services are needed.
Not covered: All charges
long-term rehabilitative therapy
exercise programs
Hearing services (testing, treatment, and supplies)
Testing only when necessitated by accidental injury or illness PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
Note: If your physician provides physical and/ or occupational therapy in his/ her office,
you pay the coinsurance above for those services.
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
Note: The Plan pays for services, supplies and tests rendered for the direct treatment of
cancer under Special Features, Section 5( g).
Note: The Plan pays for services, supplies, and testing for kidney (renal) dialysis under
Special Features, Section 5( g).
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2003 Rural Carrier Benefit Plan 24 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses to correct a change in sight caused directly by an accidental eye injury or intraocular surgery (such as
cataracts), within one year of the injury or surgery
Note: See Special features, Section 5( g), for our benefit for routine eye examinations.
Not covered: All charges
Eyeglasses or contact lenses
Eye exercises and orthoptics
Refractive eye surgery and related services
Foot care
Foot care when you are under active treatment for a metabolic or peripheral PPO: 15% of the Plan allowance vascular disease, such as diabetes.
Non-PPO: 25% of the Plan allowance and any difference between our allowance and the
billed amount
Not covered: All charges
Treatment or removal of corns and calluses, or trimming of toenails
Orthopedic shoes, orthotics, and other devices to support the feet
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy
Note: See Section 5( b) for benefits for the surgery to insert the device and Section 5( c) for services provided by a hospital.
Not covered: All charges
Orthopedic and corrective shoes and other supportive devices for the feet
Arch supports
Foot orthotics
Heel pads and heel cups
Corsets, trusses, elastic stockings, support hose and other supportive devices, unless we determine their medical necessity
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
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2003 Rural Carrier Benefit Plan 25 Section 5( a)
Durable medical equipment (DME) You pay
Durable medical equipment (DME) is equipment and supplies that:
Are prescribed by your attending physician (i. e., the physician who is treating your illness or injury);
Are medically necessary;
Are primarily and customarily used only for a medical purpose;
Are generally useful only to a person with an illness or injury;
Are designed for prolonged use; and
Serve a specific therapeutic purpose in the treatment of an illness or injury.
We cover rental or purchase, at our option, including repair and adjustment, of durable medical equipment, such as:
Oxygen
Hospital beds
Dialysis equipment
Wheelchairs
Crutches
Walkers
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible
applies).
Not covered: All charges
Sun or heat lamps, whirlpool bath, heating pads, air purifiers, humidifiers, air conditioners and exercise devices
Home health services
If home health services are precertified, 90 visits per calendar year up to a maximum plan payment of $80 per visit when:
A registered nurse (R. N.), licensed practical nurse (L. P. N.) or licensed vocational nurse (L. V. N.) provides the services;
A qualified physical therapist provides services in the home
The attending physician orders the care;
The physician identifies the specific professional skills needed by the patient and the medical necessity for skilled services; and
The physician indicates the length of time the services are needed.
If home health services are not precertified, 40 visits per calendar year up to a maximum plan payment of $40 per visit.
Not covered: All charges
Nursing care requested by, or for the convenience of, the patient or the patient's family;
Services consisting of only hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication
Custodial care as defined in Section 10
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
PPO: (No deductible); all charges after we pay $80 per visit
Non-PPO: (No deductible); all charges after we pay $80 per visit
PPO: (No deductible); all charges after we pay $40 per visit
Non-PPO: (No deductible); all charges after we pay $40 per visit
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2003 Rural Carrier Benefit Plan 26 Section 5( a)
Chiropractic You pay
Manipulation of the spine and extremities
Related procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
Alternative treatments
The Plan has no benefit for this type of care. All charges
Note: Benefits of certain alternative treatment providers may be covered in medically underserved areas; see page 10.
Not covered: All charges
Naturopathic services
Acupuncture
Educational classes and programs
Coverage is limited to:
Smoking Cessation Up to $100 maximum for one program per calendar year
Individual/ Group counseling
Over-the counter (OTC) drugs
Physician office visits for Smoking Cessation
Note: Prescription drugs are covered under Prescription drug benefits, Section 5( f).
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
Nothing up to the $100 maximum benefit, then all charges
PPO: $20 copayment (No deductible)
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
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2003 Rural Carrier Benefit Plan 27 Section 5( b)
Here are some important things you should 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.
The calendar year deductible is: $350 per person ($ 700 per family). The calendar year deductible applies to almost all benefits in this Section. We added (" No deductible") to
show when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. 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.).
YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which
services require precertification.
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Section 5( b). Surgical and anesthesia services provided by physicians and other health care professionals
Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say (" No deductible") when it does not apply.
Surgical procedures
A comprehensive range of services, such as:
Surgical procedures, including delivery of a newborn and circumcision
Treatment of fractures, including casting
Endoscopy procedures
Biopsy procedures
Removal of tumors and cysts
Correction of congenital anomalies (see Reconstructive surgery)
Surgical treatment for morbid obesity a condition where a person (1) is the greater of 100 pounds or 100% over his /her normal weight (based on
the Plan's guidelines) with medical complications; (2) is age 18 or older; and (3) has maintained this condition for at least five years with
documented evidence of unsuccessful attempts to reduce weight by following a diet and exercise program monitored by a physician
Insertion of an internal prosthetic device. See Orthopedic and prosthetic devices, Section 5( a), for device coverage information.
Surgical procedures continued on next page
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
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2003 Rural Carrier Benefit Plan 28 Section 5( b)
Surgical procedures (continued) You pay
Voluntary sterilization (e. g., tubal ligation, vasectomy)
Insertion of a surgically implanted contraceptive, like Norplant
Insertion of an intrauterine device (IUD)
Treatment of burns
Note:
Office surgery and physician office visits on the day of surgery and up to 90 days following the day of surgery are covered under Section 5( b).
Our allowance for the fee of an assistant surgeon is up to 20% of our allowance for the primary surgeon's fee.
For related services, see the applicable benefits section (i. e., for inpatient hospital benefits, see Section 5( c).
When there are multiple or bilateral surgical procedures performed during the same operative session that add time or complexity to patient care, our
benefits are:
For the primary procedure: PPO: 90% of the Plan allowance
Non-PPO: 85% of the reasonable and customary charge
For the secondary procedure( s): PPO: 90% of one-half of the Plan allowance
Non-PPO: 85% of one-half of the reasonable and customary charge
Note: Multiple or bilateral surgical procedures performed through the same incision are "incidental" to the primary surgery. That is, the procedure
would not add time or complexity to patient care. We do not pay extra for incidental procedures.
Not covered: All charges
Reversal of voluntary surgical sterilization
All refractive eye surgeries and similar services
Dental appliances, study models, splints, and other devices or services related to the treatment of TMJ dysfunction
Treatment or removal of corns and calluses, or trimming of toenails
Mutually exclusive procedures surgical procedures that are not generally performed on one patient on the same day
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; and webbed fingers and toes.
Reconstructive surgery continued on next page
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
PPO: 10% of the Plan allowance for the primary procedure and 10% of one-half of
the Plan allowance for the secondary procedure( s). (No deductible)
Non-PPO: 15% of the Plan allowance for the primary procedure and 15% of one-half
of the Plan allowance for the secondary procedure( s); and any difference between
our payment and the billed amount. (No deductible).
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
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2003 Rural Carrier Benefit Plan 29 Section 5( b)
Reconstructive surgery (continued) You pay
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, Section 5( a) for coverage)
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.
