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SSEHA Health 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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SSEHA Health Benefit Plan
http:// www. CareFirst. com 2003
A Fee-For-Service Plan
Sponsored and administered by: U. S. Secret Service Employees Health Association
Who may enroll in this Plan: Only employees and retirees of the U. S. Secret Service are
eligible to be enrolled in this Plan.
To become a member or associate member: To be enrolled you must be, or must become, a
member of the U. S. Secret Service Employees Health Association
Membership dues: There is a one-time only fee of $5. New members will be billed dues when
the Plan receives notice of enrollment.
Enrollment codes for this Plan:
Y71 -Self Only
Y72 -Self and Family
This Plan has JCAHO accreditation from
the Joint Commission on Accreditation of
Hospitals Organization
For changes
in benefits
See
Page 10
RI 72-011
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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.
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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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2003 SSEHA Health Benefit Plan Table of Contents 6
Table of Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Plain Language . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Stop Health Care Fraud! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Section 1. Facts about this fee-for-service plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Section 2. How we change for 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Section 3. How you get care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Identification cards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Where you get covered care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Covered providers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Covered facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
What you must do to get covered care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
How to get approval for. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Your hospital stay ( precertification) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Other services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Section 4. Your costs for covered services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Copayments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Deductible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Coinsurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Differences between our allowance and the bill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Your catastrophic protection out-of-pocket maximum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
When government facilities bill us. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
If we overpay you . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
When you are age 65 or over and you do not have Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
When you have Medicare. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Section 5. Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
( a) Medical services and supplies provided by physicians and other health care professionals. . . . . . . . . . . . . . . 22
( b) Surgical and anesthesia services provided by physicians and other health care professionals . . . . . . . . . . . 32
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
( d) Emergency services/ accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
( g) Special features. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Flexible benefits option
Services for deaf and hearing impaired
BlueCard Program
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
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2003 SSEHA Health Benefit Plan Table of Contents 6
( i) Non-FEHB benefits available to Plan Members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Section 6. General exclusions --things we don' t cover . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Section 7. Filing a claim for covered services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Section 8. The disputed claims process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Section 9. Coordinating benefits with other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
When you have other health coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
What is Medicare? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Medicare managed care plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
TRICARE and CHAMPVA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Workers Compensation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Medicaid. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
When other Government agencies are responsible for your care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
When others are responsible for injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Section 10. Definitions of terms we use in this brochure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Section 11. FEHB facts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Coverage information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
No pre-existing condition limitation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Where you get information about enrolling in the FEHB Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Types of coverage available for you and your family. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Children s Equity Act. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
When benefits and premiums start. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
When you retire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
When you lose benefits
When FEHB coverage ends . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Spouse equity coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Temporary Continuation of Coverage ( TCC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Converting to individual coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Getting a Certificate of Group Health Plan Coverage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Long term care insurance is still available. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Summary of benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Back cover
6.
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2003 SSEHA Health Benefit Plan 8 Introduction/ Plain Language / Advisory
Introduction
This brochure describes the benefits of U. S. Secret Service Employees Health Association under our contract ( CS
2276) with the Office of Personnel Management ( OPM) , as authorized by the Federal Employees Health Benefits law.
This Plan is underwritten by CareFirst, BlueCross and BlueShield. The address for the U. S. Secret service Employee
Health Association s administrative offices is:
U. S. Secret Service Employees Health Association ( SSEHA) Health Benefit Plan
950 H Street, NW
Washington, DC 20223
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 in 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 are
summarized on page 71. 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. For instance, you means the enrollee or family member; we means SSEHA
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 other, we tell you what they mean first.
Our brochure and other FEHB plans brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit
OPM s Rate Us feedback area at www. . opm/ insure or email OPM at fehbwebcomments@ opm. gov. You may also
write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division, 1900 E
Street, NW Washington, DC 20415-3650.
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 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.
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2003 SSEHA Health Benefit Plan 8 Introduction/ Plain Language / Advisory
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.
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 800-680-9695 and explain the situation.
If we do not resolve the issue:
Do not maintain as a family member on your policy: your former spouse after a divorce decree or annulment is final ( even if the court 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 retired.
Your 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.
CALL THE HEALTH CARE FRAUD HOTLINE
202/ 418-330
OR WRITE T0:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415.
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2003 SSEHA Health Benefit Plan 9 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.
How we pay providers
Participating providers are paid up to CareFirst Plan Allowance. CareFirst makes all payments directly to the
provider.
Non-participating providers are paid up to CareFirst Plan Allowance, all remaining balances are the responsibility of
the member. The payment is made directly to the member.
Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM s FEHB website ( www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.
The CareFirst, Inc. Board of Directors has the ultimate authority and accountability for the quality of care and service provided by the Plan. The CareFirst, Inc. Board of Directors delegates the responsibility for broad
oversight of the Quality Improvement ( QI) Program to the Service and Quality Oversight Committee, a
committee of the CareFirst, Inc. , Board of Directors. The Service and Quality Oversight Committee meets
quarterly to review and approve the QI Program Description, Annual Evaluation, and Annual QI Work Plan, and
to review progress in meeting the QI Program Objectives. CareFirst BlueCross BlueShield does evaluate the
clinician s compliance with clinical guidelines and protocols, patient centered outcomes, member health status
and patient satisfaction.
CareFirst BlueCross BlueShield has been in existence for the past 60 years. CareFirst BlueCross BlueShield became operational in 1934.
CareFirst BlueCross BlueShield is a not-for-profit company.
If you want more information about us, call 800-424-7474 extension 6039 or 202-479-6039, or write to Member
Services, 550 12 th St. , S. W. , Washington, DC 20065. You may also visit our website at www. CareFirst. com.
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2003 SSEHA Health Benefit Plan 10 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 spouse 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 20.5% for Self Only or 33.4% for Self and Family.
Lipoprotein profile once every 5 years for adults 20 years and older
Double contract barium enema once every 5-10 years at age 50
Colonoscopy once every 10 years starting at age 50
Mental Health vendor changed from HMS to Magellan
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2003 SSEHA Health Benefit Plan 15 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 obtain a
prescription at a Plan pharmacy. Until you receive your ID card, use your
copy of the Health Benefits Election Form, SF-2809, your health benefits
enrollment confirmation ( for annuitants) , or your Employee Express
confirmation letter.
If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 800-424-7474
extension 6039 or 202-479-6039.
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 use our participating 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:
a licensed doctor of medicine ( M. D) or a licensed doctor of osteopathy ( D. O. )
a licensed or certified chiropractor, nurse anesthetist, dentist, podiatrist, occupational therapist and speech therapist practicing
within the scope of their license or certification; and
other covered providers who may render services without the supervision of a M. D. but for whom the Carrier provides benefits
include a qualified clinical psychologist, clinical social worker,
optometrist, nurse midwife and nurse practitioner/ clinical specialist.
For purposes of this FEHB brochure, the term doctor includes all
of these providers when the services are performed within the scope
of their license or certification.
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 which states 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.
Covered facilities Covered facilities include: Ambulatory surgical facilities A facility Accredited by the Joint Commission on Accreditation of Health Care
Organizations or approved by the Carrier, designed for the treatment
Of minor, elective surgical procedures on an ambulatory basis
Extended care facility A facility approved by the Carrier or eligible for payment under Medicare, possessing an organized medical staff
providing continuous non-custodial inpatient care for convalescent
patients not requiring acute hospital care yet not at a stable stage of
illness.
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2003 SSEHA Health Benefit Plan 15 Section 3
Hospice A facility that provides short periods of stay for a terminally ill person in a home-like setting for either direct care or
respite. This facility may be either free standing or affiliated with
hospital. It must operate as an integral part of the hospice care
program.
Hospital A facility conforming to the standards of and accredited by the Joint Commission on Accreditation of Health Care
Organizations providing inpatient diagnosis and therapeutic facilities
for surgical and medical diagnosis, treatment and care of injured and
sick persons by or under the supervision of a staff of licensed doctors
of medicine ( M. D. ) or licensed doctors of osteopathy ( D. O. ) . The
hospital must provide continuous 24-hour-a-day professional
registered nursing ( R. N. ) services and may not be an extended care
facility ( other than an approved ECF) ; a nursing home; a place of
rest; an institution for exceptional children, the aged, drug addicts, or
alcoholics; or custodial or domiciliary institution having the primary
purpose of furnishing food, shelter, training, or non-medical personal
services. This definition includes college infirmaries and Veterans
administration hospitals.
Non-participating hospital a hospital not having, , at the time services are rendered, a participating agreement with the Blue Cross
Plan in the area where services are rendered. College infirmaries
and Veterans Administration hospitals are considered non-
participating hospitals. The Carrier may, at its discretion, recognize
any institution located outside of the 50 states and District of
Columbia as a non-participating hospital.
