Preferred Plus of Kansas http:// www. phsystems. com
2001 A
Health Maintenance Organization
Serving: Marion, Harvey, Kingman, Sedgwick, Butler, Sumner, Cowley,
and Chautauqua Counties, in Kansas
Enrollment in this Plan is
limited; see page 6 for requirements.
Enrollment codes for this Plan:
VA1 Self Only VA2 Self and Family
RI 73-604 1
1 Page
2 3
2001 Preferred Plus of Kansas Table
of Contents 2
Table of Contents
Introduction…………………………………………………………………........................................................................
4
Plain
Language……………………………………………………………….......................................................................
4
Section 1. Facts about this HMO
plan.........................................................................................................................................
5
How we pay
providers.................................................................................................................................................
5
Who provides my health
care?...................................................................................................................................
5
Patients' Bill of
Rights.................................................................................................................................................
5
Service Area
..................................................................................................................................................................
6
Section 2. How we change for
2001……………………………………….........................................................................
6
Program-wide
changes................................................................................................................................................
6
Changes to this
Plan.....................................................................................................................................................
6
Section 3. How you get care
………….......................................................................................................................................
7
Identification cards
......................................................................................................................................................
7
Where you get covered care
.......................................................................................................................................
7
· Plan providers
........................................................................................................................................................
7
· Plan
facilities..........................................................................................................................................................
7
What you must do to get covered care
.....................................................................................................................
7
· Primary care
...........................................................................................................................................................
7
· Specialty care
.........................................................................................................................................................
7
· Hospital
care...........................................................................................................................................................
8
Circumstances beyond our
control............................................................................................................................
8
Services requiring our prior
approval.......................................................................................................................
9
Section 4. Your costs for covered
services.................................................................................................................................
9
· Copayments
...........................................................................................................................................................
9
· Coinsurance
...........................................................................................................................................................
9
Your out-of-pocket
maximum....................................................................................................................................
9
Section 5.
Benefits………………………………………………………….......................................................................
10
Overview......................................................................................................................................................................
10
(a) Medical services and supplies provided by physicians and other health
care professionals ............ 11
(b) Surgical and anesthesia services
provided by physicians and other health care professionals ........ 19
(c)
Services provided by a hospital or other facility, and ambulance services
.......................................... 23
(d) Emergency services/
accidents
.....................................................................................................................
25
(e) Mental health and substance abuse
benefits..............................................................................................
27
(f) Prescription drug benefits
.............................................................................................................................
29
(g) Dental benefits
................................................................................................................................................
32
Section 6. General exclusions --things we don't
cover..........................................................................................................
33
Section 7. Filing a claim for covered services
.........................................................................................................................
34
Section 8. The disputed claims process
....................................................................................................................................
35 2
2 Page 3 4
2001 Preferred Plus of Kansas Table of Contents 3
Section 9. Coordinating benefits with other coverage
........................................................................................................
37
When you have…
·Other health coverage
......................................................................................................................................
37
·Original Medicare
.............................................................................................................................................
37
·Medicare managed care
plan...........................................................................................................................
39
TRICARE/ Workers' Compensation/ Medicaid
..................................................................................................
40
Other Government
agencies..................................................................................................................................
40
When others are responsible for injuries
............................................................................................................
40
Section 10. Definitions of terms we use in this brochure
...................................................................................................
41
Section 11. FEHB facts
............................................................................................................................................................
42
Coverage
information...........................................................................................................................................
42
· No pre-existing condition
limitation.........................................................................................................
42
· Where you get information about enrolling in the FEHB
Program.................................................... 42
·
Types of coverage available for you and your family
........................................................................... 42
· When benefits and premiums start
...........................................................................................................
43
· Your medical and claims records are
confidential.................................................................................
43
· When you
retire...........................................................................................................................................
43
When you lose benefits
.......................................................................................................................................
43
· When FEHB coverage
ends.......................................................................................................................
43
· Spouse equity coverage
.............................................................................................................................
43
· Temporary Continuation of Coverage
(TCC)........................................................................................
43
· Converting to individual
coverage...........................................................................................................
44
· Getting a Certificate of Group Health Plan
Coverage..........................................................................
44
Inspector General
advisory:..................................................................................................................................
44
Index
................................................................................................................................................................................
45
Summary of benefits
..................................................................................................................................................................
47
Rates…………………………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 Preferred Plus of Kansas 4
Introduction/ Plain Language
Introduction
Preferred Plus
of Kansas 8535 E. 21 st North
Wichita, KS 67206
This brochure describes
the benefits of Preferred Plus of Kansas under our contract (CS 2667) with the
Office of
Personnel Management (OPM), as authorized by the Federal Employees
Health Benefits law. This brochure is the official statement of benefits. No
oral statement can modify or otherwise affect the benefits, limitations, and
exclusions of this brochure.
If you are enrolled in this Plan, you are
entitled to the benefits described in this brochure. If you are enrolled for
Self and Family coverage, each eligible family member is also entitled to these
benefits. You do not have a right to
benefits that were available before
January 1, 2001, unless those benefits are also shown in this brochure.
OPM
negotiates benefits and rates with each plan annually. Benefit changes are
effective January 1, 2001, and are
summarized on page 6. Rates are shown at
the end of this brochure.
Plain Language
The President and Vice President are making the
Government's communication more responsive, accessible, and understandable to
the public by requiring agencies to use plain language. In response, a team of
health plan
representatives and OPM staff worked cooperatively to make this
brochure clearer. Except for necessary technical
terms, we use common words.
"You" means the enrollee or family member; "we" means
Preferred Plus of Kansas.
The plain language team reorganized the brochure and the way we describe our
benefits. When you compare this Plan
with other FEHB plans, you will find
that the brochures have the same format and similar information to make
comparisons easier.
If you have comments or suggestions about how to improve this brochure, let
us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure
or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436.
4
4 Page 5 6
2001 Preferred Plus of Kansas Section 1 5
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other
providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the copayments, coinsurance, and
deductibles described in this brochure. When you receive emergency services from
non-Plan
providers, you may have to submit claim forms.
You should
join an HMO because you prefer the plan's benefits, not because a particular
provider is available.
You cannot change plans because a provider leaves our
Plan. We cannot guarantee that any one physician,
hospital, or other
provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or
coinsurance.
Who provides my
health care?
Preferred Plus of Kansas is an individual practice prepayment (IPP) model
HMO. As a member of Preferred Plus of Kansas, you will select a primary care
doctor for yourself and each member of your family. Each member may
designate his or her own primary care doctor. You will be able to choose
from a list of doctors located throughout the service area. Preferred Plus of
Kansas has more than 300 primary care doctors in its Kansas service area and
more than
1,100 referral specialists.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of
Rights, recommended by the President's Advisory Commission on Consumer
Protection and Quality in the Health Care Industry. 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.