Not covered: All charges
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 and reconstruction
of a breast following mastectomy
Surgeries related to sex transformation or sexual dysfunction
Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate or severe functional malocclusion
Removal of stones from salivary ducts
Excision of pathological tori, tumors, and premalignant and malignant lesions
Dental surgical biopsy
Excision of cysts and incision of abscesses when done as independent procedures
Surgical correction of temporomandibular joint (TMJ) dysfunction
Extraction of impacted (unerupted) teeth
Frenectomy and frenotomy not as a result of orthodontic care
Not covered: All charges
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
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2003 Rural Carrier Benefit Plan 30 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single only for the following end-stage pulmonary diseases: pulmonary fibrosis, primary pulmonary hypertension, or emphysema
Double lung only for patients with cystic fibrosis
Pancreas (when condition is not treatable by insulin use)
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and
pancreas for irreversible intestinal failure
Bone marrow transplants and stem cell support for:
Allogeneic bone marrow transplants
Autologous bone marrow transplants (autologous stem cell support)
Autologous peripheral stem cell support for:
Acute lymphocytic or non-lymphocytic leukemia
Advanced Hodgkin's lymphoma
Advanced non-Hodgkin's lymphoma
Advanced neuroblastoma
Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors
Epithelial ovarian cancer
Breast cancer
Multiple myeloma
Note: We cover related medical and hospital expenses of the donor when we cover the recipient.
Note: Mutual of Omaha has special arrangements with 15 transplant facilities to provide services for tissue and organ transplants its Medical Specialty
Network. The network was designed to give you an opportunity to access providers that demonstrate high quality medical care for transplant patients.
Your physician can coordinate arrangements by calling Mutual of Omaha at 1-800/ 638-8432.
Not covered: All charges
Donor screening tests and donor search expenses, except those performed for the actual donor
Implants of artificial organs
Transplants not listed as covered above
Anesthesia
Professional services provided in a:
Hospital
Skilled nursing facility
Ambulatory surgical center
Physician's office
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
PPO: 15% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Note: If your PPO provider uses a non-PPO anesthesiologist, we will pay non-PPO
benefits for the anesthesia charges.
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2003 Rural Carrier Benefit Plan 31 Section 5( c)
Here are some important things you should 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.
In this Section 5( c), unlike Sections 5( a) and 5( b), the calendar year deductible applies to only a few benefits. In that case, we added "( calendar year deductible applies)". The
calendar year deductible is: $350 per person ($ 700 per family).
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. 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 in Sections 5( a) or (b).
YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the
precertification information shown in Section 3 to be sure which services require precertification.
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PPO: Nothing
Non-PPO: $200 copayment for each hospital stay and 15% of the charges
Note: If you use a PPO provider and a PPO facility, we may still pay non-PPO benefits if
you receive treatment from a radiologist, pathologist, or anesthesiologist who is not a
PPO provider.
Section 5( c). Services provided by a hospital or other facility, and ambulance services
Benefit Description You pay
NOTE: The calendar year deductible applies ONLY when we say below: "( calendar year deductible applies)".
Inpatient hospital
Room and board, such as
Ward, semiprivate, or intensive care accommodations
General nursing care
Meals and special diets
NOTE: We only cover a private room when you must be isolated to prevent contagion. Otherwise, we will pay the hospital's average charge
for semiprivate accommodations. If the hospital only has private rooms, we base our payment on the average semiprivate rate of the most comparable
hospital in the area.
Inpatient hospital continued on next page
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2003 Rural Carrier Benefit Plan 32 Section 5( c)
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Note: Take-home medical supplies, equipment, orthopedic and prosthetic devices are covered under Section 5( a).
Note: We base payment on whether the facility or a health care professional bills for the services or supplies. For example, when the anesthesiologist
bills, we pay Anesthesia benefits. If preadmission testing is performed in the hospital as inpatient then we pay pre-admission tests at the same coinsurance
rate as inpatient miscellaneous charges.
Not covered: All charges
Hospital charges for non-covered surgery
Any part of a hospital admission that is not medically necessary (see definition), such as when you do not need acute hospital inpatient
(overnight) care, but could receive care in some other setting without
adversely affecting your condition or the quality of your medical care. Note: In this event, we pay benefits for services and supplies other than
room and board and in-hospital physician care at the level they would
have been covered if provided in an alternative setting
Custodial care (see definition) even when in a hospital
Non-covered facilities, such as nursing homes, rest homes, convalescent
homes, facilities for the aged, and schools
Personal comfort items, such as telephone, television, radio, newspapers,
air conditioner, beauty and barber services, guest meal and beds
Private nursing care during a hospital stay
Outpatient hospital or ambulatory surgical center
Services and supplies, such as:
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines (not take home drugs)
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
Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment even if we do not
cover the dental procedures.
Take-home drugs, medical supplies, equipment, orthopedic and prosthetic devices are covered under Section 5( a).
We base payment on whether the facility or a health care professional bills for the services or supplies. For example, when the physician bills for surgery,
we pay Surgery benefits.
PPO: Nothing
Non-PPO: 15% of charges
PPO: 15% of Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amounts
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2003 Rural Carrier Benefit Plan 33 Section 5( c)
Extended care benefits/ Skilled nursing care facility benefits You pay
If care is precertified, we cover semiprivate room and board services and supplies in a Skilled Nursing Facility (SNF) for up to 60 days per calendar
year when:
The stay is medically necessary and
The stay is under the supervision of a physician
If care not precertified, we cover semiprivate room and board services and PPO: 20% for the first 30 days then all supplies for up to 30 days per calendar year, subject to the above conditions. charges
Non-PPO: 20% for the first 30 days, then all charges
Not covered: All charges
Custodial care
Hospice care
Hospice care is a coordinated program of maintenance and supportive care Nothing up to $7,500, then all charges for the terminally ill prescribed by a physician and provided by a medically
supervised team under the direction of a Plan-approved independent hospice administration.
If care is precertified, we pay up to $7500 for inpatient or outpatient hospice care.
Note: We pay for a hospice program once per lifetime. This benefit does not apply to services covered under any other benefit of the Plan.
If care is not precertified, we pay up to $5,500 for inpatient or outpatient Nothing up to $5,500, then all charges hospice care.
Note: We pay for a hospice program once per lifetime. This benefit does not apply to services covered under any other benefit of the Plan.
Not covered: All charges
Private duty nursing
Custodial care
Ambulance
Professional ambulance service to the nearest hospital equipped to PPO: 15% of the Plan allowance (calendar handle the patient's condition year deductible applies)
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount (calendar year deductible applies)
Not covered: All charges
Ambulance transportation from the hospital to home
Ambulance transport for your or your family's convenience
PPO: Charges in excess of 60-day maximum
Non-PPO: Charges in excess of 60-day maximum and the difference between the
plan allowance and the billed amount
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2003 Rural Carrier Benefit Plan 34 Section 5( d)
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.
The calendar year deductible is: $350 per person ($ 700 per family). The calendar year deductible applies to almost all benefits in this Section. We added "( No deductible)" to
show when the calendar year deductible does not apply.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.
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What is an accidental injury? An accidental injury is a bodily injury that requires immediate medical attention and is sustained solely through violent,
external, and accidental means, such as broken bones, animal bites, insect bites and stings and poisonings. An accidental dental injury is covered under Dental benefits, Section 5( h).
Section 5( d). Emergency services/ accidents
Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say (" No deductible") when it does not apply.
Accidental injury
If you or a family member is accidentally injured, the Plan will pay up to the Plan allowance for:
Emergency room
First physician office visit
Note: The first physician office visit does not include any charges for x-rays, laboratory tests, drugs, or other services and supplies. Charges for x-rays,
laboratory tests, drugs, services or supplies are under Sections 5( a) or 5( b).