Participating hospital A participating hospital having, , at the time services are rendered, a participating agreement with the Blue Cross
Plan in the area where services are rendered, and thereby agreeing to
complete and file claims for covered hospital billed services on
behalf of covered patients, to admit covered patients without
requiring admission deposits, and to accept benefit payments directly
from the Blue Cross Plan with which the hospital participates.
Cancer research facility A facility that is: :
1) A National Cooperative Cancer Study Group Institution that is
funded by the National Cancer Institute ( NCI) , and has been
approved by a cooperative Group as a bone marrow transplant
center;
2) A NCI-designated Cancer Center; or
3) An Institution that has an NCI-funded, peer-review grant to
study allogenic bone marrow transplants of autologous bone
marrow transplants ( autologous stem cell support) and
autologous peripheral stem cell support.
Renal dialysis center A freestanding facility approved by the Carrier and designed specifically for the treatment of chronic renal
disease.
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2003 SSEHA Health Benefit Plan 15 Section 3
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 specialist because we terminate our contract with specialist for other than cause,
you may be able to continue seeing your specialist and receive 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 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 800-424-7474 extension 6039 or
202-479-6039.
If you changed from another FEHB plan to us, your former plan will pay for the
hospital stay until:
You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.
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. In addition, if the stay is not
medically necessary, we will not pay any benefits.
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2003 SSEHA Health Benefit Plan 15 Section 3
How to precertify an admission:
You, your representative, your doctor, or your hospital must call us at 866-PREAUTH at least two 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 doctor, 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 doctor;
Name of hospital or facility; and
Number of planned days of confinement.
We will then tell the doctor and/ or hospital the number of approved inpatient days and we will send written confirmation of our decision
to you, your doctor, and the hospital.
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
needs to be extended: extended, your doctor 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
do not follow the medically 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
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2003 SSEHA Health Benefit Plan 15 Section 3
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 precertification.
All inpatient medical services. All inpatient mental health and substance abuse services.
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2003 SSEHA Health Benefit Plan 18 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 pharmacy when you receive services.
Example: When you purchase prescription drugs you pay a copay of $ 10
generic/ $ 20 brand name for network retail and $ 20 generic/ $ 40 brand
name for mail order. If you are enrolled in a Medicare Part B, the Plan
will waive the mail order copays.
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 $ 200 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 $ 400.
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.
And, if you change options in this Plan during the year, we will credit the
amount covered expenses already applied toward the deductible of your
old option to deductible of your new option.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn t begin until you meet your $ 200 per
calendar year deductible.
Example: You pay 20% of our allowance for office visits.
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 charges $ 100 for a service, but routinely
waives your 20% coinsurance, the actual charge is $ 80. We will pay $ 64.
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2003 SSEHA Health Benefit Plan 18 Section 4
Differences between Our " Plan allowance" is the amount we use to calculate our payment our allowance and for covered services. Fee-for-service plans arrive at their allowances in
the bill different ways, so their allowances vary. For more information about
how we determine our Plan allowance, see the definition of Plan
allowance in Section 10, page 70.
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.
Participating providers ( Par) , agree to limit what they will bill you.
Because of that, when you use a participating provider, your share of
covered charges consists only of your deductible and coinsurance.
Here is an example: You see a Participating 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 -
-20% of our $ 100 allowance ( $ 20) . Because of the agreement, your
Participating physician will not bill you for the $ 50 difference
between our allowance and his bill.
Non-Participating providers ( Non-Par) , on the other hand, have no
agreement to limit what they will bill you. When you use a Non-Par
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-Par 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 20% of our $ 100
allowance ( $ 20) . Plus, because there is no agreement between the
non-Par 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 Par physician vs. a non-Par
physician. 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 Par physician Non-Par physician
Physician' s charge $ 150 $ 150
Our allowance We set it at: $ 100 We set it at: $ 100
We pay 80% of our allowance: $ 80 80% of our allowance: $ 80
You owe:
Coinsurance 20% of our allowance: $ 20 20% of our allowance: $ 20
+ Difference up to
charge? No: $ 0 Yes: $ 50
TOTAL YOU PAY $ 20 $ 70
Your out-of-pocket maximum
for deductibles and coinsurance For those services with coinsurance, the Plan pays 100% of the Carrier allowance charges for the remainder of the calendar year after the
calendar year deductible is met, if out-of-pocket expenses for the
deductible and the coinsurance in that calendar year exceed $ 1000 per
member or $ 2000 per family.
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2003 SSEHA Health Benefit Plan 18 Section 4
Out-of-Pocket expenses for the purposes of this benefit are:
The calendar year deductible; The 20% you pay for Surgical Benefits;
The 20% you pay for Maternity Benefits; and The 20% you pay for Other Medical Benefits.
The following cannot be counted toward out-of-pocket expenses:
Expenses for Inpatient Hospital Benefits; Expenses in excess of the Carrier allowance or maximum benefit
limitations;
Expenses for mental conditions, substance abuse or dental care; Any amounts you pay if benefits have been reduced because of non-
compliance with this Plan s cost containment requirements ;
Expenses for prescription drugs purchase through retail or mail program.
Inpatient hospital per admission deductible.
If you changed to this Plan during open season from a plan with a
catastrophic protection benefit and the effective date of the change was
after January 1, any expenses that would have applied to the plan s
catastrophic protection benefit during the prior year will be covered by
your old plan if they are for care you received in January before the
effective date of your coverage in this Plan.
If you have already met the covered out-of-pocket maximum expense
level in full, your old plan s catastrophic protection benefit will continue
to apply until the effective date of your coverage in this plan.
If you have not met this expense level in full, your old plan will first
apply your covered out-of-pocket expense until the prior year s
catastrophic level is reached and then apply the catastrophic benefit to
covered out-of-pocket expenses incurred from that point until the
effective date. The old plan will pay these covered expenses according to
this year s benefits; benefit changes are effective on January 1.
When government facilities Facilities of the Department of Veterans Affairs, the Department of
bill us Defense, and the 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 We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to
offset overpayments.
18.
18
Page 19
20
2003 SSEHA Health Benefit Plan 18 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 or coinsurance 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
Medicare assignment for the claim
your deductibles, coinsurance, and copayments;
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.
19.
19
Page 20
21
2003 SSEHA Health Benefit Plan 18 Section 4
When you have the
Original Medicare Plan
( Part A, Part B, or both)
We limit our payment to an amount that supplements the benefits that
Medicare would pay under Medicare Part A ( Hospital insurance) and
Medicare Part B ( Medical 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 our
deductible and coinsurance.
If your physician does not accept Medicare assignment, then you pay
the difference between the charge and 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)
form 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 your physician to reduce the charges. If the physician does not,
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.
20.
20
Page 21
22
2003 SSEHA Health Benefit Plan 21 Section 5
Section 5. Benefits --OVERVIEW
( See page 10 for how our benefits changed this year and page 79 for a benefits summary. )
NOTE : This benefits section is divided into subsections. Please read the important things you should keep in
mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the following subsections. To obtain claims forms, claims filing advice, or more information
about our benefits, contact us at 800-424-7474 extension 603 9 or 202-479-6039 or at our website at
www. CareFirst. com.
( a) Medical services and supplies provided by physicians and other health care professionals . . . . . . . . . . . . . . . . . . . . . . . . . 22-31
Diagnostic and treatment services
Lab, X-ray, and other diagnostic tests
Preventive care, adult
Preventive care, children
Maternity care
Family planning
Infertility services
Allergy care
Treatment therapies
Physical and occupational therapy
Speech therapy
Hearing services ( testing, treatment, and
supplies)
Vision services ( testing, treatment, and
supplies)
Foot care
Orthopedic and prosthetic devices
Durable medical equipment ( DME)
Home health services
Chiropractic Services
Alternative treatments
Educational classes and programs
( b) Surgical and anesthesia services provided by physicians and other health care professionals. . . . . . . . . . . . . . . . . . . . . . . . 32-37
Surgical procedures
Reconstructive surgery
Oral and maxillofacial surgery
Organ/ tissue transplants
Anesthesia
( c) Services provided by a hospital or other facility, and ambulance services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38-41
Inpatient hospital
Outpatient hospital or ambulatory surgical
center
Extended care benefits/ Skilled nursing care
facility benefits
Hospice care
Ambulance
( d) Emergency services/ Accidents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42-43
Accidental injury
Medical emergency
Ambulance
( e) Mental health and substance abuse benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44-46
( f) Prescription drug benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47-50
( g) Special features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51-53
Flexible benefits option
Services for deaf and hearing impaired
BlueCard Program
Travel benefit/ services overseas
( h) Dental benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54-55
Non-FEHB benefits available to Plan members. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
SUMMARY OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
21.