· Preferred Plus of Kansas is licensed under the laws or Kansas, as a
Health Maintenance Organization
· Preferred Plus of Kansas was
incorporated in 1991. ·
Preferred Plus of Kansas is a for-profit
company.
If you want more information about us, call (316) 609-2390 or (800) 990-0345,
or write to Preferred Health Systems,
8535 E. 21 st North, Wichita, KS
67206. You may also contact us by fax at (316) 609-2483, or visit our website at
www. phsystems. com. 5
5 Page
6 7
2001 Preferred Plus of Kansas
Section 2 6
Service Area
To enroll with us, you must live or
work in our service area. This is where our providers practice. Our service area
is
the following counties in Kansas: Marion, Harvey, Kingman, Sedgwick,
Butler, Sumner, Cowley and Chautauqa.
You may also enroll with us if you live or work in the following places:
The Kansas counties of Saline, Dickenson, Morris, McPherson, Chase, Reno,
Harper, Greenwood and Elk.
Ordinarily, you must get your care from providers who contract with us. If
you receive care outside our service area,
we will pay only for emergency
care. We will not pay for any other health care services.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents
live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you do
not have to wait until Open Season to change plans. Contact your employing or
retirement office.
Section 2. How we change for 2001
Program-wide changes
· The plain language team reorganized the brochure and the way we
describe our benefits. We hope this will make it easier for you to compare
plans.
· This year, the Federal Employees Health Benefits Program is
implementing network mental health and substance abuse parity. This means that
your coverage for mental health, substance abuse, medical, surgical, and
hospital
services from providers in our plan network will be the same with
regard to deductibles, coinsurance, copays, and
day and visit limitations
when you follow a treatment plan that we approve. Previously, we placed higher
patient cost sharing on mental health and substance abuse services than we did
on services to treat physical illness, injury,
or disease.
· Many healthcare organizations have turned their
attention this past year to improving healthcare quality and patient safety. OPM
asked all FEHB plans to join them in this effort. You can find specific
information on our patient
safety activities by calling (316) 609-2390, or checking our website
www. phsystems. com. You can find out more about patient safety on the OPM
website, www. opm. gov/ insure. To improve your healthcare, take these five
steps:
·· Speak up if you have questions or concerns.
·· Keep a list of all the medicines you take.
·· Make sure you get the results of any test or procedure.
·· Talk with your doctor and health care team about your
options if you need hospital care.
·· Make sure you understand
what will happen if you need surgery.
· We clarified the language to show that anyone who needs a mastectomy
may choose to have the procedure performed on an inpatient basis and remain in
the hospital up to 48 hours after the procedure. Previously, the
language referenced only women.
Changes to this Plan
·
Your share of the non-Postal premium will increase by 9.4% for Self Only or 6.1%
for Self and Family.
· This Plan will pay for the following limited dental services; see
Section 5 (g) Dental benefits:
··Services relating to the
trauma of sound natural teeth caused directly by an accidental injury (not from
biting or chewing), including replacement of teeth.
··We will cover the administration of general anesthetic and
the facility charges for dental care provided for special conditions. We will
determine the medical necessity for these services.
· This Plan will
cover one pair of orthopedic shoes per calendar year for diabetics. Commercial
over the counter shoe inserts or orthotic devices are not covered. 6
6 Page 7 8
2001 Preferred Plus of Kansas Section 3 7
Section 3. How you get care
Identification cards We will send you
an identification (ID) card when you enroll. You should carry your ID card with
you at all times. You must show it whenever you
receive services from a Plan
provider, or fill a prescription at a Plan
pharmacy. Until you receive your
ID card, use your copy of the Health Benefits Election Form, SF-2809, your
health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call us at (316)
609-2390.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments
and you will not have to file claims.
· · Plan providers
Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.
· ·Plan facilities Plan facilities are hospitals and
other facilities in our service area that we
contract with to provide
covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our
website.
What you must do to get care It depends on the type of care you need.
First, you and each family member must choose a primary care physician. This
decision is important since
your primary care physician provides or arranges
for most of your health care. A list of primary care providers can be reviewed
in our provider
directory for Preferred Plus of Kansas. You must complete a
physician
selection form or you may call Customer Services Department at
(316) 609-2390, or (800) 660-8114.
· ·Primary care Your primary care physician can be a
family practitioner, internist, general practitioner or pediatrician. Your
primary care physician will provide most
of your health care, or give you a
referral to see a specialist.
If you want to change primary care physicians
or if your primary care physician leaves the Plan, call us. We will help you
select a new one.
· · Specialty care Your primary care physician will
refer you to a specialist for needed care. However, you may see a contracting
OB/ Gyn for an annual well-women
exam once a year without a referral.
When services are needed for Mental Health and Substance Abuse
treatment, you will need to contact Mental Health Network at (800) 456-5641,
to coordinate your care.
Here are other things you should know about specialty care: 7
7 Page 8 9
2001 Preferred Plus of Kansas Section 3 8
· If you need to see a specialist frequently because of a chronic,
complex, or serious medical condition, your primary care physician will develop
a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals. Your primary care physician
will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).
· If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does not
participate with our Plan.
· If you are seeing a specialist and your specialist leaves the Plan,
call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.
· If you have a chronic or disabling condition and lose access to your
specialist because we:
·· terminate our contract with your specialist for other than
cause; or
·· drop out of the Federal Employees Health Benefits
(FEHB) Program and you enroll in another FEHB Plan; or
·· reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after
you receive notice of the change. Contact us or, if we drop out of
the
Program, contact your new plan.
If you are in the second or third trimester
of pregnancy and you lose access to your specialist based on the above
circumstances, you can continue to
see your specialist until the end of your
postpartum care, even if it is beyond the 90 days.
· · Hospital care Your Plan primary care physician or
specialist will make necessary hospital arrangements and supervise your care.
This includes admission to
a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our
customer service department immediately at (316) 609-2390 or (800) 660-
8114.
If you are new to the FEHB Program, we will arrange for you to receive care.
If you changed from another FEHB plan to us, your former plan will pay for
the hospital stay until:
· You are discharged, not merely moved to an
alternative care center; or
· The day your benefits from your former
plan run out; or
· The 92 nd day after you become a member of this
Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. 8
8 Page 9 10
2001 Preferred Plus of Kansas Section 4 9
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to provide them. In
that case, we will make all reasonable
efforts to provide you with the
necessary care.