Medical Emergency
Regular plan benefits are paid for care you receive because of a medical PPO: Services in a physician's office emergency (non-accident) like a heart attack or stroke. $20 copayment (No deductible)
Services outside the physician's office 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
Ambulance
Professional ambulance service to the nearest hospital equipped to handle the patient's condition, including air ambulance when medically necessary
Note: See Section 5( c) for non-emergency service
Not covered: All charges
Ambulance transport for you or your family's convenience
PPO: Nothing (No deductible)
Non-PPO: Nothing (No deductible)
PPO: 15% of the Plan allowance
Non-PPO: 25% of the Plan allowance and any difference between our allowance and
the billed amount
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2003 Rural Carrier Benefit Plan 35 Section 5( e)
You may choose to get care Out-of-Network (non-PPO) or In-Network (PPO). When you receive In-Network care, you must get our approval for all services and follow a treatment plan
we approve. If you do, cost-sharing and limitations for In-Network mental health and substance abuse benefits will be no greater than for similar benefits for other 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.
The calendar year deductible or, for facility care, the inpatient deductible apply to almost all benefits in this Section. We added "( No deductible)" to show when a deductible does not
apply.
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/ PRECERTIFICATION OF THESE SERVICES. See the instructions after the benefits descriptions below.
In-Network mental health and substance abuse benefits are below, then Out-of-Network (Non-PPO) benefits begin on page 38.
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Section 5( e). Mental health and substance abuse benefits
Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say (" No deductible") when it does not apply.
In-Network benefits
All diagnostic and treatment services contained in a treatment plan that Your cost sharing responsibilities are no we approve. The treatment plan may include services, drugs, and supplies greater than for other illness or conditions.
described elsewhere in this brochure.
Note: In-Network 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. We will reduce your benefits if you do not precertify, preauthorize, get review of continuing
treatment, or follow our approved treatment plan for all levels of care.
Professional services, including individual or group therapy by providers 15% of Plan allowance (No deductible for such as psychiatrists, psychologists, or clinical social workers outpatient physician visits)
Medication management $20 copayment (No deductible)
Diagnostic tests including psychological testing 15% of Plan allowance
Services provided in a hospital or other facility as an inpatient Nothing (No deductible)
In-Network benefits continued on next page
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2003 Rural Carrier Benefit Plan 36 Section 5( e)
In-Network benefits (continued) You pay
Services in approved alternative care settings such as: 15% of Plan allowance
Partial hospitalization includes a time-limited, ambulatory, active treatment program that:
Offers intensive clinical services that are coordinated and structured in stable surroundings; and
Provides at least 20 hours of scheduled programs in a licensed or accredited facility over at least five days per week
Intensive outpatient programs offer time-limited programs that:
Are coordinated, structured and intensively therapeutic;
Are designed to treat a variety of people with moderate to severe problems with at least one area of daily life because of a mental
health or substance abuse condition; and
Provide 3-4 hours of active treatment each day for at least 2-3 days a week
Not covered: All charges
Services we have not approved
All charges (including room and board) for chemical aversion therapy,
conditioned reflex treatments, narcotherapy, and similar aversion treatments
Biofeedback conjoint therapy, hypnotherapy, and milieu therapy
Counseling or therapy for educational or behavioral problems, mental
retardation or learning disabilities
Counseling services for marital or family problems
Community based programs such as self-help groups or 12-step programs
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.
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Preauthorization and To be eligible to receive these enhanced mental health and substance abuse benefits precertification you must follow your treatment plan and all of our authorization processes. These
include:
Precertification to establish the medical necessity of your stay in a hospital or other facility. Please see page 12 for information on how to precertify your care. If you
do not precertify your stay, we will reduce our benefits by $500.
Preauthorization to establish the medical necessity for all levels of outpatient or office care by your physician or other covered provider. Please see pages 12 and 13
for information on how to preauthorize your care. If you do not preauthorize your care within two business days of the first visit, we will reduce any available benefits
by 50%.
Review of continuing treatment to establish the medical necessity of your
continuing treatment for all levels of outpatient or office care. Please see page 13, for information on how to get review of continuing treatment. If you do not get
your continuing treatment reviewed or you do not follow your treatment plan, we will reduce any available benefits by 50%.
Network deductibles and A $350 per person ($ 700 per family) calendar year deductible applies to outpatient out-of-pocket maximums charges and inpatient and outpatient professional charges. We waive the calendar year
deductible for office visits with PPO physicians. Once you reach the combined out-of-pocket maximum (see page 15), the Plan will pay 100% of its allowance for the rest of
the calendar year.
Network limitation If you do not obtain an approved treatment plan, we will provide only Out-of-Network benefits.
How to submit Follow the normal claim procedure on page 49. network claims
2003 Rural Carrier Benefit Plan 37 Section 5( e)
In-Network benefits (continued)
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2003 Rural Carrier Benefit Plan 38 Section 5( e)
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.
See pages 35-37 for In-Network (PPO) benefits.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.
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Out-of-Network benefit
$200 copayment for each hospital stay and 15% of room and board charges (No
deductible)
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say (" No deductible") when it does not apply.
Out-of-Network inpatient mental health benefits You pay
We pay 85% of room and board, such as
ward, semiprivate, or intensive care accommodations
general nursing care
meals and special diets
We pay 85% of other hospital services and supplies, such as: 15% of charges (No deductible)
Prescribed drugs and medicines
Diagnostic laboratory tests
Medical supplies and equipment
Not covered: All charges
Services we have not approved.
All charges (including room and board) for chemical aversion therapy, conditioned reflex treatments, narcotherapy, and similar aversion
treatments.
Biofeedback conjoint therapy, hypnotherapy, and milieu therapy
Counseling or therapy for educational or behavioral problems, mental
retardation or learning disabilities
Counseling services for marital or family problems
Community based programs such as self-help groups or 12-Step programs.
Services in Alternative Care Settings
Partial hospitalization includes a time-limited, ambulatory, active treatment 25% of Plan allowance and any difference program that: between our allowance and the billed amount
Offers intensive clinical services that are coordinated and structured in stable surroundings; and
Provides at least 20 hours of scheduled programs in a licensed or accredited facility over at least five days per week
Intensive outpatient programs offer time-limited programs that:
Are coordinated, structured and intensively therapeutic;
Are designed to treat a variety of people with moderate to severe problems with at least one area of daily life because of a mental health
or substance abuse condition; and
Provide 3-4 hours of active treatment each day for at least 2-3 days a week
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2003 Rural Carrier Benefit Plan 39 Section 5( e)
Inpatient/ Outpatient Mental Health/ Substance Abuse Treatment Sessions You pay
We pay for mental health/ substance abuse treatment sessions (including All charges in excess of $75 (No deductible) group sessions) up to a maximum of $75 per session. This benefit also
applies to treatment sessions billed by a hospital or provided by the hospital staff.
Medication management 25% of the Plan allowances and any differences between our allowance and
Diagnostic testing (including psychological testing) the billed amount
Out-of-Network substance abuse benefits
We will pay up to a maximum of $11,000 per person per lifetime Nothing up to $11,000, then all charges for inpatient treatment in an accredited facility or for an outpatient treatment
program.
Not covered: All charges
Services we have not approved
All charges (including room and board) for chemical aversion therapy,
conditioned reflex treatments, narcotherapy, and similar aversion
treatments
Biofeedback conjoint therapy, hypnotherapy, and milieu therapy
Counseling or therapy for educational or behavioral problems related to mental retardation or learning disabilities
Counseling services for marital or family problems
Community based programs such as self-help groups or 12-step programs
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.