21
Page 22
23
2003 SSEHA Health Benefit Plan 22 Section 5( a)
Section 5 ( a) . Medical services and supplies provided by physicians and other
health care professionals
I M
P O
R T
A N
T
Here are some important things 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: $ 200 per person ( $ 400 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.
I M
P O
R T
A N
T
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
In physician s office Par Doctor: 20% of the Plan allowance
Non-Par doctor: Any difference
between. the plan allowance and the
provider s charge
Professional services of physicians
In an urgent care center
During a hospital stay
In a skilled nursing facility
Initial examination of a newborn child covered under a family enrollment
Office medical consultations
Second surgical opinion
At home
Par Doctor: 20% of the Plan allowance
Non-Par doctor: Any difference
between. the plan allowance and the
provider s charge
22.
22
Page 23
24
2003 SSEHA Health Benefit Plan 25 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
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between. the plan allowance and the
provider s charge
Preventive care, adult
Routine screenings, limited to:
Total Blood Cholesterol once every three years
Chlamydial infection
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50
Par doctor: Nothing No
deductible
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge. No deductible
Routine Prostate Specific Antigen ( PSA) test one annually for
men age 40 and older
Par doctor: Nothing No
deductible
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge. No deductible
Routine pap test
Note: The office visit is covered if pap test is received on the
same day; see Diagnosis and Treatment, above.
Par doctor: Nothing No
deductible
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge. No deductible
Routine mammogram covered for women age 35 and older, ,
as follows:
From age 35 through 39, one during this five year period
From age 40 through 49, one every two years
At age 50 and older, one every calendar year
Par doctor: Nothing No
deductible
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge. No deductible
23.
23
Page 24
25
2003 SSEHA Health Benefit Plan 25 Section 5( a)
Preventive care, adult ( continued) You pay
Routine immunizations, limited to:
Tetanus-diphtheria ( Td) booster once every 10 years, , ages19 and over ( except as provided for under Childhood
immunizations)
Influenza vaccines, annually
Pneumococcal vaccine, age 65 and older
Par doctor: Nothing No
deductible
Non-Par doctor: 100% of Plan
allowance and any difference
between the plan allowance and the
provider s charge. No deductible
Preventive care, children
For well-child care charges for routine examinations, immunizations and care ( to age 22) Par doctor: Nothing No deductible
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge. No deductible
Examinations, limited to:
Examinations for amblyopia and strabismus limited to one screening examination ( ages 2 through 6)
Examinations done on the day of immunizations ( ages 3 through 22)
Par doctor: Nothing No
deductible
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge. No deductible
24.
24
Page 25
26
2003 SSEHA Health Benefit Plan 25 Section 5( a)
Maternity care You pay
Par doctor: 20% of plan allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Complete maternity ( obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You do not need to precertify your normal delivery; see pages 19-20 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 doctor, or your hospital
must precertify.
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 pay hospitalization and surgeon services ( delivery) the same as for illness and injury. See Hospital benefits
( Section 5c) and Surgery benefits ( Section 5b) .
( see above)
Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization ( See Surgical procedures Section 5 ( b) )
Surgically implanted contraceptives ( such as Norplant)
Injectable contraceptive drugs ( such as Depo provera)
Intrauterine devices ( IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug
benefit in Section 5( f) .
Par doctor: 20% of Plan allowance.
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered: reversal of voluntary surgical sterilization,
genetic counseling,
All charges.
Infertility services You pay
Diagnosis and treatment of infertility, except as shown in Not
covered.
Par doctor: 20% of the Plan
allowance.
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
25.
25
Page 26
27
2003 SSEHA Health Benefit Plan 25 Section 5( a)
Not covered:
Infertility services after voluntary sterilization
Fertility drugs
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 eggs
All charges.
Allergy care
Testing and treatment, including materials such as allergy
serum and injections.
Par doctor: 20% of the Plan allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Allergy injections Par doctor: 20% of the Plan allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered: provocative food testing and sublingual allergy
desensitization
All charges
26.
26
Page 27
28
2003 SSEHA Health Benefit Plan 25 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 22.
Dialysis hemodialysis and peritoneal dialysis
Intravenous ( IV) / Infusion Therapy Home IV and antibiotic therapy
Growth hormone therapy ( GHT)
Note: Growth hormone is covered under the prescription drug
benefit
Note: We only cover GHT when we preauthorize the
treatment. Call 866-PREAUTH for preauthorization. We will
ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you
begin treatment; otherwise, we will only cover GHT services
from the date you submit the information. If you do not ask or
if we determine GHT is not medically necessary, we will not
cover the GHT or related services and supplies. See Services
requiring our prior approval in Section 3.
Respiratory and inhalation therapies
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Physical and occupational therapies
90 visits per calendar year for the services of each of the following:
qualified physical therapists;
occupational therapists.
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Physical and occupational therapies -continued on next page
27.
27
Page 28
29
2003 SSEHA Health Benefit Plan 25 Section 5( a)
Physical and occupational therapies ( continued) You pay
Note: We only cover therapy to restore bodily function when
there has been a total or partial loss of bodily function due to
illness or injury and when a physician:
1) orders the care;
2) identifies the specific professional skills the patient requires and
the medical necessity for skilled services; and
3) indicates the length of time the services are needed.
See above
Not covered:
long-term rehabilitative therapy exercise programs All charges.
Speech therapy
90 visits per calendar year Par doctor: 20% of the Plan allowance
Non-Par doctor: any difference between
the plan allowance and the provider s
charge.
Hearing services ( testing, treatment, and supplies)
First hearing aid and testing only when necessitated by
accidental injury
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered:
hearing testing hearing aids, testing and examinations for them, except
for accidental injury
All charges.
Vision services ( testing, treatment, and supplies)
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or
intraocular surgery ( such as for cataracts)
Note: See Preventive care, children for eye exams for children
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Vision services ( testing, treatment, and supplies) -continued on next page
28.
28
Page 29
30
2003 SSEHA Health Benefit Plan 25 Section 5( a)
Vision services ( testing, treatment, and supplies) ( continued) You pay
Not covered:
Eyeglasses or contact lenses and examinations for them
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery
All charges.
Foot care
Routine foot care when you are under active treatment for a
metabolic or peripheral vascular disease, such as diabetes.
See orthopedic and prosthetic devices for information on
podiatric shoe inserts.
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of
conditions of the foot, except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of
the foot ( unless the treatment is by open cutting surgery)
All charges
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted
breast implant following mastectomy. Note: See 5( b) for
coverage of the surgery to insert the device.
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices
Prosthetic replacements provided less than 3 years after the last one we covered
All charges.
29.
29
Page 30
31
2003 SSEHA Health Benefit Plan 25 Section 5( a)
Durable medical equipment ( DME) You pay
Durable medical equipment ( DME) is equipment and supplies
that:
1. Are prescribed by your attending physician ( i. e. , the physician
who is treating your illness or injury) ;
2. Are medically necessary;
3. Are primarily and customarily used only for a medical purpose;
4. Are generally useful only to a person with an illness or injury;
5. Are designed for prolonged use; and
6. 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 and dialysis
equipment. Under this benefit, we also cover:
Hospital beds;
Wheelchairs;
Apnea Monitors
Respirators
Commodes
Suction Machines
Crutches; and
Walkers.
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered:
Wigs
Orthotics
All charges
Home health services
90 days per calendar year up to a maximum plan payment of 100% of
Plan allowance per day when:
A registered nurse ( R. N. ) , licensed practical nurse ( L. P. N. ) or licensed vocational nurse ( L. V. N. ) provides the services;
The attending physician orders the care;
The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services; and
The physician indicates the length of time the services are needed.
Par: Nothing No deductible
Non-Par: Any difference between
the plan allowance and the
provider s charge. No deductible
Home health services -continued on next page
30.
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Page 31
32
2003 SSEHA Health Benefit Plan 25 Section 5( a)
Home health services ( continued) You pay
Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient s family;
Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or
giving oral medication.
All charges.
Chiropractic
Manipulation of the spine and extremities Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application
Par doctor: 20% of the Plan allowance
Non-Par doctor: Any difference between
the plan allowance and the provider s
charge.
Alternative treatments
Acupuncture by a doctor of medicine or osteopathy for: : anesthesia Par doctor: 20% of the Plan allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered:
naturopathic services
( Note: benefits of certain alternative treatment providers may
be covered in medically underserved areas; see page 11)
All charges
Educational classes and programs
Coverage is limited to:
Smoking Cessation Up to $ $ 100 for one smoking cessation program per member per lifetime, including all related
expenses such as drugs.
Diabetes self management
Par doctor: Nothing
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
31.