Services requiring our
prior approval Your primary care physician
has authority to refer you for most services. For certain services, however,
your physician must obtain approval from
us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.
We call this review and approval process, pre-certification. Your physician
must obtain pre-certification for the following services:
·
cardiac catheterization; ·
developmental therapy;
·
durable medical equipment; ·
home IV services;
· hospice;
·
inpatient hospitalizations;
· matrix therapy; ·
OB care;
· occupational therapy, under age 12;
·
outpatient IV services; ·
out of the service area referrals;
· outpatient surgical procedures; ·
pain management
programs;
· physical therapy, under age 12; ·
prosthetics;
· request for use of non-contracting provider;
· speech
therapy, under age 12. ·
Mental conditions and substance abuse
services – Contact Mental Health Network at (800) 456-5641.
It is the responsibility of the provider to receive precertification from us
for the primary care physician authorized services. If the provider fails to
pre-certify
the services, he/ she will be held responsible for the services.
If you choose to seek any services without coordinating them with your primary
care physician, you will be responsible for the costs of the services.
Section 4. Your costs for covered services
You must share the cost
of some services. You are responsible for:
· · Copayments
A copayment is a fixed amount of money you pay when you receive services.
Example: When you see your primary care physician you pay a copayment of $10
per office visit.
· · Deductible We do not have a
deductible
· · Coinsurance We do not have coinsurance.
Your out-of-pocket maximum We do not have an out-of-pocket maximum. 9
9 Page 10 11
2001 Preferred Plus of Kansas Section 5 10
Section 5. Benefits --OVERVIEW
(See page 6 for how our
benefits changed this year and page 47 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 (316) 609-2390 or
(800) 660-8114 or at our website at www. phsystems. com.
(a) Medical services and supplies provided by physicians and other health
care professionals .............................. 11-18
·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
·Rehabilitative therapies
·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
·Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals .......................... 19-22
·Surgical
procedures
·Reconstructive surgery
·Oral and maxillofacial
surgery
·Organ/ tissue transplants ·Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services
............................................................ 23-24
·Inpatient hospital
·Outpatient hospital or ambulatory
surgical center
·Extended care benefits/ skilled nursing care
facility benefits
·Hospice care ·Ambulance
(d) Emergency services/ accidents
.......................................................................................................................................
25-26
·Medical emergency ·Ambulance
(e) Mental health and substance abuse
benefits................................................................................................................
27-28
(f) Prescription drug benefits
...............................................................................................................................................
29-31
(g) Dental benefits
........................................................................................................................................................................
32
Summary of
benefits......................................................................................................................................................................
47 10
10 Page 11
12
2001 Preferred Plus of Kansas Section 5( a)
11
Section 5 (a) Medical services and supplies provided by physicians
and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
· Plan physicians must provide or arrange your care.
· We
have no calendar year deductible.
· Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
· In physician's office
$10 per office visit
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
$10 per office visit
At home Nothing
Lab, X-ray and other diagnostic tests
Tests,
such as:
· Blood tests
· Urinalysis
·
Non-routine pap tests
· Pathology
· X-rays
·
Non-routine Mammograms
· Cat Scans/ MRI
· Ultrasound
· Electrocardiogram and EEG
Nothing if you receive these services during your office visit;
otherwise, $10 per visit. 11
11 Page 12 13
2001 Preferred
Plus of Kansas Section 5( a) 12
Preventive care, adult You Pay
Routine screenings, such as:
· Blood lead level – One
annually
· Total Blood Cholesterol – once every three years,
ages 19 through 64
· Colorectal Cancer Screening, including
··Fecal occult blood test
$10 per office visit
··Sigmoidoscopy, screening – every five years starting at
age 50 $10 per office visit
Prostate Specific Antigen (PSA test) – one
annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.
$10 per office visit
Routine mammogram –covered for women age 35 and older, as
follows:
· From age 35 through 39, one during this five year period
· From age 40 through 64, one every calendar year
· At age
65 and older, one every two consecutive calendar years
$10 per office visit
Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel. All charges
Routine Immunizations, limited to:
· Tetanus-diphtheria (Td)
booster – once every 10 years, ages19 and over (except as provided for
under Childhood immunizations)
Influenza/ Pneumococcal vaccines, annually, age 65 and over
$10 per office visit
Dietitian services for up to 4 visits per member, per calendar year when
authorized by your primary care doctor $10 per office visit
Preventive
care, children
· Childhood immunizations recommended by the
American Academy
of Pediatrics
Nothing for children up to age 72
months, otherwise $10 per office visit
· Examinations, such as:
··Eye exams through age 17
to determine the need for vision correction.
··Ear exams through age 17 to determine the need for hearing
correction
··Examinations done on the day of immunizations ( through age
22)
· Well-child care charges for routine examinations, immunizations and
care (through age 22)
$10 per office visit 12
12 Page 13 14
2001 Preferred
Plus of Kansas Section 5( a) 13
Maternity care You Pay
Complete maternity (obstetrical) care, such as:
· Prenatal
care
· Delivery
· Postnatal care
· Prospective
parents may receive authorization to select a primary care physician for their
unborn child and we will cover one visit to
that physician prior to the birth of the child
Note: Here are some things
to keep in mind:
· You do not need to precertify your normal
delivery; see page xx for
other circumstances, such as extended stays for
you or your baby.
· You may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
· We cover routine
nursery care of the newborn child during the covered portion of the mother's
maternity stay. We will cover other
care of an infant who requires non-routine treatment only if we cover the
infant under a Self and Family enrollment.
· We pay hospitalization and surgeon services (delivery) the same as
for illness and injury. See Hospital benefits (Section 5c) and Surgery
benefits (Section 5b).
Nothing
· We cover Lamaze childbirth classes from a participating hospital or
OB/ GYN up to a maximum benefit of $30. 50% of the charges up to a maximum Plan
benefit of $30. You
must submit proof of payment and
class completion to
our Member Services Department.
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning
· Voluntary sterilization
· Surgically implanted contraceptives
· Injectable
contraceptive drugs
· Intrauterine devices (IUDs)
$10 per office visit
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, or elective abortions
All charges. 13
13 Page 14 15
2001 Preferred Plus of Kansas Section 5( a) 14
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
· Artificial insemination:
··intravaginal insemination (IVI)
··intracervical insemination (ICI)
··intrauterine insemination (IUI)
·
Diagnostic services to establish the cause or reason for infertility, including:
Medical evaluation limited to sperm counts
Hysterosalpingography
Endometrial biopsy
Counseling
Surgical correction of physiological
abnormalities causing infertility
$10 per office visit
Not covered:
· Assisted reproductive technology (ART)
procedures, such as:
··in vitro fertilization
··embryo transfer and GIFT
· Services and
supplies related to excluded ART procedures
· Cost of donor sperm
· Fertility drugs and
surrogate parenting
All charges.