Precertification Follow the normal procedure on page 12 to get approval for your hospital stay, partial hospitalization, or intensive outpatient program.
Out-of-Network out-of-pocket For those benefits where coinsurance applies, we pay 100% of the Plan allowance for maximum the rest of the calendar year after your expenses (including the deductible) total to
$8,000 per person during a calendar year. Please see page 15.
How to submit Follow the normal claim procedure on page 49. Out-of-Network claims
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2003 Rural Carrier Benefit Plan 40 Section 5( f)
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.
The calendar year deductible is: $350 per person ($ 700 per family). The calendar year deductible applies to almost all benefits in this Section. We added (" No deductible") to
show when the calendar year deductible does not apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage, including with Medicare.
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician must write the prescription.
Where you can obtain your prescription. You may fill your prescription at a Caremark network pharmacy, a non-network pharmacy, or through the Caremark mail order prescription program.
Caremark network pharmacy You may fill your prescription at a Caremark network pharmacy. To find a participating pharmacy where you
live, call Caremark toll-free at 1-800/ 831-4440 or on the Internet at www. rxrequest. com
or as a link through our web page at www. nrlca. org.
You must show the pharmacy your Plan ID card (that
includes the
Caremark logo) or a Caremark
prescription drug card to receive the negotiated discount price. You pay the full discounted price for your prescription and then file a claim with us. Prescriptions you purchase
at a Caremark network pharmacy without using your ID card or a Caremark drug card are at the full regular price charged by the pharmacy.
Non-Network Pharmacy You may fill your prescription at any non-network pharmacy. You pay the full regular price for your
prescription and then file a claim with us.
Caremark mail order prescription program You may fill your long-term prescription through the Caremark mail order prescription program. You will
receive order forms and information on how to use the mail order prescription program with your Plan ID card. To order your prescription by mail: 1) complete the Caremark order form; 2) enclose your
prescription( s) and copayment( s); 3) mail your order to Caremark, P O Box 659572, San Antonio, TX 78256-9572; and 4) allow approximately two weeks for delivery. You will receive order forms for refills and future
prescription orders each time you use the mail order program. You can also order refills from the mail order program by telephone toll-free at 1-800/ 344-8075 or on the Internet at www. rxrequest. com.
These are the dispensing limitations.
You may purchase up to a 34-day supply of medication at a Caremark network pharmacy. There is no limit on the number of refills that you can buy at a Caremark network pharmacy.
There is no day supply or refill limit for medications that you buy at a non-network pharmacy.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a brand name.
You may purchase up to a 90-day supply of a medication through the Caremark mail order prescription program. If you request a refill before you use 75% of the medication (based on your physician's written
directions for taking the medication), Caremark will return the refill request to you. Caremark follows generally accepted pharmacy standards when filling your prescriptions. These include Federal and state
pharmacy regulations, the professional judgment of the pharmacist, and the usage recommendations of the
Prescription drug benefits continued on next page
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Section 5( f). Prescription drug benefits
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2003 Rural Carrier Benefit Plan 41 Section 5( f)
drug manufacturer as approved by the U. S. Food and Drug Administration (FDA). If a Federally approved generic drug is available, Caremark will substitute for a brand name drug unless your physician specifies
that it is medically necessary that you receive the brand name drug. Certain types of prescription medications are not available through the mail order program such as:
Specially mixed (compounded) capsules and suppositories
Vaccines
Frozen medications
Dental products
Most medical devices
Infertility drugs
Caremark will fill prescriptions for medications designated as Class II, III, IV, and V controlled substances by the FDA. However, Federal or state law may limit the supply of these medications to less than 90 days.
We have an open formulary for our mail order prescription program. If your physician believes a brand name drug is necessary or there is no generic available, your physician may prescribe a brand name drug from a
formulary list. This list of brand name drugs is a preferred (not required) list of drugs that we selected to meet patient needs. To request a prescription drug formulary list, call Caremark toll-free at 1-800/ 831-4440.
If you have Medicare Part B, we do not waive your deductible or coinsurance for prescription drugs and supplies that you buy at a Caremark network pharmacy or at a non-network pharmacy. However, your
copayment is reduced for prescriptions that you order through the Caremark mail order prescription program.
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. Generic drugs contain the same active ingredients and are equivalent in
strength and dosage to the original brand name product. All manufacturing and marketing of a generic drug is conducted following strict guidelines established by the U. S. Food and Drug Administration (FDA). No
prescription drug can be sold in the U. S. without FDA approval. The manufacturing facilities of all drug companies, whether they make generic or brand name drugs, must pass stringent, regular inspections by the FDA.
There is no difference between the standards set for drug companies that make brand name or generic medications. Many drug companies that make brand name drugs also make generic drugs. A generic prescription
costs you and us less than a name brand prescription.
When you have to file a claim. Follow the normal claim procedure on page 49. There is no special claim form to fill out for your prescription drug expenses.
Prescription drug benefits begin on next page
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2003 Rural Carrier Benefit Plan 42 Section 5( f)
Section 5( f). Prescription drug benefits (continued)
Benefit Description You pay After the calendar year deductible
NOTE: The calendar year deductible applies to almost all benefits in this Section. We say "No deductible" when it does not apply.
Covered medications and supplies
When you enroll in the Plan, you will receive a description of our prescription drug program, a combined prescription drug/ Plan identification
card, a mail order form/ patient profile and a pre-addressed reply envelope for the mail-order prescription program.
You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by mail:
Drugs and medicines (including those prescribed during a non-covered hospital stay or in a non-covered facility) that require a physician's
prescription by Federal law of the United States except those listed as Not covered.
Insulin
Needles and syringes for the administration of covered medications
Contraceptive drugs and devices
Not covered: All charges
Drugs and supplies for cosmetic purposes
Drugs to treat impotence and sexual dysfunction
Vitamins, nutrients and food supplements even if a physician prescribes
or administers them
Nonprescription (over-the-counter) medicines
Network Retail: 25% of cost
Network Retail when Medicare Part B pays first: 25% of cost
Non-Network Retail: 25% of cost
Non-Network Retail when Medicare Part B pays first: 25% of cost
Network Mail Order: $15 generic/$ 25 brand name (no deductible)
Network Mail Order when Medicare Part B pays first: $6 generic/$ 12 brand
name (No deductible)
Note: If there is no generic equivalent drug available, you will still have to pay the
brand name copayment.
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Page 43
44
2003 Rural Carrier Benefit Plan 43 Section 5( g)
Section 5( g). Special features
Special feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.
The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.
24 hour nurse line We have entered into an agreement with Optum, a division of United Healthcare Services, Inc., to provide you with access to a 24 hour-a-day nurse help line.
For any of your health concerns, 24 hours a day, 7 days a week, you may call Optum NurseLine toll-free at 1-877/ 610-9822 and talk with a registered nurse who will
discuss treatment options and answer your health questions and concerns. This service is also available on the Internet at www. healthforums. com.
Optum NurseLine provides assistance with:
General Health information
Deciding where to go for care
Choosing self-care measures
Guidance for difficult conditions
Communicating with your health care provider
Services for deaf and No benefit hearing impaired
Cancer treatment benefit We will pay 100% of the Plan allowance for services and supplies normally covered by the Plan for treatment of an illness diagnosed as cancer. The service or supply
must be for the treatment of a malignancy. A diagnosis secondary to cancer is not covered under this benefit.
Kidney (renal) dialysis We will pay 100% of the Plan allowance for services, supplies and testing for kidney benefit (renal) dialysis. This benefit applies to inpatient and outpatient kidney dialysis.