31
Page 32
33
2003 SSEHA Health Benefit Plan 32 Section 5( b)
Section 5 ( b) . Surgical and anesthesia services provided by physicians and
other health care professionals
I M
P O
R T
A N
T
Here are some important things 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: $ 200 per person ( $ 400 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.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Any costs associated with the facility charge ( i. e.
hospital, surgical center, etc. ) are in Section 5 ( c) .
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.
I M
P O
R T
A N
T
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:
Operative procedures Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Electroconvulsive therapy
Par doctor: 20% of the Plan
allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Surgical procedures -continued on next page.
32.
32
Page 33
34
2003 SSEHA Health Benefit Plan 37 Section 5( b)
Surgical procedures ( continued) You pay
Removal of tumors and cysts Correction of congenital anomalies ( see Reconstructive
surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his
or her normal weight according to current underwriting
standards; eligible members must be age 18 or over.
Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage
information
Voluntary sterilization, Norplant ( a surgically implanted contraceptive) , and intrauterine devices ( IUDs)
Treatment of burns Assistant surgeons-we cover up to 80% of our allowance
for the surgeon' s charge
Par doctor: 20% of the Plan allowance for
the primary procedure and 20% of one-half
of the Plan allowance for the secondary
procedure( s)
Non Par doctor: 20% of the Plan allowance
for the primary procedure and 20% of one-
half of the Plan allowance for the secondary
procedure( s) ; and any difference between
our payment and the billed amount
When multiple or bilateral surgical procedures performed
during the same operative session add time or complexity to
patient care, our benefits are:
For the primary procedure:
Par: 80% of the Plan allowance or
Non-Par: 80% of the Plan allowance
For the secondary procedure( s) :
Par: 80% of one-half of the Plan allowance or
Non-Par: 80% 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.
Par: 20% of the Plan allowance for the
primary procedure and 20% of one-half of
the Plan allowance for the secondary
procedure( s)
Non-Par doctor: 20% of the Plan allowance
for the primary procedure and 20% of one-
half of the Plan allowance for the secondary
procedure( s) ; and any difference between
our payment and the billed amount
Not covered:
Reversal of voluntary sterilization Services of a standby surgeon, except during angioplasty or other high
risk procedures when we determine standbys are medically necessary
Routine treatment of conditions of the foot; see Foot care
All charges.
33.
33
Page 34
35
2003 SSEHA Health Benefit Plan 37 Section 5( b)
Reconstructive surgery You pay
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member s appearance and
the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm.
Examples of congenital anomalies are: protruding ear
deformaties; cleft lip; cleft palate; birth marks; and webbed
fingers and toes.
All stages of breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses; and surgical bras and replacements ( see Prosthetic devices for coverage)
Par: 20% of the Plan allowance
Non-Par: Any difference between
the plan allowance and the
provider s charge.
Note: We may pay for internal breast prostheses as hospital
benefits.
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:
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 if repair is initiated within negotiated
limit, if any
Surgeries related to sex transformation or sexual dysfunction
All charges
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36
2003 SSEHA Health Benefit Plan 37 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones Surgical correction of cleft lip, cleft palate or severe
functional malocclusion
Removal of stones from salivary ducts Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures
Other surgical procedures that do not involve the teeth or their supporting structures
Removal of impacted teeth No deductible
Par doctor: 20% of the Plan allowance
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting
structures ( such as the periodontal membrane, gingiva,
and alveolar bone)
All charges
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37
2003 SSEHA Health Benefit Plan 37 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 only for patients
with cystic fibrosis
Pancreas Allogeneic bone marrow transplants only for patients
with acute leukemia, advanced Hodgkins disease
Intestinal transplants ( small intestine) and the small intestine with the liver or small intestine with multiple
organs such as liver, stomach, and pancreas.
Autologous bone marrow transplants ( autologous stem cell support) and autogogous peripheral stem cell support,
limited to patients with acute lymphocytic, or
nonplymphocytic leukemia; advanced Hodgkin s
lymphoma, advanced non-Hodgkin s lymphoma, advance
neuroblastoma ( limited to children over age one) :
testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors, breast cancer; multiple myeloma, epithelial
ovarian cancer
National Transplant Program ( NTP) SSEHA does not have a
NTP.
Treatment for breast cancer, multiple myeloma, and epithelial
ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if
approved by the Plan s medical director in accordance with the
Plan s protocols.
Note: We cover related medical and hospital expenses of the donor
when we cover the recipient.
Par doctor: 20% of the Plan allowance.
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor
Implants of artificial organs Transplants not listed as covered
All charges
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38
2003 SSEHA Health Benefit Plan 37 Section 5( b)
Anesthesia You pay
Professional services provided in
Hospital ( inpatient)
Par doctor: 20% of the Plan allowance.
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
Professional services provided in
Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office
Par doctor: 20% of the Plan allowance.
Non-Par doctor: Any difference
between the plan allowance and the
provider s charge.
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39
2003 SSEHA Health Benefit Plan 38 Section 5( c)
Section 5( c) . Services provided by a hospital or other facility, and ambulance
services
I M
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A N
T
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, 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: $ 200 per person ( $ 400 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.
I M
P O
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T
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; and
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.
Participating hospital: $ 100 per
admission deductible.
Non-Participating hospital: $ 100 per
admission.
Note: If you use a Participating provider
and a Participating facility, we may still
pay non-Participating benefits if you
receive treatment from a radiologist,
pathologist, or anesthesiologist who is not
a Participating provider.
Inpatient hospital -continued on next page.
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2003 SSEHA Health Benefit Plan 41 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 Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home ( Note:
calendar year deductible applies. )
NOTE: We base payment on whether the facility or a health
care professional bills for the services or supplies. For
example, when the hospital bills for its nurse anesthetists
services, we pay Hospital benefits and when the
anesthesiologist bills, we pay Surgery benefits.
Par hospital: $ 100 per admission
deductible.
Non-Par hospital: Any difference
between the plan allowance and the
provider s charge, the $ 100 per
admission deductible.
Not covered:
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. Non-covered facilities, such as nursing homes, schools,
Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care
All charges.
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment room
Prescribed 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
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical
impairment. We do not cover the dental procedures.
Par hospital: Nothing No
deductible
Non-Par hospital: Any difference
between the plan allowance and the
provider s charge. No deductible
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41
2003 SSEHA Health Benefit Plan 41 Section 5( c)
Extended care benefits/ Skilled nursing care facility
benefits
You pay
Skilled nursing facility ( SNF) : We cover semiprivate room,
board, services and supplies in a SNF for up to 365 days per
confinement when:
1) You are admitted directly from a precertified hospital stay
of at least 3 consecutive days; and
2) You are admitted for the same condition as the hospital
stay; and
3) your skilled nursing care is supervised by a physician and
provided by an R. N. , L. P. N. , or L. V. N. ; and
4) SNF care is medically appropriate.
Par SNF: Nothing No deductible
Non-Par SNF:
Any difference between the plan
allowance and the provider s charge.
No deductible
Extended care benefit:
We cover semiprivate room, board, services and supplies for
up to 365 days per confinement when :
1) If you are admitted directly from a percertified hospital
stay of at least 3 consecutive days; and
2) Extended Care Facility confinements follow and are
related to a hospital admission; therefore, Extended Care
Facility admissions are not subject to the per admission
inpatient hospital benefits deductible
Note: Each day a patient receives benefits in a hospital
reduces by two days the number of Extended Care Facility
benefit days available for the confinement.
Note: Extended Care Facility benefits are not provided for
admissions for mental conditions or substance abuse.
Par Extended Care Facility: Nothing
No deductible
Non-Par Extended Care Facility:
Any difference between the plan
allowance and the provider s charge.
No deductible
Not covered: Custodial care All charges.
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42
2003 SSEHA Health Benefit Plan 41 Section 5( c)
Hospice care You pay
Hospice is a coordinated program of maintenance and
supportive care for the terminally ill provided by a medically
supervised team under the direction of a Plan-approved
independent hospice administration.
We cover :
services provided to terminally ill patients with a life expectancy of 6 months or less for whom no further
curative therapy is indicated;
condition management services provided at home or as an inpatient;
palliative care delivered by a team of hospice professionals and volunteers with family members participating as active
members of that team;
inpatient hospice care when the patient requires 24-hour-a-day care or when the proper care cannot be provided in the
home; and
up to 180 days per lifetime, 60 of which can be used for inpatient hospital care.
Note: If a patient requires hospice care benefits beyond the 6
months life expectancy period and has exhausted 180 hospice
benefit days 45 reserve days are available.
Par hospital: Nothing No
deductible
Non-Par hospital: Any difference
between the plan allowance and the
provider s charge. No deductible
Not covered: Independent nursing, homemaker All charges.