Allergy care You pay
Testing and treatment
· Allergy injection
Nothing
· Allergy serum Nothing
Not covered: provocative food testing
and sublingual allergy
desensitization
All charges 14
14 Page 15 16
2001 Preferred Plus of Kansas Section 5( a) 15
Treatment therapies
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow
transplants are limited to those transplants listed under Organ/ Tissue
Transplants on page xx.
· Respiratory and inhalation therapy
· Dialysis –
Hemodialysis and peritoneal dialysis
· Intravenous (IV)/ Infusion
Therapy – Home IV and antibiotic therapy
· Growth hormone therapy (GHT)
Note: – We will only cover
GHT when we preauthorize the treatment. Call 1-( 800)-424-0345 or (316) 609-2359
for preauthorization. We will
ask you to submit information that establishes if the GHT is medically
necessary. Ask us to authorize GHT before you begin treatment;
otherwise, we
will only cover GHT services from the date you submit the
information. If
you do not ask or if we determine GHT is not medically necessary, we will not
cover the GHT or related services and supplies.
See Services requiring our prior approval in Section 3.
$10 per office visit
Rehabilitative therapies You pay
Physical therapy, occupational
therapy and speech therapy --
· 60 outpatient visits per condition for
the services of each of the
following:
··qualified physical therapists;
··speech
therapists; and
··occupational therapists.
Note: We only
cover therapy to restore bodily function or speech when there has been a total
or partial loss of bodily function or
functional speech due to illness or injury.
Cardiac rehabilitation
following a heart transplant, bypass surgery or a myocardial infarction, is
provided for up to 60 sessions per
condition
$10 per office visit
Not covered:
· long-term rehabilitative therapy
· exercise programs
All charges
Developmental therapy You pay
Developmental therapy includes
physical, speech, and occupational therapy. Your primary care physician must
pre-certify your care. We
will cover as follows:
· for children under age 6 up to a maximum
benefit of $1,000 for
each therapy listed in this section per calendar year
Nothing up to our maximum payment of $1,000; all charges thereafter 15
15 Page 16 17
2001 Preferred Plus of Kansas Section 5( a) 16
Hearing services (testing, treatment, and supplies)
·
First hearing aid and testing only when necessitated by accidental injury
· Hearing testing for children through age 17 (see Preventive care,
children)
$10 per office visit
Not covered:
· all other hearing testing ·
hearing aids, testing and examinations for them
All charges.
Vision services (testing, treatment, and supplies) You pay
· Lenses and Frames immediately following cataract surgery under
the following payment schedule. We will pay for two (2) lenses at $41
for
single lenses, $62 for bifocal, $76 for trifocal or seamless, $140
for
lenticular, $30 for frames, and $80 for contacts in lieu of lenses and frames.
All charges above our allowance
· Eye exam to determine the need for vision correction for children
through age 17 (see preventive care) $10 per office visit
Not covered:
· Eyeglasses or contact lenses. Eye examinations for persons
over age 17
· 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.
$10 per office visit
Not covered:
· Cutting, trimming or removal of corns,
calluses, or the free edge of toenails, and similar routine treatment of
conditions of the foot,
except as stated above
· Treatment of weak, strained or
flat feet or bunions or spurs; and of any instability, imbalance or subluxation
of the foot (unless the
treatment is by open cutting surgery)
All charges. 16
16 Page 17 18
2001 Preferred
Plus of Kansas Section 5( a) 17
Orthopedic and prosthetic devices You
pay
· 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.
· Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, and surgically implanted breast implant following
mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5 (c) for payment information. See
5( b)
for coverage of the surgery to insert the device.
· Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
· One pair of orthopedic shoes per diabetic member, per calendar year
Note: We will cover one standard appliance device per lifetime, unless
repair/ replacement is medically necessary as a result of normal usage or
changes in condition.
Nothing
Not covered:
· arch supports
· foot
orthotics
· heel pads and heel cups
·
lumbosacral supports
· corsets, trusses, elastic stockings,
support hose, and other supportive
devices
All charges.
Durable medical equipment (DME) You pay
Rental or purchase, at our
option, including repair and adjustment, of
durable medical equipment
prescribed by your Plan physician, such as oxygen and dialysis equipment. Under
this benefit, we also cover:
· hospital beds;
· wheelchairs;
· crutches;
· walkers;
· blood glucose monitors; and
·
insulin pumps
All charges over the $1,000 yearly
benefit maximum.
Not covered:
· Motorized wheel chairs All charges.
17
17 Page 18
19
2001 Preferred Plus of Kansas Section 5( a)
18
Home health services
· Home health care ordered by
a Plan physician and provided by a
registered nurse (R. N.), licensed
practical nurse (L. P. N.), licensed vocational nurse (L. V. N.), or home health
aide. Services include
oxygen therapy, intravenous therapy and medications.
$10 per visit
Not covered:
· nursing care requested by, or for the
convenience of, the patient or the patient's family;
· care by nurses primarily for hygiene, feeding, exercising, moving
the patient, homemaking, companionship or giving oral medication.
All charges.
Alternative treatments
Not covered:
·
naturopathic services
· hypnotherapy ·
biofeedback
· music therapy
· guided
imagery ·
therapeutic touch
· aroma therapy
·
acupressure
· reflexology ·
cranio-sacral therapy
· acupuncture
All charges.
Educational classes and programs
Coverage is limited to:
· Diabetes self-management
Outpatient self management training, and education for diabetics is covered
if treated in an approved program, and such treatment is rendered by a
person certified by the National Certification Board of Diabetic Educators.
Nothing 18
18 Page
19 20
2001 Preferred Plus of Kansas
19 Section 5( b)
Section 5 (b). Surgical and anesthesia
services provided by physicians and other health care professionals
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this
brochure and are payable
only when we determine they are medically necessary.
· Plan physicians must provide or arrange your care.
· We
have no calendar year deductible.
· Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with
Medicare.
· The amounts listed below are for the charges billed by
a physician or other health care professional for your surgical care. Look in
Section 5( c) for charges associated with the facility
(i. e. hospital, surgical center, etc.).
· YOU MUST GET
PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the
pre-certification information shown in Section 3 to be sure which
services require pre-certification and identify which surgeries require
pre-certification.