Routine eye exam benefit We will pay up to $45 per person for one routine eye exam each calendar year.
Note: The itemized bill must show that you had a routine eye exam to qualify for this benefit.
Reciprocity benefit No benefit
High risk pregnancies No benefit
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Page 44
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2003 Rural Carrier Benefit Plan 44 Section 5( g)
Section 5( g). Special features (continued)
Special feature Description
Healthy maternity program You have access to Mutual of Omaha's Healthy Maternity Program, which provides educational material and support to pregnant women. Contact Customer Service at
1-800/ 638-8432 for more information
Disease management Healthydirections sm , is our disease management program for congestive heart failure programs (CHF). Your health is important to us! If you have congestive heart failure (CHF), we
will contact you to participate in this voluntary program. If you would like to contact us for more information about this program, please call us toll-free at 1-800/ 638-8432.
Healthydirections sm , is provided at no additional cost to you. The program provides education and management programs through:
Nurse support
Education about the disease and how it affects your body
Proper medical management that can help lead you to a healthier lifestyle
You and your physician remain in charge of your treatment plan.
CarePatterns is provided at no additional cost to you. The program is voluntary and provides education and management programs for:
Diabetes
Asthma, including pediatric asthma
Osteoarthritis
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Artery Disease (CAD)
Note: CarePatterns programs are provided through Caremark, our prescription benefit management company. For more information on the CarePatterns programs
call toll-free at 1-800/ 227-3728.
Travel benefit/ services We have entered into an agreement with Worldwide Assistance Services, Inc. to overseas provide you with a travel assistance program. In case of a medical problem while
traveling in a foreign country or more than 100 miles from home, you can call toll-free 1-877/ 715-2596 for a referral to an English-speaking physician, clinic or
hospital. This service is available 24 hours a day, 7 days a week anywhere in the world.
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2003 Rural Carrier Benefit Plan 45 Section 5( h)
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.
The dental deductible is: $50 per person. The dental deductible applies to almost all benefits in this Section. We added (" No deductible") to show when the calendar year deductible does
not apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also
read Section 9 about coordinating benefits with other coverage.
Note: We cover a hospital stay for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient.
We cover the dental procedure under Dental benefits listed below.
I M
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I M
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Dental benefits continued on next page
Accidental injury benefit You pay
The Plan will pay reasonable and customary charges (no deductible) for the treatment or repair (including root canal therapy and crowns) of an accidental
injury to sound natural teeth (not from biting or chewing), provided the accident occurs while covered by the FEHB Program, and the treatment or
repair is completed while covered by the Plan.
Note: We may request dental records, including x-rays, to verify the condition of your teeth before the accidental injury. Charges covered for dental
accidents cannot be considered under Dental Benefits.
Dental benefits Class A Schedule
Service We pay You pay (scheduled allowance)
The plan pays actual charges for no more than two All charges that exceed the preventive care visits per person each calendar year Plan's scheduled allowance for
up to the scheduled Plan allowance (No deductible) the service
Oral exam $12.50 twice each calendar year
Prophylaxis, adult $22.00 twice each calendar year
Prophylaxis, child (thru age 14) $15.00 twice each calendar year with fluoride treatment $24.00 twice each calendar year
The Plan also covers: All charges that exceed the
Space maintainer $88.00 Plan's scheduled allowance for
Complete X-ray series $34.00
the service
Panoramic X-ray $34.00
Single film X-ray $ 5.50
Each additional X-ray film (up to 7) $ 4.00
Bitewings 2 films $ 9.00
Bitewings 4 films $14.00
PPO: 10% of the Plan allowance (No deductible)
Non-PPO: 15% of the Plan allowance and any difference between our allowance and
the billed amount (No deductible)
Section 5( h). Dental benefits
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Page 46
47
Dental benefits Class B Schedule
Service We pay You pay (scheduled allowance)
After a deductible of $50 per person during the All charges that exceed the calendar year, the Plan pays actual charges up to the Plan's scheduled allowance for
scheduled allowance for each service. There is no the service annual limit on the amount of services you receive.
Restorations
1 surface deciduous $ 12.50
2 surface deciduous $ 18.50
3 surface deciduous $ 23.50
1 surface permanent $ 14.00
2 surface permanent $ 20.50
3 or more surface permanent $ 26.50
Gold restoration $103.50
Extractions
Single tooth $ 16.00
Each additional tooth $ 15.00
Pulp capping-direct $ 9.50
Pulpotomy-vital $ 21.00
Root canal therapy
This includes the actual root canal treatment and any retreatments
One root $106.00
Two roots $126.00
Three or more roots $170.00
Periodontics
Gingival curettage (per quadrant) $ 26.50
Crowns/ abutments
Resin and Resin with metal $120.00
Porcelain $113.50
Porcelain with gold $120.00
Gold (full cast and 3/ 4 cast) $120.00
Prefabricated resin and stainless steel $ 21.50
Pontics
Porcelain and Porcelain with gold $120.00
Dentures
Complete upper or lower $126.00
Partial without bar $138.00
Partial with bar $157.00
Repairs (dentures and partials) $ 14.00
Denture relining $ 40.50
2003 Rural Carrier Benefit Plan 46 Section 5( h)
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Page 47
48
2003 Rural Carrier Benefit Plan 47 Section 5( i)
Section 5( i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.
Long term care insurance Long term care is open to NRLCA members, their spouse, parents and parents-in-law under age 80. Premium rates are based on your age at the time of approval for coverage. Please consult the separate descriptive
pamphlet for detailed information. This insurance plan is separate from the Federal Long Term Care Insurance Program.
Covers skilled nursing, intermediate nursing and custodial care in a nursing home, skilled nursing facility, or assisted living home; $100 per day benefit
Covers outpatient care for home health care, adult day care and respite care; $50 per day benefit Includes return of premium feature
Includes inflation protection option
Long term disability income insurance The Rural Letter Carrier Long Term Disability (RLCLTD) Income Plan protects an individual from being unable to work and earn a paycheck because of an illness or injury. The RLCLTD Plan is available
to active regular rural letter carriers that are members of the NRLCA. Premium rates are based on your age and benefit level selected. Please consult the separate descriptive pamphlet for detailed information.
Two benefit levels with a waiting period Replacement of 50% or 60% of your basic pay tax-free
Benefits payable to age 65 Premiums payable through payroll allotment
Supplemental dental insurance The NRLCA Dental Plans are available to all NRLCA members. The Plans feature a schedule of benefits for a variety of dental care services. Premium rates are based on geographic regions across the country
and are guaranteed for three years from the time of initial enrollment in the Plan. The Plans allow members to use any licensed dentist with improved benefits if you use one of more than 45,000 preferred dental offices throughout the country.
Benefits include:
Diagnostic and Preventive Care Oral Surgery
Restorative Care Endodontic Care (Root Canals)
Periodontic Care (Gum Disease) Prosthodontic Care (Crowns and Dentures)
Please consult the separate descriptive pamphlets for detailed information.
Term life insurance The NRLCA Life Insurance Plan is available to actively employed members of the NRLCA under age 60. Premium rates are based on your age at time of approval for coverage and at each renewal date. Please consult the
separate descriptive pamphlet for detailed information.
Provides up to $200,000 of term life insurance coverage in $25,000 multiples Provides up to $40,000 accidental death and dismemberment coverage
Family life insurance coverage up to $10,000 Living Care benefit for terminally ill enrollees
Vision and Hearing Insurance The NRLCA Vision and Hearing Plan is available to all members of the NRLCA. Please see the separate pamphlet for complete information.