Ambulance
Local professional ambulance service when medically appropriate 20% of the Plan Allowance
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43
2003 SSEHA Health Benefit Plan 43 Section 5( d)
Section 5 ( d) . Emergency services/ accidents
I M
P O
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A N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.
The calendar year deductible is: $ 200 per person ( $ 400 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.
I M
P O
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A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could
result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not
treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because
they are potentially life threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There
are many other acute conditions that we may determine are medical emergencies, what they all have in common is the need for quick
action.
What is an accidental injury?
An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as
broken bones, animal bites, and poisonings. We do cover dental care for accidental injury .
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 receive care for your accidental injury within 72 hours, for the initial
care we cover:
Non-surgical physician services and supplies
Related outpatient hospital services
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.
Par hospital: Nothing No deductible
Non-Par hospital: Any difference between
the plan allowance and the provider s
charge. No deductible
Accidental injury -continued on next page
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44
2003 SSEHA Health Benefit Plan 43 Section 5( d)
Accidental injury ( continued ) You pay
If you receive care for your accidental injury after 72 hours, we cover:
Non-surgical physician services and supplies
Surgical care
Note: We pay Hospital benefits if you are admitted.
Par hospital: Nothing No
deductible
Non-Par hospital: 20% of Plan
allowance and any difference
between our allowance and the billed
amount No deductible
Medical emergency
If you receive care for your medical emergency within 72 hours,
for the initial care we cover:
Non surgical physician services and supplies
Related outpatient hospital services
Par hospital: Nothing No
deductible
Non-Par Hospital: Any difference
between the plan allowance and the
provider s charge. No deductible
If you receive care for you medical emergency after 72 hours,
we cover
Non surgical physician services and supplies
Surgical care
Note: We pay Hospital benefits if you are admitted
Outpatient medical or surgical services and supplies
Par hospital: 20% of the Plan
allowance.
Non-Par hospital: Any difference
between the plan allowance and the
provider s charge.
Ambulance
Professional ambulance service
Note: See 5( c) for non-emergency service.
After $ 200 deductible, 20% of the
Plan Allowance
Not covered: air ambulance All charges
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45
2003 SSEHA Benefit Plan 44 Section 5( e)
Section 5 ( e) . Mental health and substance abuse benefits
I M
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A N
T
You may choose to get care Out-of-Network or In-Network. When you receive In-Network care, you
must get our approval for 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:
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 or, for facility care, the inpatient deductible apply to almost all benefits in this Section. We say ( no deductible) to show when a deductible does not apply to
Description header.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits descriptions below.
In-Network mental health and substance abuse benefits are below, then Out-of-Network benefits begin on page 46
I M
P O
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A N
T
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 we approve. The treatment plan may include services,
drugs and supplies 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 a part of the treatment plan that we
approve.
Your cost sharing responsibilities are no
greater than for other illness or conditions.
In-Network benefits -continued on next page
44.
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46
2003 SSEHA Health Benefit Plan 45 Section 5( e)
In-Network benefits ( continued) You pay
Professional services, including individual or group therapy by providers such as psychiatrists, psychologists,
or clinical social workers
Medication management
Inpatient Visits: Par doctor -20% of the
Plan allowance .
Inpatient Visits: Non-Par-any difference
between the plan allowance and the
provider s charge.
Outpatient Visits: Par doctor-20% of the
Plan allowance.
Outpatient Visits: Non-Par doctor-After $ 200
deductible, any difference between the plan
allowance and the provider s charge.
Diagnostic Tests Par doctor: 20% of the Plan allowance
Non-Par doctor: any difference
between the plan allowance and the
provider s charge.
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial hospitalization, half-way house, residential
treatment, full day hospitalization, facility based intensive
outpatient treatment
Par doctor: 20% of the Plan allowance
Non-Par doctor: any difference
between the plan allowance and the
provider s charge.
Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment
plans on the treatment plan s clinical appropriateness. OPM
will generally not order us to pay or provide one clinically
appropriate treatment plan in favor of another .
All charges.
Preauthorization To be eligible to receive these enhanced mental health and substance abuse benefits you must obtain a treatment plan and
follow all of the following network authorization processes:
You, your representative, your doctor, or your hospital must call
CareFirst BlueCross Blue Shield for medical admissions, at least two
days prior to admission. The toll free number is 866-PREAUTH.
For mental health and substance abuse admissions call Magellan at
1-800-245-7013.
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47
2003 SSEHA Health Benefit Plan 46 Section 5( e)
Out-of Network benefits You pay
Professional services to treat mental conditions and substance abuse After $ 200 mental conditions/ substance
abuse calendar year deductible, any
difference between the plan allowance
and the provider s charge.
Inpatient care to treat mental conditions includes ward or semiprivate
accommodations and other hospital charges After a $ 200 deductible per admission to a non-Par hospital, any difference
between the plan allowance and the
provider s charge.
Inpatient care to treat substance abuse includes room and board and
ancillary charges for confinements in a treatment facility for
rehabilitative treatment of alcoholism or substance abuse
After $ 200 inpatient substance abuse
calendar year deductible, any difference
between the plan allowance and the
provider s charge.
Not covered out-of-network;
Services by pastoral, marital, drug/ alcohol and other counselors
Treatment for learning disabilities and mental retardation
Services rendered or billed by schools, residential treatment
centers or halfway houses or members of their staff
All charges
Lifetime Maximum Out-of-network inpatient care for the treatment of alcoholism and drug abuse is limited to one treatment program
( 28-day maximum) per lifetime.
Precertification The medical necessity of your admission to a hospital or
covered facility must be precertified for you to receive these
Out-of-Network benefits. Emergency admissions must be
reported within two business days following the days of
admission even if you have been discharges. Otherwise the
benefits payable will be reduced by $ 500. See Section 3 for
details. Call Magellan for precertification at 1-800-245-7013.
See these sections of the brochure for more valuable information about these benefits:
Section 3, How you get care, for information about catastrophic protection for these benefits.
Section 7, Filing a claim for covered services, for more information about submitting out-of-network claims.
46.
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48
2003 SSEHA Health Benefit Plan 48 Section 5( f)
Section 5 ( f) . Prescription drug benefits
I
M
P
O
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T
A
N
T
Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works, with special sections for members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage, including
with Medicare.
Calendar year deductible does not apply.
I
M
P
O
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T
A
N
T
There are important features you should be aware of. These include:
Who can write your prescription . A licensed physician must write the prescription.
Where you can obtain them . You may fill the prescription at a pharmacy that participates with Advance Paradigm, Inc, a non-network pharmacy, or by mail. We pay a higher level of benefits
when you use a network pharmacy.
These are the dispensing limitations:
Simply present your identification card together with the prescription to the pharmacist. Under the Prescription Drug Card Program, you may only obtain a 30-day supply and one
refill. For the initial 30-day supply and the one refill, you pay $ 20 for brand name and $ 10 for
generic drugs. You may fill your prescription at a participating pharmacy. You may obtain
the names of participating pharmacies by calling AdvancePCS Member Services at 1-800-
241-3371.
Through the AdvancePCS Mail Order Service you may receive up to a 90-day supply of maintenance medications for drugs which require a prescription, diabetic supplies, and insulin
( including syringes) and oral contraceptives. You may receive refills of the original prescription
for up to one year. You must pay a copayment of $ 40 for brand name drugs and $ 20 for generic
drugs
We will send you information on the Mail Order Program. To use the Program:
1) Complete the Mail Order Form. Complete the information on the back of the pre-addressed
envelope.
2) Enclose your prescription and your $ 20 or $ 40 copayment.
3) Mail your order in the pre-addressed envelope to AdvancePCS, P. O. Box 830070, Birmingham,
AL 35283-0070.
4) Allow approximately two weeks for delivery.
You will receive forms for refills and future prescription orders each time you receive drugs or
supplies under this Program. In the meantime, if you have any questions about a particular drug or a
prescription, and to request your first order forms, you may call toll free: 1-800-241-3371 form 8 a. m.
to 11 p. m. Monday through Friday, 8 a. m. to 7 p. m. on Saturday, and 8 a. m. to 5: 30 p. m. on Sunday,
EST. Emergency consultation is available seven days a week, 24 hours per day.
47.
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49
2003 SSEHA Health Benefit Plan 48 Section 5( f)
Prescription drugs ( Continued)
A generic equivalent will be dispensed if it is available, unless our physician specifically requires a name brand. If you receive a name brand drug when a Federally approved generic drug is
available, and your physician has not specified Dispense as Written for the name brand drug, ,
you have to pay the difference in cost between the name brand drug and the generic.
Why use generic drugs? A generic drug is a prescription drug that by law must have the same chemical composition as a specific brand-name prescription drug. Generic medications that are
recommended for use by CareFirst members have been thoroughly evaluated and certified by the
FCA as bioequivalent to their brand-name counterparts. Using generics saves you money, yet
provides the same quality.