I M
P O
R T
A N
T
Benefit Description You pay
Surgical procedures
Such as:
· Treatment of fractures, including casting ·
Normal
pre-and post-operative care by the surgeon
· Correction of amblyopia
and strabismus ·
Endoscopy procedure
· Biopsy procedure
·
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 prostethic devices. See 5( a) –
Orthopedic braces and prosthetic devices for device coverage information.
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per office visit; nothing for hospital visits.
· Voluntary sterilization ·
Norplant (a surgically
implanted contraceptive) and intrauterine
devices (IUDs) Note: Devices are
covered under 5( a).
· Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the pacemaker.
$10 per office visit
Surgical procedures-Continued on next page. 19
19 Page 20 21
2001 Preferred Plus of Kansas 20 Section 5(
b)
Surgical procedures (Continued) You pay
Not covered:
· Reversal of voluntary sterilization
· Routine treatment of conditions of the foot; see Foot care.
All charges.
Reconstructive surgery
· Surgery to correct a functional
defect
· Surgery to correct a condition caused by injury or illness
if:
··the condition produced a major effect on the member's
appearance and
··the condition can reasonably be expected to be corrected by
such
surgery
· Surgery to correct a condition that existed at or from birth and is
a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
$10 per office visit
Reconstructive surgery
· All stages of breast
reconstruction surgery following a mastectomy, such as:
·· surgery to produce a symmetrical appearance on the other
breast;
·· treatment of any physical complications, such as
lymphedemas;
·· breast prostheses and surgical bras and
replacements (see
Prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
See above.
Not covered:
· Cosmetic surgery – any surgical
procedure (or any portion of a
procedure) performed primarily to improve
physical appearance through change in bodily form, except repair of accidental
injury
· Surgeries related to sex transformation
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited
to:
· Reduction of fractures of the jaws or facial bones; ·
Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
· Removal of stones from salivary ducts; ·
Excision of
leukoplakia or malignancies;
· Excision of cysts and incision of
abscesses when done as independent
procedures; and
· Other
surgical procedures that do not involve the teeth or their supporting
structures.
$10 per visit
Oral and maxillofacial surgery – Continued on next page 20
20 Page 21 22
2001 Preferred Plus of Kansas 21 Section 5(
b)
Oral and maxillofacial surgery (Continued) You Pay
Not covered:
· Oral implants and transplants
· Procedures that involve the teeth or their supporting
structures (such as the periodontal membrane, gingiva, and alveolar bone)
· Dental work related to TMJ
All charges.
Organ/ tissue transplants
Limited to:
· Cornea
· Heart
· Heart/ lung
· Kidney
·
Kidney/ Pancreas
· Liver
· Lung: Single –Double
· Pancreas
· Allogenic (donor) bone marrow transplants
· Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer; multiple
myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors
· National Transplant Program (NTP) -United Resource Network
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved clinical
trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient. We also cover transportation costs for the
member and a
companion when the member resides more than 50 miles from the transplant site
and if the transplant is performed outside our
service area. We define
transportation costs as commercial
transportation for the member receiving
the transplant, and a companion, to and from the site of the transplant. We also
cover
reasonable and necessary lodging and meal costs of the member and
companion beginning 24 hours prior to the hospitalization and 48 hours after
discharge. We cover transportation, lodging and meals up to $125
per day up to a maximum benefit of $2,000.
Nothing
Not covered:
· Donor screening tests and donor search
expenses, except those performed for the actual donor
· Implants of artificial organs
· Transplants not
listed as covered
All charges 21
21 Page 22 23
2001 Preferred
Plus of Kansas 22 Section 5( b)
Anesthesia You pay
Professional services provided in –
· Hospital (inpatient)
Nothing
Professional services provided in –
· Hospital outpatient
department ·
Skilled nursing facility
· Ambulatory
surgical center ·
Office
$10 per visit 22
22 Page
23 24
2001 Preferred Plus of Kansas
23 Section 5( c)
Section 5 (c). Services provided by a
hospital or other facility, and ambulance services
I M
P O
R T
A
N
T
Here are some important things to remember about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and
exclusions in this brochure and are payable
only when we determine they are medically necessary.
· Plan physicians must provide or arrange your care and you must be
hospitalized
in a Plan facility.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about
coordinating benefits with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by the facility
(i. e., hospital or surgical center) or ambulance service for your surgery or
care. Any costs
associated with the professional charge (i. e., physicians, etc.) are covered
in Section 5( a) or (b).
· YOU MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require pre-certification.
I M
P O
R T
A N
T
Benefit Description You pay
Inpatient hospital
Room and board,
such as
· ward, semiprivate, or intensive care accommodations;
·
general nursing care; and
· meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you pay
the additional charge above the semiprivate room rate.
Nothing
Other hospital services and supplies, such as:
· Operating,
recovery, maternity, and other treatment rooms ·
Prescribed drugs and
medicines
· Diagnostic laboratory tests and X-rays ·
Administration of blood and blood products
· Blood or blood
plasma, if not donated or replaced
· Dressings, splints, casts, and
sterile tray services ·
Medical supplies and equipment, including
oxygen
· Anesthetics, including nurse anesthetist services ·
Take-home items
· Medical supplies, appliances, medical
equipment, and any covered items billed by a hospital for use at home
Nothing
Not covered:
· Custodial care ·
Non-covered facilities, such as nursing homes, extended care facilities,
schools
· Personal comfort items, such as telephone, television, barber
services, guest meals and beds
· Private nursing care
All charges 23
23 Page 24 25
2001 Preferred
Plus of Kansas 24 Section 5( c)
Outpatient hospital or
ambulatory surgical center You Pay
· Operating, recovery, and
other treatment rooms ·
Prescribed drugs and medicines
·
Diagnostic laboratory tests, X-rays, and pathology services
·
Administration of blood, blood plasma, and other biologicals ·
Blood
and blood plasma, if not donated or replaced
· Pre-surgical testing
· Dressings, casts, and sterile tray services ·
Medical
supplies, including oxygen
· Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not
cover the dental procedures.
Nothing
Not covered: blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care facility
benefits
We cover all necessary services with no dollar or day limit,
including:
· Bed, board and general nursing care.
· Drugs,
biologicals, supplies, and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a
Plan doctor.
Nothing
Not covered: custodial care All charges
Hospice care
We
cover supportive and palliative care for a terminally ill member in the home or
hospice facility. Services include inpatient and outpatient
care, and family counseling; these services are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness, with a life expectancy of approximately six months or
less.
Nothing
Not covered: Independent nursing, and homemaker services All charges
Ambulance
· Ambulance service when medically
appropriate Nothing 24
24 Page
25 26
2001 Preferred Plus of Kansas
25 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions,
limitations, and exclusions in this brochure.