Provides discounts on frames, lenses, and contact lenses at participating providers Provides discounts on hearing aids at Beltone Hearing Centers, free hearing exam and an extended warranty on
the hearing aid.
For further information on any of the above benefits, contact the NRLCA Insurance Department at:
NRLCA Group Insurance Department 1630 Duke Street, First Floor
Alexandria, VA 22314-3466 1-703/ 684-5552
Benefits on this page are not part of the FEHB contract
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Page 48
49
2003 Rural Carrier Benefit Plan 48 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 we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. Even
if a covered provider prescribes, recommends, or approves a service or supply does not make it medically necessary or eligible for coverage.
We do not cover the following:
Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related sex transformations, sexual dysfunction or impotence;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you receive when no charge would be made if you had no health insurance coverage;
Services, drugs, or supplies you receive without charge while in active military service;
Services, drugs, or supplies you receive from immediate relatives or household members, such as spouse, parents, child, brother or sister by blood, marriage, or adoption;
Services, drugs, or supplies you receive at a facility not covered under the Plan, except that medically necessary prescription drugs are covered;
Any part of a provider's fee or charge that you would ordinarily pay but is waived by the provider. If a provider routinely waives (does not require you to pay) a deductible or coinsurance, we will calculate the actual provider fee or charge by
reducing the fee or charge by the amount waived;
Charges that you or we have no legal obligation to pay, such as: excess charges for an annuitant age 65 or older who is not covered by Medicare Part A and/ or B, (see page 16), physician charges exceeding the amount specified by the
Department of Health and Human Services when benefits are payable under Medicare (limiting charge) or State premium taxes however applied;
Custodial care;
Acupuncture;
Services, drugs, or supplies related to weight control or any treatment of obesity except surgery for morbid obesity;
Chelation therapy, except for acute arsenic, gold, mercury or lead poisoning;
Nonmedical services such as social services and recreational, educational, visual, and nutritional counseling;
Non-surgical treatment of temporomandibular joint (TMJ) dysfunction including dental appliances, study models, splints and other devices;
Services, drugs and supplies for cosmetic purposes, except repair of accidental injury;
Charges for completion of reports or forms;
Charges for interest on unpaid balances;
Charges for missed or cancelled appointments;
Charges for telephone consultations, conferences, or treatment by telephone, mailings, faxes, e-mails or any other communication to or from a hospital or covered provider;
Biofeedback and milieu therapy;
Preventive medical care and services, except those provided under Preventive care adult and Preventive care children in Section 5( a);
Private duty nursing care that you receive during a hospital stay;
Any services you receive related to a learning disability;
Breast implants (except after mastectomy), injections of silicone or other substances, and all related charges;
Hearing aids and examinations for them;
Eyeglasses and contact lenses (except as covered under Vision services in Section 5( a); or
Services and supplies not specifically listed as covered.
Note: Exclusions that are primarily identified with a single benefit category are listed along with that benefit category, but may apply to other categories.
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Page 49
50
2003 Rural Carrier Benefit Plan 49 Section 7
Section 7. Filing a claim for covered services
How to claim benefits To obtain claim forms or other claims filing advice or answers about our benefits, contact us at 1-800/ 638-8432.
In most cases, providers and facilities file claims for you. Your physician must file on the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the
UB-92 form. For claims questions and assistance, call us at 1-800/ 638-8432.
When you must file a claim such as for services you receive overseas or when another group health plan is primary submit it on the HCFA-1500 or a claim form
that includes the information shown below. Send your claims to:
Rural Carrier Benefit Plan P. O. Box 668329
Charlotte, NC 28266-8329
Bills and receipts should be itemized and show:
Name of patient and relationship to enrollee;
Plan identification number of the enrollee;
Name and address of person or firm providing the service or supply;
Dates that services or supplies were furnished;
Diagnosis;
Type of each service or supply; and
The charge for each service or supply.
Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.
In addition:
You must send a copy of the explanation of benefits (EOB) from any primary payer (such as the Medicare Summary Notice (MSN)) with your claim.
Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
Claims for rental or purchase of durable medical equipment; private duty nursing; and physical, occupational, and speech therapy require a written statement from the
physician specifying the medical necessity for the service or supply and the length of time needed.
Claims for prescription drugs and supplies that are not ordered through the Mail Order Prescription Drug Program must include receipts that have the patient's name,
the prescription number, name of drug or supply, prescribing physician's name, date, charge, and pharmacy name. The pharmacist must sign any computer printout or
pharmacy ledger.
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Page 50
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2003 Rural Carrier Benefit Plan 50 Section 7
Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of
all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or
year-end statements. .
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim no more than two years after you receive 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. Once we pay benefits, there is a
three-year limitation on reissuing uncashed checks.
Overseas claims Follow the same procedures when submitting claims for overseas (foreign) services as you would when submitting claims for stateside services. Claims for overseas services
should include an English translation. Charges should be converted to U. S. dollars using the exchange rate applicable at the time the expense was incurred. We will
provide translation and currency conversion services for claims for overseas (foreign) services.
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.
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Page 51
52
2003 Rural Carrier Benefit Plan 51 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/ prior approval:
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: Rural Carrier Benefit Plan, P. O. Box 668329, Charlotte, NC 28266-8432 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 2, 1900 E Street, NW, Washington, DC 20415-3620
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 more than one claim, 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.
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53
5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs,
or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM
decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-800/ 638-8432 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 may call OPM's Health Benefits Contracts Division 2 at 1-202/ 606-3818 between 8 a. m. and 5 p. m. Eastern Time.
2003 Rural Carrier Benefit Plan 52 Section 8
The disputed claims process (continued)
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Page 53
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2003 Rural Carrier Benefit Plan 53 Section 9
Section 9. Coordinating benefits with other coverage
When you have other You must tell us if you or a covered family member have coverage under another health coverage group health plan or have automobile insurance that pays health care expenses without
regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We,
like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will
not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).
Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if
you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE (1-800/ 633-4227) for more information
Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement
check.
If you are eligible for Medicare, you may have choices in how you get your health care. Medicare managed care plan is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on the type of Medicare
managed care plan you have. .
The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in the United (Part A or Part B) States. It is the way everyone used to get Medicare benefits and is the way most
people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share
and you pay your share. Some things are not covered under Original Medicare, like prescription drugs.
When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care except you do not need to
get a hospital stay approved when Medicare pays first.
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2003 Rural Carrier Benefit Plan 54 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 claim will be coordinated automatically and we will provide
secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claims, call us at 1-800/ 638-8432.
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 our $350
calendar year deductible and pay the $100 Part B deductible for you.
NOTE: We do not waive the $350 calendar year deductible for prescription drug expenses when the medication is purchased at a pharmacy.
Services and supplies provided in a hospital or other covered facility. If you are enrolled in Medicare Part A, we will waive our $200 hospital copayment and pay
the Part A deductible for you.
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2003 Rural Carrier Benefit Plan 55 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered family member
has Medicare coverage so we can administer these requirements correctly.
Primary Payer Chart
Then the primary payer is A. When either you or your covered spouse are age 65 or over and
Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or a family member are eligible for Medicare solely because of a disability), 3
2) Are an annuitant, 3
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or................................................................. 3
b) The position is not excluded from FEHB ............................................................... 3
(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 3
is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status, 3 3 (for Part B (for other
services) services)
6) Are a former Federal employee receiving Workers' Compensation and the 3 Office of Workers' Compensation Programs has determined that you are unable (except for claims
to return to duty, related to Workers' Compensation.)