When you have to file a prescription drug claim . Use a claim form to claim benefits for
prescription drugs and supplies you purchased ( without your AdvanceRx drug card) . You may
obtain these forms by calling 1-800-241-3371. Follow instructions on the form and mail it to the
address referenced on this page.
If a participating pharmacy is not available where you reside or you do not use your identification
Card, you must submit your claim to:
AdvancePCS
P. O. Box 830070
Birmingham Al 35283-0070
Your claim will be reimbursed subject to the copayment level shown above and based on SSEHA s
cost for the drug had a participating pharmacy been used.
Claims must be filed within 12 months of the date of service.
Note: If you are enrolled in a Medicare Part B, the Plan will waive the $ 20 or $ 40 copayment ONLY
through the Mail Order Program. Notify your personnel office when you become medicare
eligible in order to receive this benefit.
48.
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Page 49
50
2003 SSEHA Health Benefit Plan 50 Section 5( f)
Benefit Description You pay
Covered medications and supplies
Each new enrollee will receive a description of our prescription drug
program, a combined prescription drug/ Plan identification card, a mail
order form/ patient profile and a preaddressed reply envelope.
You may purchase the following medications and supplies
prescribed by a physician from either a pharmacy or by mail:
Drugs for which a prescription is required by Federal law
Oral contraception drugs; diaphragms
Insulin and the following injectables; Heparin, Glucagon, Initrex, EpiPen and Anakit
Smoking deterrents, limited to one series per member per lifetime.
Diabetic supplies, including insulin syringes, needles, glucose test strips, lancets and alcohol swabs
Implantable drugs ( such as Norplant) , some injectable drugs ( such as Depo Provera) , and IUDs are covered under Section
( 5a-Family planning)
Drugs to treat sexual dysfunctions are limited to drugs for male impotence ( i. e. , Viagra) limited to 6 pills per 30 days
Allergy serum and intravenous fluids and medication for home use under Section ( 5a-Allergy care)
Drugs and medicines ( including those administered during a non-covered admission or in a non-covered facility) that
by Federal law of the United States require a physician s
prescription for their purchase, those listed as not
covered
Needles and syringes for the administration of covered medications
Network Retail: $ 10 generic/ $ 20 brand name
Network Retail Medicare: $ 10generic/ $ 20 brand
Non-Network Retail: Copayment Average wholesale price
Non-Network Retail Medicare: 40% of cost
Network Mail Order: $ 20 generic/ $ 40brand
Network Mail Order Medicare: Copay is waived Copayment
Average wholesale price
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay.
Covered medications and supplies -continued on next page
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Page 50
51
2003 SSEHA Health Benefit Plan 50 Section 5( f)
Covered medications and supplies ( c ontinued ) You pay
Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them ( except
injectable B12 for treatment of pernicious anemia)
Nonprescription medicines
Drugs available without a prescription
Drugs to aid in smoking cessation except those limited to $ 100 lifetime maximum as a part of the smoking
cessation benefit ( see page 31) .
All Charges
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52
2003 SSEHA Health Benefit Plan 53 Section 5( g)
Section 5 ( g) . Special features
Special features 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.
Services for deaf and
hearing impaired
TDD Telecommunications Device for the deaf
202-479-3546
51.
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53
2003 SSEHA Health Benefit Plan 53 Section 5( g)
Section 5 ( g) . Special features
BlueCard Program
BlueCard Program. The independent Blue Cross and Blue Shield
licensees throughout the country are working together in a new
cooperative arrangement called the BlueCard Program. Under this
program, if the Member receives services outside the CareFirst
service area from a health care provider that participates with
another Blue Cross and/ or Blue Shield licensee ( Host Plan ) , the
Member is responsible only for the Coinsurance, Copayment,
and/ or Deductible. The calculation of the Member' s liability for
covered services for claims incurred will be processed through the
BlueCard Program. The Member' s Coinsurance, Copayment,
and/ or Deductible payments will be based on the lower of the
provider' s billed charges or the negotiated rate that CareFirst pays
the Host Plan.
The negotiated rate paid by CareFirst to the Host plan for health
care services provided through the BlueCard Program will represent
one of the following:
the actual price paid on the claim; or an estimated price that reflects adjusted aggregate
payments expected to result from settlements or other
non-claims transactions with all of the host plan' s health
care providers OR one or more particular providers; or
a discount from billed charges representing the Host plan' s expected average savings for all of its providers or
for a specified group of providers.
Host Plans using either the estimated price or average savings
factor may prospectively adjust the estimated or average price to
correct for overestimated or underestimated past prices.
In addition, in a small number of states, statutes require Blue
Cross and/ or Blue Shield Plans to use a basis for calculating the
Member' s liability for covered services that does not reflect the
entire savings realized or expected to be realized on a particular
claim. Therefore, when this payment method results in a conflict
of statutes or regulations between two states, CareFirst is
obligated to comply with the statutes of the jurisdiction in which
this Agreement was issued.
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2003 SSEHA Health Benefit Plan 53 Section 5( g)
Special features ( c ontinued) Description
Travel benefit/ services
overseas
BlueCard Worldwide enables Blue Cross and Blue Shield Plan
members to traveling or living abroad to receive impatient,
outpatient and professional services from healthcare providers
worldwide.
Provider Referral
If a member is traveling or living outside the United States and requires medical attention, the member calls the
BlueCard Access line at 800-810-BLUE ( 2583) . A medical
assistance coordinator, in conjuction with a nurse, will
facilitate the hospitalization.
The member presents his or her Blue Cross Blue Shield Plan ID card to the provider. The provider will verify the
member s eligibility and coverage by calling the BlueCard
Worldwide Service Center. ( For hospital services only) .
In emergency cases, members should go directly to the nearest hospital.
Claims Processing
Inpatient Participating Hospital Care the provider files the claim. The member is not required to pay up front and is
only responsible for deductibles, coinsurance and non-
covered services.
Outpatient Hospital or Professional Care The member pays the provider, and completes and sends an international claim
form to the BlueCard Worldwide Service Center.
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2003 SSEHA Health Benefit Plan 54 Section 5( h)
Section 5 ( h) . Dental benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine
they are medically necessary.
There is no calendar year deductible for dental services
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.
Note: We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to
safeguard the health of the patient. We do not cover the dental procedure.
See Section 5 ( c) for inpatient hospital benefits.
I
M
P
O
R
T
A
N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to
promptly repair ( but not replace) sound natural teeth. The
need for these services must result from an accidental injury.
Par doctor: After $ 200 deductible, 20%
of the Plan allowance
Non-Par doctor: After $ 200
deductible, any difference between
the plan allowance and the
provider s charge
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2003 SSEHA Health Benefit Plan 55 Section 5( h)
Dental benefits
Service We pay ( scheduled allowance) You pay
Routine cleaning including scaling and
polishing
Two oral examinations per
person, per calendar
year
Two topical flouride applications per
calendar year
( children up to the
age of 16)
Regular x-rays
Palliative emergency services
Space maintainers ( for deciduous teeth
only)
Pulp vitality tests
Consultation by a dental consultant
Panoramic X-rays ( 1 every 3 years)
100% up to $ 1000 per person, per calendar
year
Par doctor: Any
balances in excess of
the $ 1000 per person
maximum per calendar
year.
Non-par: Any balances
in excess of the $ 1000
per person maximum
per calendar year and
difference up to the
provider s charges.
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2003 SSEHA Health Benefit Plan 56 Section 5( i)
Section 5 ( i) . Non-FEHB benefits available to Plan members
My CareFirst. com is a health resource guide for members. CareFirst BlueCross BlueShield makes this Web site
available for the sole purposes of providing education health related issues and providing access to health-related
resources for care that patients receive from their physician. This Web site s health related resources are not intended
to be a substitute for professional medical advice. Please review the Terms of Use before using this Web site. Using
this Web site indicates your agreement to be bound by the Terms of Use. This Web site includes the following types
of information.
Customized Personal Health Assessments Disease and conditions information
Health News Fitness Information
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2003 SSEHA Health Benefit Plan 57 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.