· We have no deductible.
· Be sure to read Section 4,
Your costs for covered services for valuable information about how cost
sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or
an injury that you believe endangers your life or could result in serious injury
or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated
promptly, they might become more
serious; examples include deep cuts and
broken bones. Others are emergencies because they are potentially
life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability
to breathe. There are many other acute conditions that we may determine are
medical emergencies – what
they all have in common is the need for
quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care
doctor. In extreme emergencies, if you are unable to contact your doctor,
contact the local emergency system (e. g., the 911 telephone system) or go to
the nearest hospital emergency room. Be sure to tell the emergency
room personnel that you are a Plan member so they can notify us. You or a
family member should notify us
within 48 hours. It is your responsibility to
ensure that we have been timely notified. We can be reached by phone at (316)
609-2390, or (800) 660-8114.
If you need to be hospitalized, we must be notified within 48 hours or on the
first working day following your admission, unless it was not reasonably
possible to notify us within that time. If you are hospitalized in non-Plan
facilities and Plan doctors believe care can be better provided in a Plan
hospital, you will be transferred
when medically feasible with any ambulance
charges covered in full.
Benefits are available for care from non-Plan providers in a medical
emergency only if delay in reaching a
Plan provider would result in death,
disability or significant jeopardy to your condition. To be covered by this
Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by
Plan providers.
Emergencies outside the service area: Benefits are
available for any medically necessary health service that
is immediately
required because of injury or unforeseen illness. If you need to be
hospitalized, we must be
notified within 48 hours or on the first working
day following your admission, unless it was not reasonably possible to notify us
within that time. If a Plan doctor believes care can be better provided in a
Plan hospital,
you will be transferred when medically feasible with any ambulance charges
covered in full. 25
25 Page
26 27
2001 Preferred Plus of Kansas
26 Section 5( d)
Benefit Description You pay
Emergency
within our service area
· Emergency care at a doctor's office
· Emergency care at
an urgent care center
$10 per visit
· Emergency care as an outpatient or inpatient at a hospital,
including doctors' services $50 per visit
Not covered: Elective care or
non-emergency care All charges.
Emergency outside our service area
· Emergency care at a doctor's office
· Emergency care at
an urgent care center
$10 per visit
· Emergency care as an outpatient or inpatient at a hospital,
including doctors' services $50 per visit
Not covered:
· Elective care or non-emergency care
·
Emergency care provided outside the service area if the need
for
care could have been foreseen before leaving the service area
· Medical and hospital costs resulting from a normal full-term
delivery of a baby outside the service area
All charges.
Ambulance
Ambulance service when medically appropriate including,
air ambulance
See 5( c) for non-emergency service.
Nothing 26
26 Page 27 28
2001 Preferred Plus of Kansas 27 Section 5(
e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
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A N
T
Parity
Beginning in 2001, all FEHB plans' mental health and
substance abuse benefits will achieve
"parity" with other
benefits. This means that we will provide mental health and substance abuse
benefits differently than in the past.
When you get our approval for services and follow a treatment plan we
approve, cost-sharing
and limitations for Plan mental health and substance
abuse benefits will be no greater than for similar benefits for other illnesses
and conditions.
Here are some important things to keep in mind about these benefits:
· All benefits are subject to the definitions, limitations, and
exclusions in this brochure.
· Be sure to read Section 4, Your
costs for covered services for valuable information about how cost sharing
works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
· YOU MUST GET
PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits
description below.
I M
P O
R T
A N
T
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and
contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.
Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive the
care as part of a treatment plan that Mental Health Network, Inc.
approves.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
· Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social workers
· Medication management
$10 per office visit
· Diagnostic tests $10 per visit
· Services provided by a
hospital or other facility
· Services in approved alternative care
settings such as partial
hospitalization, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
Mental health and substance abuse benefits -Continued on next page 27
27 Page 28 29
2001 Preferred Plus of Kansas 28 Section 5(
e)
Mental health and substance abuse benefits (Continued)
You pay
Not covered: Services not approved in advance by
Mental Health Network, Inc.
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.
Pre-authorization
To be eligible to receive these benefits you
must follow your treatment plan and all the following authorization processes:
All services for mental conditions/ substance abuse benefits must be
coordinated by Mental Health Network, Inc. prior to receiving services. Please
contact Mental Health Network, Inc. at 1-800-456-5641.
Special transitional benefit If a mental health or substance abuse
professional provider is treating you under our plan as of January 1, 2001, you
will be eligible for continued
coverage with your provider for up to 90 days
under the following condition:
· If your mental health or substance abuse professional provider with
whom you are currently in treatment leaves the plan at our request for other
than cause.
If this condition applies to you, we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse professional
provider. During the transitional period, you may continue to see your
treating provider and will not pay any more out-of-pocket than you did in
the year 2000 for services. This transitional period will begin with our
notice to you of the change in coverage and will end 90 days after you
receive our notice. If we write to you before October 1, 2000, the 90-day
period ends before January 1 and this transitional benefit does not apply.
Limitation We may limit your benefits if you do not follow your
treatment plan. 28
28 Page
29 30
2001 Preferred Plus of Kansas
29 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T
Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the
chart beginning on the next page.
· All benefits are subject to the definitions, limitations and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
· Be sure to read Section 4, Your costs for
covered services for valuable information about how cost sharing works. Also
read Section 9 about coordinating benefits with other
coverage, including
with Medicare.
I
M
P
O
R
T
A
N
T
There are important features you should be aware of. These include:
· Who can write your prescription. A licensed physician must
write the prescription
· Where you can obtain them. You must
fill the prescription at a plan pharmacy, or by mail for a maintenance
medication.
· These are the dispensing limitations.
Participating Retail
Pharmacy: Covered prescriptions are limited to a 34 day supply or 100 unit
dose, whichever is less. Covered prescriptions for erectile dysfunction are
limited to an eight (8) unit dose per 34 day supply. Oral Contraceptives may be
dispensed in a three month supply,
however, a co-payment is required for each months supply. If we authorize an
exception to the dispensing limitation, each supply given will be subject to a
co-payment.
Participating Mail Order or Internet Pharmacy (PlanetRx. com): Covered
prescriptions are
limited to a 90 day supply, except as follows:
· Covered narcotic prescriptions, except Ritalin, are limited to a 34
day supply or a 100 dose of tablets or capsules, whichever is less.
· Covered prescriptions for erectile dysfunction are limited to a
twenty-four (24) unit dose per 90 day supply.