B. When you or a covered family member have Medicare based on end stage renal disease (ESRD) and
1) Are within the first 30 months of eligibility to receive Part A benefits solely because of ESRD 3
2) Have completed the 30-month ESRD coordination period and are still eligible for Medicare due to ESRD, 3
3) Become eligible for Medicare due to ESRD after Medicare became primary for you under another provision, 3
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or ................................................................................................. 3
b) Are an active employee ........................................................................................... 3
c) Are a former spouse of an annuitant........................................................................ 3
d) Are a former spouse of an active employee ........................................................... 3
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2003 Rural Carrier Benefit Plan 56 Section 9
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from 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, but we will not
waive any of our copayments, coinsurance, or deductibles. 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.
Private Contract with your physician A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an
agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after
Original Medicare's payment.
If you do not enroll in Medicare If you do not have one or both Parts of Medicare, you can still be covered under the Part A or Part B 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 and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPVA 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.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) 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 under the program.
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2003 Rural Carrier Benefit Plan 57 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.
Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB 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
under the State program.
When other Government agencies We do not cover services and supplies when a local, State, or Federal Government are responsible for your care agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for medical or hospital care for injuries for injuries or illness caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you received in the settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.
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2003 Rural Carrier Benefit Plan 58 Section 10
Section 10. Definitions of terms we use in this brochure
Admission The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of
discharge are counted as the same day.
Acupuncture The technique of passing long thin needles through the skin into specific external body locations to relieve pain, to produce regional anesthesia, or for other therapeutic
purposes.
Calendar year The period of time from 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.
Chiropractic A system of therapy that attributes disease to abnormal function of the nervous system and attempts to restore normal function by manipulation of the spinal column
and other body structures.
Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 14.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See page 14.
Covered services Services we provide benefits for, as described in this brochure.
Custodial care Treatment or services, no matter who recommends them or where you receive them, which a person without medical skills can provide safely and reasonably. In addition,
treatment and services designed mainly to help the patient with daily living activities. These include:
personal care like help in: walking; getting in and out of bed; bathing; eating (by spoon, gastostomy or tube); exercising; dressing
homemaking services, like preparing meals or special diets
moving the patient
acting as a companion or sitter
supervising the taking of medication that can usually be self-administered; or
treatment or services that anyone can perform with minimal training like recording temperature, pulse and respirations or administering and monitoring a feeding
system.
Custodial care that lasts for 90 days or more is sometimes called long term care. We determine what treatments or services is custodial care.
Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See
page 14.
Experimental/ A drug, device or biological product is experimental or investigational if the drug, investigational services device or biological product cannot be lawfully marketed without the approval of the
U. S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished to you. Approval means all forms of acceptance by
the FDA.
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2003 Rural Carrier Benefit Plan 59 Section 10
A medical treatment or procedure, or a drug, device or biological product is experimental or investigational if:
reliable evidence shows that it is the subject of on-going phase I, II or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its
safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that
further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with the
standard means of treatment or diagnosis.
Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating
facility or the protocol( s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the
treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure.
Home health care agency A public agency or private organization under Medicare that is licensed as a home health care agency by the State and is certified as such.
Home health care plan A plan of continued care and treatment when you are under the care of a physician, and when certified by the physician that, without the home health care, confinement
in a hospital or skilled nursing facility would be required.
Hospice care program A coordinated program of home or inpatient pain control and supportive care for a terminally-ill patient and the patient's family. Care is provided by a medically
supervised team under the direction of an independent hospice administration that we approve.
Hospital stay An admission (or series of admissions separated by less than 60 days) to a hospital as an inpatient for any illness or injury. You start a new hospital stay (1) when the
admission is for a cause unrelated to the previous admission; (2) when an employee returns to work for at least one day before the next admission; or (3) when the
hospital stays are separated by at least 60 days for a dependent or retiree.
Long term rehabilitation therapy Physical, speech, and occupational therapy, which can be expected to last longer than a two month period in order to achieve a significant improvement in your condition.
Medical necessity Services, supplies, drugs, or equipment provided by a hospital or covered provider of the health care services that we determine:
are appropriate to diagnose or treat the patient's condition, illness or injury;
are consistent with standards of good medical practice in the United States;
are not primarily for the personal comfort or convenience of the patient, the family, or the provider;
are not a part of or associated with the scholastic education or vocational training of the patient; and
in the case of inpatient care, cannot be provided safely in an outpatient setting.
The fact that a covered provider prescribes, recommends, or approves a service, supply, drug or equipment does not, by itself, make it a medical necessity.
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Plan allowance Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Fee-for-service plans determine their allowances in
different ways. We determine our allowance as follows:
We base our Plan allowance on reasonable and customary charges. Reasonable and customary charges are those charges that are comparable to charges made by other
providers for similar services and supplies under comparable circumstances in the same geographic area. We develop the Plan's allowances from actual claims received
in each zip code throughout the United States, as complied by the Healthcare Charges Database (HCD). We review and update the allowances twice a year (January 1 and
July 1), using the 90th percentile for all charges for a medical procedure. Preferred providers accept the plan allowance as payment in full. For certain services,
exceptions may exist to this general method for determining the Plan's allowance.
For more information, see Differences between our allowance and the bill in Section 4.
Prosthetic device An artificial substitute for a missing body part, such as an arm or leg, used for functional reasons, because a part of the body is permanently damaged, is absent or is
malfunctioning. A prosthetic device is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body.
Routine testing/ screening Healthcare services you receive from a covered provider without any apparent signs or symptoms of an illness, injury or disease.
Us/ We Us and we refer to the Rural Carrier Benefit Plan.
You You refers to the enrollee and each covered family member.
2003 Rural Carrier Benefit Plan 60 Section 10
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Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had before you limitation enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get information See www. opm. gov/ insure.
Also, your employing or retirement office can answer your about enrolling in the questions, and give you a
Guide to Federal Employees Health Benefits Plans,
FEHB Program 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 you, your spouse, for you and your family 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.
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and Family coverage in the
Federal Employees Health Benefits (FEHB) Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your
child( ren).
2003 Rural Carrier Benefit Plan 61 Section 11
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63
If this law applies to you, you must enroll for Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide
documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you
involuntarily as follows:
If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the option of the Blue Cross and Blue Shield Service Benefit
Plan's Basic Option;
If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your
enrollment to Self and Family in the same option of the same plan; or
If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self and Family in the Blue
Cross and Blue Shield Service Benefit Plan's Basic Option.
As long as the court/ administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn't serve the area in which your children live, unless you provide documentation that you have other
coverage for the children. If the court/ administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must
continue your FEHB coverage into retirement (if eligible) and cannot make any changes after retirement. Contact your employing office for further information.
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
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 If you leave Federal service, or if you lose coverage because you no longer qualify as Coverage (TCC) a family member, you may be eligible for Temporary Continuation of Coverage (TCC).
For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal job, if your child turns 22 or
marries, etc.
2003 Rural Carrier Benefit Plan 62 Section 11
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You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Enrolling in TCC. Get OPM pamphlet RI 79-27, which describes TCC under the FEHB Program, and the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, RI 70-5, from your employing or retirement office or from www. opm. gov/ insure. It explains what
you have to do to enroll.
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 a pre-existing health condition.
Getting a Certificate of You may be entitled to continued coverage through the Health Insurance Portability Group Health Plan Coverage and Accountability Act of 1996 (HIPAA). This Federal law 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.
Get OPM pamphlet RI 79-27, Temporary Continuation of Coverage (TCC) under the FEHB Program. It highlights 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 it has information about Federal and
State agencies you can contact for more information.
2003 Rural Carrier Benefit Plan 63 Section 11
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Long Term Care Insurance Is Still Available!
2003 Rural Carrier Benefit Plan 64 Long Term Care Insurance
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC partners ends on December 31, 2002.