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 to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
Services, drugs, or supplies you receive without charge while in active military service;
Services and supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption;
Services and supplies furnished or billed by a non-covered facility, except that medically necessary prescription drugs are covered;
Services and supplies not specifically listed as covered;
Any portion of a provider s fee or charge that is ordinarily due from the enrollee but has been waived. If a provider routinely waives ( does not require the enrollee to pay) a deductible or coinsurance, the Carrier will
calculate the actual provider fee or charge by reducing the fee or charge by the amount waived;
Charges the enrollee or Plan has no legal obligation to pay, such as; excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/ or B ( see page19) , doctor charges exceeding the amount
specified by the Department of Health and Human Services when benefits are payable under Medicare ( limiting
charge; see page 20) , or State premium taxes however applied;
Rest, institutional, or rehabilitation care not specifically stated as covered;
Treatment of obesity; weight reduction, except surgery for morbid obesity;
Biofeedback;
Charges for stand-by services;
Any portion of a charge which is determined by the Carrier to be in excess of the carrier allowance;
Charges for completion of claim forms or similar charges;
Charges for services rendered to a patient after the date of death; or
Travel, even if prescribed by a doctor.
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Page 58
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2003 SSEHA Health Benefit Plan 59 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 800-424-7474 ext. 6039or 202-479-6039, or
at our website at www. CareFirst. com.
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 1-800-424-7474 or 202-479-6039.
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. 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 Service Prescription Drug Program must include
receipts that include the prescription number, name of drug or
supply, prescribing physician s name, date, and charge.
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2003 SSEHA Health Benefit Plan 59 Section 7
We will not provide translation and currency conversion for claims overseas ( foreign) services.
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 by December 31 of the year after the year you
received the service, unless timely filing was prevented by
administrative operations of Government or legal incapacity, provided
the claim was submitted as soon as reasonably possible. Once we pay
benefits, there is a three-year limitation on the reissuance of uncashed
checks.
Overseas Claims For covered services you receive in hospitals outside the US and Puerto Rico and performed by physicians outside the United States send a
completed claim form and the itemized bill 550 12 th Street, SW,
Washington, DC 20065. Obtain Overseas Claim forms and send any
written inquiries concerning the processing of overseas claims to this
address.
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 60
61
2003 SSEHA Health Benefit Plan 61 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: Write to us within 6 months from the date of our decision; and
( a) Send your request to us at: Member Services, 550 12 th St. S. W. , Washington D. C. 20065 and
( b) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and
( c) 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, Health Benefits
Contracts Division II, 1900 E Street, NW, 20415-3630.
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2003 SSEHA Health Benefit Plan 61 Section 8
The Disputed Claims process ( C ontinued)
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.
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
866-PREAUTH 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 II at 202/ 606-3818 between 8 a. m. and 5 p. m. eastern time.
61.
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Page 62
63
2003 SSEHA Health Benefit Plan 63 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays
health care expenses without regard to fault. This is called double
coverage.
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as
the secondary payer. We, like other insurers, determine which
coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in
this brochure.
When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance,
up to our regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for: People 65 years of age and older
Some people with disabilities, under 65 years of age
People with End-Stage Renal Disease ( permanent kidney failure requiring dialysis or a transplant)
Medicare has two parts:
Part A ( Hospital Insurance) . Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in
Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. ( Someone who was a Federal
employee on January 1, 1983 or since automatically qualifies. )
Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for information.
Part B ( Medical Insurance) . Most 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 healthcare. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare + Choice Plan you
have.
The Original Medicare Plan ( Part A or Part B) The Original Medicare Plan ( Original Medicare is a Medicare+ Choice plan that is available everywhere in the United States. It is the way
everyone used to get Medicare benefits and is the way most people get
their Medicare Part A and Part B benefits now. You may go to any
doctor, specialist, or hospital that accepts Medicare. The Original
Medicare Plan pays its share and you pay your share. Some things are
not covered under Original Medicare, like prescription drugs.
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Page 63
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2003 SSEHA Health Benefit Plan 63 Section 9
When you are enrolled in Original Medicare along with this plan, you
still need to follow the rules in this brochure for us to cover your care.
Your care must continue to be pre-certified by the Plan.
Claims process when you have Original Medicare Plan--You
probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated
automatically and we will 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 800-424-7474
extension 6039 toll free outside the Washington, DC area; or 202-
479-6039. ( You may also contact us at our web site at
http: / / www. carefirst. com. )
We waive some costs when you have the Original Medicare
Plan--When Original Medicare is the primary payer, we will waive
some out-of pocket costs, as follows:
Medical services and supplies provided by physician and other healthcare professionals.
If you are enrolled in Medicare Part B, we will waive the $ 20 or $ 40 Mail order Copayment.
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2003 SSEHA Health Benefit Plan 67 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 anactive employee with theFederalgovernment( including whenyou or
afamily member areeligiblefor Medicaresolely because of adisability) , .
2) Are an annuitant, .
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or .
b) The position is not excluded from FEHB
( Ask your employing office which of these applies to you. )
.
4) Are a Federal judge who retired under title 28, U. S. C. , or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. ( or if
your covered spouse is this type of judge) , .
5) Are enrolled in Part B only, regardless of your employment status, . ( for Part B
services)
.
( for other
services)
6) Are a former Federal employee receiving Workers Compensation
and the Office of Workers Compensation Programs has determined
that you are unable to return to duty,
.
( except for claims
related to Workers
Compensation. )
B. When you --or a covered family member --have Medicare
based on end stage renal disease ( ESRD) and
1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, .
2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, .
3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, .
C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, .
b) Are an active employee, .
c) Are a former spouse of an annuitant .
d) Are a former spouse of an active employee .
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2003 SSEHA Health Benefit Plan 67 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 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 only do so 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 Part A or Part B If you do not have one or both Parts of Medicare, you can still be covered under the FEHB Program. We will not require you to enroll in
Medicare Part B and, if you can t get premium-free Part A, we will not
ask you to enroll in it.
TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the
CHAMPUS program. CHAMPVA provides health coverage to
disabled Veterans and their dependents. If TRICARE or CHAMPVA
and this Plan cover you, we pay first. See your TRICARE or
CHAMPVA Health Benefits Advisor if you have questions about these
programs.
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2003 SSEHA Health Benefit Plan 67 Section 9
Suspended FEHB coverage to enroll in TRICARE of CHAMPVA:
If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a 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 SSEHA Health Benefit Plan 67 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: I f 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 FEB 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,
are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for
for injuries medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will
cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures.
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2003 SSEHA Health Benefit Plan 70 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and
ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. See
page 16.
Copayment A copayment is a fixed amount of money you pay to the pharmacy when you receive covered services. See page 16.
Covered services Services we provide benefits for, as described in this brochure.
Custodial care Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a
person not medically skilled, or that are designed mainly to help the
patient with daily living activities. Custodial care that lasts 90 days or
more is sometimes known as Long Term Care . These activities
include but are not limited to:
1) Personal care such as help in: walking; getting in and out of bed;
bathing; eating by spoon, tube or gastrostomy; exercising;
dressing;
2) homemaking, such as preparing meals or special diets;
3) moving the patient;
4) acting as companion or sitter;
5) supervising medication that can usually be self administered; or
6) treatment or services that any person may be able to perform with
minimal instruction, including but not limited to recording
temperature, pulse, and respirations, or administration and
monitoring of feeding systems.
The Carrier determines which services are 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 16.
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2003 SSEHA Health Benefit Plan 70 Section 10
Experimental or investigational A medical treatment or procedure, or a drug, device or biological
services product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing 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 2) 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
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, or medical treatment or procedure. If you desire additional
information concerning the experimental/ investigational determination
process, please contact the Plan
Group health coverage Health care coverage that a member is eligible for because of employment, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies, including extension of any of
these benefits through COBRA. Group health coverage also includes
coverage that pays a specific amount for each day or period of
hospitalization if the specified amount exceeds $ 100 per day. The
Carrier will coordinate benefits against the amount that exceeds $ 100
per day.
Medical necessity Services, supplies or equipment provided by a hospital or covered provider of the health care services that the Carrier determines:
1) are appropriate to diagnose or treat the patient s condition, illness,
or injury;
2) are consistent with standards of good medical practice in the
United States;
3) are not primarily for the personal comfort or convenience of the
patient, the family, or the provider;
4) are not a part of or associated with the scholastic education or
vocational training of the patient; and
5) in case of inpatient care, cannot be provided safely on an outpatient
basis.
The fact that a covered provider has prescribed, recommended, or
approved a service, supply or equipment does not, in itself, make it
medically necessary.
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2003 SSEHA Health Benefit Plan 70 Section 10
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:
For claims in the Washington D. C. area, Resource Based Relative
Value Scale ( RBRVS) is the methodology we use for paying physicians
based on a schedule of relative procedure values which reflect the
resource costs and effort used to perform each procedure.
Us/ We Us and we refer to SSEHA
You You refers to the enrollee and each covered family member.
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Page 71
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2003 SSEHA Health Benefit Plan 74 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office
about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage.
These materials tell you:
When you may change your enrollment;
How you can cover your family members;
What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;
When your enrollment ends; and
When the next open season for enrollment begins.
We don t determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.