· When you have to
file a claim. The pharmacy will file the claim for you. If you have a
situation
where the pharmacy is unable to file the claim for your
prescription, contact our Member Service Department at (316) 609-2390 or (800)
660-8114, and ask them to send you a prescription
reimbursement form.
Prescription drug benefits begin on the next page. 29
29 Page 30 31
2001 Preferred Plus of Kansas 30 Section 5(
f)
Benefit Description You pay
Covered medications and supplies
.
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:
· Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase, except as excluded below.
· Insulin, with a copay charge applied to each vial
·
Disposable needles and syringes for the administration of covered medications
· Contraceptive drugs and devices
· Oral contraceptive
drugs -up to a three-cycle supply may be obtained at one time with a copay
charge applied to each cycle.
· Contraceptive devices, such as diaphragms and IUD's
Diabetic
supplies, including syringes, diagnostic strips, alcohol swabs and lancets.
Diagnostic strips will be subject to the name brand
copayment. All other diabetic supplies will be subject to the generic
copayment.
· Intravenous fluids and medication for home use,
implantable drugs, such as Norplant and some injectable drugs, such as Depo
Provera are
covered under Medical and Surgical Benefits.
· Drugs to treat
sexual dysfunction are limited to an 8 unit dose per 34-day supply and a 24 unit
dose per 90-day supply
$5 copay per generic prescription – retail.
$15 copay per brand
name prescription – retail
$10 copay per mail-order
prescription.
When generic substitution is permissible (i. e., a generic drug is
available and the prescribing doctor does not require the use of
a brand
name drug), but you
request the brand name drug, you pay the difference
between the
generic and brand name drug as
well as the $15 copay
Note: If there is no generic equivalent available, you will still
have to pay the brand name copay.
Here are some things to keep in mind about our prescription drug
program:
· A generic equivalent will be dispensed if it is available, unless
your
physician specifically requires a brand name. If you receive a brand
name drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as Written
for
the brand name drug, you have to pay the difference in cost between the brand
name drug and the generic as well as the
copayment.
· We have an open formulary. If your physician believes a brand name
product is necessary or there is no generic available, your
physician may
prescribe a brand name drug from a formulary list.
This list of brand name
drugs is a preferred list of drugs that we selected to meet patient needs at a
lower cost.
· Medications requiring pre-authorization include: Adderal, Dexedrine
and
Desoxyn; Oral Anabolic Steroids; Medications to treat acne for persons
over the age of 30 including, but not limited to, Retin-A, Accutane, and
Differin;
Hormone suppositories and powders; Anti-fungal medication including, but
not limited to, Lamisil or Sporanox; and Wellbutrin SR/ 150 mg.
Covered medications and supplies – Continued on next page 30
30 Page 31 32
2001 Preferred Plus of Kansas 31 Section 5(
f)
Covered medications and supplies (continued) You pay
Not covered:
· Drugs and supplies for cosmetic
purposes
· Vitamins, nutrients and food supplements even if a
physician prescribes or administers them
· Drugs available without a prescription or for which there is a
nonprescription equivalent available.
· Drugs obtained at a non-Plan pharmacy except for out-of-area
emergencies.
· Medical supplies such as dressings and antiseptic.
· Drugs to enhance athletic performance.
·
Drugs to aid in smoking cessation, including nicotine patches.
· Fertility drugs.
· Appetite suppressants,
except for treatment of morbid obesity.
All Charges 31
31 Page 32 33
2001 Preferred
Plus of Kansas 32 Section 5( g)
Section 5 (g). Dental benefits
I M
P O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in
this brochure and are payable
only when we determine they are medically necessary.
· Plan dentists must provide or arrange your care.
· We
cover hospitalization for dental procedures only when a nondental physical
impairment
exists which makes hospitalization necessary to safeguard the
health of the patient; we do not cover the dental procedure unless it is
described below.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other coverage,
including with Medicare.
I M
P O
R T
A N
T
Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury. Treatment must be initiated within 30
days of the date of injury.
$10 copay per office visit
Dental benefits
We cover the administration of general anesthetic
and hospital inpatient
charges (not the dental procedure) we determine to be
medically necessary for dental care for the following persons:
· Dependent children five years of age or under; or
· A
member who is severely disabled; or
· A member who has a medical or
behavioral condition which requires hospitalization or general anesthesia when
dental care is
provided.
Nothing
We have no other dental benefits. 32
32 Page 33 34
2001 Preferred
Plus of Kansas Section 6 33
Section 6. General exclusions --things we
don't cover
The exclusions in this section apply to all benefits.
Although we may list a specific service as a benefit, we
will not cover
it unless your Plan doctor determines it is medically necessary to prevent,
diagnose, or
treat your illness, disease, injury, or condition.
We do not cover the following:
· Care by non-Plan providers except
for authorized referrals or emergencies (see Emergency Benefits);
· Services, drugs, or supplies you receive while you are not enrolled
in this Plan;
· Services, drugs, or supplies that are not medically
necessary;
· Services, drugs, or supplies not required according to
accepted standards of medical, dental, or psychiatric practice;
· Experimental or investigational procedures, treatments, drugs or
devices;
· Services, drugs, or supplies related to abortions, except
when the life of the mother would be endangered if the fetus were carried to
term or when the pregnancy is the result of an act of rape or
incest;
· Services, drugs, or supplies related to sex
transformations; or
· Services, drugs, or supplies you receive from a
provider or facility barred from the FEHB Program. 33
33 Page 34 35
2001 Preferred Plus of Kansas 34 Section 7
Section 7. Filing a claim for covered services
When you see
Plan physicians, receive services at Plan hospitals and facilities, or obtain
your prescription drugs at
Plan pharmacies, you will not have to file
claims. Just present your identification card and pay your copayment.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these providers bill us directly. Check with the
provider. If you need to file the claim, here is the process:
Medical, hospital, drug benefits In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance Claim Form.
Facilities will file on the UB-92 form. For
claims questions and
assistance, call us at 1-( 800)-660-8114 or 316-(
609)-2390.
When you must file a claim --such as for out-of-area care --submit it on the
HCFA-1500 or a claim form that includes the information shown
below. Bills
and receipts should be itemized and show:
· Covered member's name and
ID number;
· Name and address physician or facility that provided the
service
or supply,
· Dates you received the services or supplies;
· Diagnosis;
· Type of each service or supply;
· The charge for each
service or supply;
· A copy of the explanation of benefits, payments,
or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and
· Receipts, if you paid for your services.