If you're a Federal employee, you and your spouse need only answer a few questions about your health during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.
FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide help you may need due to a
severe cognitive impairment such as Alzheimer's disease.
You Can Apply Later, But...
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer to more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.
You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze"!
Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800/ 582-3337) (TDD for the hearing impaired: 1-800/ 843-3557) or visiting www. ltcfeds. com
to get more information and to request an application.
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Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury 34 Allergy tests 22
Allogenetic (donor) bone marrow transplant 30
Alternative treatment 26 Ambulance 33, 34
Anesthesia 30 Autologous bone marrow transplant 30
Biopsies 27, 29 Birthing centers 11
Blood and blood plasma 32 Breast cancer screening 20
Casts 27, 32 Catastrophic protection 15
Changes for 2003 9 Chemotherapy 23
Childbirth 21, 27 Chiropractic 26
Cholesterol tests 20 Circumcision 27
Claims 49, 50, 54 Coinsurance 14, 15, 58
Colorectal cancer screening 20 Congenital anomalies 27, 28
Contraceptive devices and drugs 21, 28, 42
Coordination of benefits 53-57 Covered charges 14, 58
Covered providers 10 Crutches 25
Deductible 14, 15, 58 Definitions 58-60
Dental care 45-46 Diagnostic services 19-20
Disputed claims review 51-52 Donor expenses (transplants) 30
Dressings 32 Durable medical equipment 25
Educational classes and programs 26 Effective date of enrollment 10, 62
Emergency 12, 17, 34 Experimental or investigational 48, 58-59
Eyeglasses 24, 47, 48 Family planning 21
Fecal occult blood test 20
Flexible benefits option 43 Foot care 24
Freestanding ambulatory facilities 30, 32, 36, 38
General Exclusions 48 Hearing services 23, 47
Home health services 25 Hospice care 11, 33, 59
Home nursing care 25 Hospital 11, 31-32, 35, 38
Immunizations 20 Infertility 22
Inhospital physician care 19 Inpatient Hospital Benefits 31-32, 35, 38
Insulin 42 Laboratory and pathological services 20
Machine diagnostic tests 20 Magnetic Resonance Imagings (MRIs)
20 Mail Order Prescription Drugs 40-42
Mammograms 20 Maternity Benefits 21
Medicaid 57 Medical necessity 59
Medically underserved areas 10 Medicare 16-17, 53-56
Mental Conditions/ Substance Abuse Benefits 35-39
Neurological testing 20 Newborn care 21, 27
Non-FEHB Benefits 47 Nurse 10, 25
Licensed Practical Nurse 25 Nurse Midwife 10
Nurse Practitioner 10 Registered Nurse 25
Nursery charges 21 Nursing School Administered Clinic 10
Obstetrical care 21, 27 Occupational therapy 23
Ocular injury 24 Office visits 19, 35, 39
Oral and maxillofacial surgery 29 Orthopedic devices 24
Out-of-pocket expenses 15, 37, 39
Outpatient facility care 32, 36, 38, 39 Overseas claims 50
Oxygen 25 Pap test 20
Physical examination 19 Physical therapy 23
Physician 10, 19 Pre-admission testing 20
Preauthorization 37 Precertification 12-13, 25, 33, 37, 39
Preferred Provider Organization (PPO) 8 Prescription drugs 19, 21, 22, 32, 40-42
Preventive care, adult 20 Preventive care, children 20
Prostate cancer screening 20 Prosthetic devices 24, 27
Psychologist 10, 35 Psychotherapy 35, 39
Radiation therapy 23 Renal dialysis 43
Room and board 31, 38 Skilled nursing facility care 11, 13, 33
Smoking cessation 26 Social Worker 10, 35
Speech therapy 23 Splints 27, 32
Sterilization procedures 21, 28 Subrogation 57
Substance abuse 13, 36, 39 Surgery 27-30
Anesthesia 30 Assistant surgeon 28
Multiple procedures 28 Oral 29
Outpatient 27-30 Reconstructive 28
Syringes 42 Temporary continuation of coverage 62-
63 Transplants 30
Vision services 24, 43, 47 Well child care 19, 20
Wheelchairs 25 Workers' compensation 57
X-rays 20, 32, 45
2003 Rural Carrier Benefit Plan 65 Index
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2003 Rural Carrier Benefit Plan 66 Summary
Summary of benefits for the Rural Carrier Benefit Plan 2003
Do not rely on this chart alone. All benefits 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.
Below, an asterisk (*) means the item is subject to the $350 calendar year deductible. And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-PPO physician or other health care professional.
Benefits You pay Page
Medical services provided by physicians: PPO: $20/ office visit 19
Diagnostic and treatment services provided in the office ................. Non-PPO: 25% of our allowance and any difference between our allowance and the
billed amount*
Surgery................................................................................................. PPO: 10% of our allowance 27-30
Non-PPO: 15% of our allowance and any difference between our allowance and the
billed amount
Services provided by a hospital: PPO: Nothing 31-32
Inpatient .............................................................................................. Non-PPO: $200 copayment per admission; 15% of room and board and other charges
Outpatient ............................................................................................ PPO: 15% of our allowance* 32
Non-PPO: 25% of our allowance* and any difference between our allowance and the
billed amount
Emergency benefits: Accidental injury ................................................................................ Nothing for emergency room visit and first 34
physician office visit
Medical emergency.............................................................................. Regular benefits 19-33
Summary of benefits continued on next page
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2003 Rural Carrier Benefit Plan 67 Summary
Benefits You pay Page
Mental health and substance abuse treatment PPO: Nothing 35
Inpatient ............................................................................................... Non-PPO: $200 copayment per admission; 38 15% for room and board; 15% of other
charges. For substance abuse, charges over $11,000 per person per lifetime
Outpatient ............................................................................................ PPO: 15% of our allowance* (no 35-36 deductible on physician visits)
Non-PPO: Charges over $75 per treatment 38-39 session (no deductible). For substance
abuse, charges over $11,000 per person per lifetime for an aftercare program
(combined with inpatient)
Prescription drugs .................................................................................... Network and Non-network Pharmacy: 40-42 25% of the cost*
Mail Order Pharmacy: $15/ generic drug; $25/ brand name drug
Mail Order With Medicare Part B: $6/ generic; $12/ brand name drug
Dental Care .............................................................................................. Any difference between our scheduled 45-46 allowance and the billed amount
Special features: Flexible benefits option; Cancer treatment benefit; Kidney dialysis benefit; 24 hour nurse line, 43-44 Travel assistance program; Routine eye exam benefit; Healthy maternity program; Disease management programs
Protection against catastrophic costs PPO: Nothing after $2,500/ Person 15 (your out-of-pocket maximum) ............................................................... or $3,000/ Family per calendar year
Non-PPO: Nothing after $3,000/ Person or $3,500/ Family per calendar year.
Note: Benefit maximums apply and some costs do not count toward this protection
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2003 Rate Information for
Rural Carrier Benefit Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category,
refer to the FEHB Guide for that category or contact the agency that maintains your health
benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB
Guide for United States Postal Service Employees, RI 70-2. Different postal rates apply and
special FEHB guides are published for Postal Service Nurses and Tool & Die employees (see RI
70-2B); and for Postal Service Inspectors and Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of
any postal employee organization. Refer to the applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Gov't Your Gov't Your USPS Your Enrollment Code Share Share Share Share Share Share
High Option Self Only 381 N/ A N/ A $236.82 $153.14 $129.03 $50.95
High Option Self and Family 382 N/ A N/ A $540.84 $253.46 $294.70 $71.90
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