If you have a Self Only enrollment, you may change to a Self and
Family enrollment if you marry, give birth, or add a child to your
family. You may change your enrollment 31 days before to 60 days
after that event. The Self and Family enrollment begins on the first day
of the pay period in which the child is born or becomes an eligible
family member. When you change to Self and Family because you
marry, the change is effective on the first day of the pay period that
begins after your employing office receives your enrollment form;
benefits will not be available to your spouse until you marry.
Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, or when your
child under age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that person may not be enrolled in or covered as a family member by
another FEHB plan.
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2003 SSEHA Health Benefit Plan 74 Section 11
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) .
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 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 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.
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74
2003 SSEHA Health Benefit Plan 74 Section 11
When benefits and The benefits in this brochure are effective January 1. If you joined this Plan
premiums start during Open Season , your coverage begins on the first day of your pay period that starts on or after January 1. Annuitants coverage and premiums begin on
January 1. If you joined at any other time of 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. This is
the case even when the court has ordered your former spouse to supply
health coverage to you. But, you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation of
Coverage ( TCC) . 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. You can also
download the guide from OPM s website, www. opm. gov/ insure.
Temporary Continuation If you leave Federal service, or if you lose coverage because you no of Coverage ( TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage ( TCC) . For example, you can receive TCC
if you are not able to continue your FEHB enrollment after you retire, if
you loose your Federal job, if you are a covered dependent child and
you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to
gross misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI
70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees ,
from your employing or retirement office or from
www. opm. gov/ insure. It explains what you have to do to enroll.
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2003 SSEHA Health Benefit Plan 74 Section 11
Converting to You may convert to a non-FEHB individual policy if: individual coverage
Your coverage under TCC or the spouse equity law ends ( If you canceled your coverage or did not pay your premium, you cannot
convert) ;
You decided not to receive coverage under TCC or the spouse equity law; or
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member
who is losing coverage, the employing or retirement office will not
notify you. You must apply in writing to us within 31 days after you
are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB
Program; however, you will not have to answer questions about your
health, and we will not impose a waiting period or limit your coverage
due to pre-existing conditions.
Getting a Certificate of Group Health Plan Coverage The Health Insurance Portability and Accountability Act of 1996 ( HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose
employer group coverage. If you leave the FEHB Program, we will give you
a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance
or other health care coverage23. Your new plan must reduce or eliminate waiting
periods, limitations, or exclusions for health related conditions based on the
information in the certificate, as long as you enroll within 63 days of losing
coverage under this Plan. If you have been enrolled with us for less than
12 months, but were previously enrolled in other FEHB plans, you may
also request a certificate from those plans.
For more information get OPM pamphlet RI 72-27, Temporary Continuation of
Coverage ( TCC) under the FEHB Program. See also the FEHB web site
( www. opm. gov/ insure/ health) ; refer to the TCC and HIPAA frequently
asked questions. These highlight HIPAA rules, such as the requirement that
Federal employees must exhaust any TCC eligibility as one condition for
guaranteed access to individual health coverage under HIPAA, have information
about Federal and State agencies you contact for more information.
74.
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76
2003 SSEHA Health Benefit Plan 75 Long Term Care Insurance
Long Term Care Insurance Is Still Available!
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 Also 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 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.
75.
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Page 76
77
2003 SSEHA Health Benefit Plan 76 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
A ccidental injury 42-43 Allergy tests 26
Alternative treatment 31 Ambulance 41,43
Anesthesia 37 Autologous bone marrow
transplant 36
B iopsies 32 Blood and blood plasma 39
Breast cancer screening 23 Casts 39
Catastrophic protection 17 Changes for 2002 10
Chemotherapy 27 Childbirth 25
Cholesterol tests 23 Circumcision 25
Claims 58 Coinsurance 16
Colorectal cancer screening 23 Congenital anomalies 33
Contraceptive devices and drugs 25, 33, 49
Coordination of benefits 62 Covered charges 68
Covered providers 11
Crutches 30
D eductible 16 Definitions 68
Dental care 54-55 Diagnostic services 22
Disputed claims review 60-61 Donor expenses ( transplants) 36
Dressings 39 Durable medical equipment 30
E ducational classes and programs 31 Effective date of enrollment 7
Emergency 42 Experimental or investigational 69
Eyeglasses 28 F amily planning 25
Fecal occult blood test 23 Flexible benefits option 51
Foot care 29 Freestanding ambulatory
facilities 11, 37 G eneral Exclusions 57
H earing services 28 Home health services 30-31
Hospice care 41 Home nursing care 30-31
Hospital 38-39 I mmunizations 24
Infertility 26 Inhospital physician care 22
Inpatient Hospital Benefits 38-39
Insulin 49 L aboratory and pathological
services 23
L ong Term Care Insurance 75
M achine diagnostic tests 23 Magnetic Resonance Imagings
( MRIs) 23 Mail Order Prescription Drugs 47
Mammograms 23 Maternity Benefits 25
Medicaid 67 Medically necessary 13-15, 69
Medically underserved areas 11 ( ( FFS only) )
Medicare 20 Members 71
Mental Conditions/ Substance Abuse Benefits 44-46
N eurological testing 45 Newborn care 25
Non-FEHB Benefits 56 Nurse
Licensed Practical Nurse 11 Nurse Anesthetist 11
Nurse Midwife 11 Nurse Practitioner 11
Psychiatric Nurse 11 Registered Nurse 11
Nursery charges 25
O bstetrical care 25 Occupational therapy 27-28
Ocular injury 28 Oral and maxillofacial surgery 35
Orthopedic devices 29 Ostomy and catheter supplies 29
Out-of-pocket expenses 17 Outpatient facility care 39
Overseas claims 59 Oxygen 30, 39
P ap test 23 Physical examination 22
Physical therapy 27-28 Physician 11
Pre-admission testing 39 Precertification 14-15, 45
Prescription drugs 47-50 Preventive care, adult 23-24
Preventive care, children 24 Prior approval 13-14
Prostate cancer screening 23 Prosthetic devices 29
Psychologist 11
Psychotherapy 44-46
R adiation therapy 27 Rehabilitative therapies 27-28
Renal dialysis 36 Room and board 38
S econd surgical opinion 22 Skilled nursing facility care 40
Smoking cessation 31 Social Worker 11
Speech therapy 28 Splints 39
Sterilization procedures 25-26 Subrogation 67
Substance abuse 44-46 Surgery 32-36
Anesthesia 37 Oral 35
Outpatient 39 Reconstructive 32
Syringes 49
T emporary continuation of coverage 73-74
Transplants 36 Treatment therapies 27
V ision services 28-29 W ell child care 24
Wheelchairs 30 Workers compensation 67
X -rays 23
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2003 SSEHA Health Benefit Plan 78 Notes
Notes
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79
2003 SSEHA Health Benefit Plan 78 Notes
Notes
78.
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Page 79
80
2003 SSEHA Health Benefit Plan 79 Summary
Summary of benefits for the U. S. Secret Service Employees Health
Association -2002
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 $ 200 calendar year deductible. And, after we pay, you
generally pay any difference between our allowance and the billed amount if you use a Non-Par physician or
other health care professional.
Benefits You Pay Page
* Medical services provided by physicians:
Diagnostic and treatment services provided in the office. . . . . . . . . . . . . . . . . . . .
Par doctor: 20% of the Plan
allowance
Non-Par doctor: 20% of Plan
allowance and any difference up
to the billed amount.
22
Services provided by a hospital:
Inpatient. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Outpatient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Par hospital: $ 100 per admission
deductible.
Non-Par hospital: 20% of the
Plan allowance and any
difference between our
allowance, the $ 100 per
admission deductible and the
billed amount.
Par hospital: Nothing
Non-Par hospital: 20% of the
Plan allowance and any
difference between our allowance
and the billed amount.
38
Emergency benefits:
Accidental injury. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Medical emergency. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Par hospital: Nothing
Non-Par hospital: Any difference
between our allowance and the
billed amount
42
* Mental health and substance abuse treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regular benefits 44
Prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ 10 generic/ $ 20 brand name 47
Special features: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nothing 54
Protection against catastrophic costs
( your out-of-pocket maximum) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nothing after ( example-$ 1,000
Self Only or $ 2,000/ Family
enrollment per year)
Some costs do not count toward
this protection
17
79.
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Page 80
2002 Rate Information for
U. S. Secret Service Employees Health Association
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 a
special FEHB guide is published 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
Enrollment Code
Gov t
Share
Your
Share
Gov t
Share
Your
Share
USPS
Share
Your
Share
Self Only Y71 $ 109.30 $ 37.15 $ 236.82 $ 80.49 $ 129.03 $ 17.42
Self and Family Y72 $ 249.62 $ 97.46 $ 540.84 $ 211.17 294.70 $ 52.38
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