Submit your claims to: Preferred Health Systems, 8535 E. 21 st
North,
Wichita, Kansas 67206
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by administrative operations of Government or legal incapacity, provided the
claim was
submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 34
34 Page
35 36
2001 Preferred Plus of Kansas
35 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on
your claim or request for
services, drugs, or supplies – including a request for preauthorization:
Step Description
1 1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send
your request to us at: 8535 E. 21 st Street North, Wichita, Kansas 67206; and
(c) Include a statement about why you believe our initial decision was
wrong, based on specific benefit
provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 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 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 4 If you do not agree with our decision, you may ask OPM to review
it.
You must write to OPM within:
· 90 days after the date of our
letter upholding our initial decision; or
· 120 days after you first
wrote to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division III,
P. O. Box 436, Washington, D. C.
20044-0436.
Send OPM the following information:
· A statement about why you
believe our decision was wrong, based on specific benefit provisions in
this
brochure;
· Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms;
· Copies of all letters you sent to us about the claim;
·
Copies of all letters we sent to you about the claim; and
· Your
daytime phone number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to which claim. 35
35 Page 36 37
2001 Preferred
Plus of Kansas 36 Section 8
The Disputed Claims Process
(Continued)
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 provide 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 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 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. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your lawsuit, benefits, and payment of benefits.
The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily
functions or death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at 1-
(800)-424-0345 or
(316)-609-2359; and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior
approval, then:
·· If we expedite our review and maintain our
denial, we will inform OPM so that they can give your
claim expedited
treatment too, or
·· You can call OPM's Health Benefits Contracts Division III at
202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 36
36 Page 37 38
2001 Preferred Plus of Kansas 37 Section 9
Section 9. Coordinating benefits with other coverage
When you
have other health coverage You must tell us if you are covered or a family
member is covered under another group health plan or have automobile insurance
that pays health
care expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan
normally pays its benefits in full as the primary payer and the other plan pays
a reduced benefit as the
secondary payer. We, like other insurers, determine
which coverage is primary according to the National Association of Insurance
Commissioners' guidelines.
When we are the primary payer, we will pay
the benefits described in this brochure.
When we are the secondary payer, we will determine our allowance. After the
primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. We will not pay more than our allowance.
· ·What is Medicare? Medicare is a Health Insurance
Program for:
·· People 65 years of age and older.
·· Some people with disabilities, under 65 years of age.
·· People with End-Stage Renal Disease (permanent kidney
failure requiring dialysis or a transplant).
Medicare has two parts:
·· Part A (Hospital Insurance).
Most people do not have to pay for Part A.
·· Part B (Medical
Insurance). Most people pay monthly for Part B.
If you are eligible for Medicare, you may have choices in how you get your
health care. Medicare + Choice is the term used to describe the various health
plan
choices available to Medicare beneficiaries. The information in the
next few pages shows how we coordinate benefits with Medicare, depending on the
type of
Medicare managed care plan you have.
· ·The Original Medicare Plan The Original Medicare Plan
is available everywhere in the United States. It is the way most people get
their Medicare Part A and Part B benefits.
You may go to any doctor,
specialist, or hospital that accepts Medicare. Medicare pays its share and you
pay your share. Some things are not
covered under Original Medicare, like
prescription drugs.
When you are enrolled in this Plan and Original
Medicare, you still need
to follow the rules in this brochure for us to
cover your care. We will not waive any of our copayments. Your care must
continue to be authorized
by your primary care physician, or precertified as required.
(Primary payer chart begins on next page.) 37
37 Page 38 39
2001 Preferred Plus of Kansas 38 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) Areanactiveemployee
withtheFederalgovernment (includingwhenyouor afamilymemberare
eligibleforMedicaresolely becauseofadisability), ü
2) Are an annuitant, ü
3) Are a reemployed annuitant with the
Federal government when…
a) The position is excluded from FEHB, or
……………………
……….. ü
b) The position is not excluded from FEHB
Ask your employing office which
of these applies to you.
……………………..………
ü
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), ü ü
5) Are enrolled in Part B only, regardless of your employment status, ü
(for Part B
services)
ü
(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,
ü
(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, ü
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD, ü
3) Become eligible for Medicare due to ESRD after Medicare became primary for
you under another provision, ü
C. When you or a covered family
member have FEHB and…
1) Are eligible for Medicare based on
disability, and
a) Are an annuitant,
or…………………………………………………
………. ü
b) Are an active employee…
…………………………………
………………………..…….
ü 38
38 Page
39 40
2001 Preferred Plus of Kansas
39 Section 9
Claims process --You probably will never have
to file a claim form
when you have both our Plan and Medicare.
· When we are the primary payer, we process the claim first.
· When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something about
filing your claims, call us at (316) 609-2390 or 1-( 800)-660-
8114 or locate
us at www. phsystems. com.
· · 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 cover all
Medicare Part A and B benefits. Some cover extras, like prescription
drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a Medicare managed care plan, the
following options are available to you:
This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB plan. In
this case, we do not waive any of our copayments.
This Plan and another Plan's Medicare managed care plan: You may
enroll in another plan's Medicare managed care plan and also remain
enrolled in our FEHB plan. We will still provide benefits when your Medicare
managed care plan is primary, even out of the managed care
plan's network and/ or service area (if you use our Plan providers), but we
will not waive any of our copayments.
Suspended FEHB coverage and a Medicare managed care plan: If
you
are an annuitant or former spouse, you can suspend your FEHB coverage to enroll
in a Medicare managed care plan , eliminating your
FEHB premium (OPM does not contribute to your Medicare managed
care plan
premium) . For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open
season
unless you involuntarily lose coverage or move out of the Medicare+ Choice
service area. 39
39 Page
40 41
2001 Preferred Plus of Kansas
40 Section 9
· · Enrollment in Note: If you
choose not to enroll in Medicare Part B, you can still be Medicare Part B
covered under the FEHB Program. We cannot require you to enroll in
Medicare.
TRICARE TRICARE is the health care program for eligible dependents of
military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your
TRICARE Health Benefits Advisor if you have questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
· you
need because of a workplace-related disease 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 benefits. You must use
our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other Government agencies We do not cover services and supplies
when a local, State, are responsible for your care or Federal Government
agency directly or indirectly pays for them.
When others are responsible for injuries When you receive money to
compensate you for 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. 40
40 Page
41 42
2001 Preferred Plus of Kansas
41 Section 10
Section 10. Definitions of terms we use in this
brochure
Calendar year January 1 through December 31 of the same year.
For new enrollees, the calendar year begins on the effective date of their
enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services.
Covered services Care we provide benefits for, as described in this
brochure.
Experimental or If a service has not been approved by the
Federal Drug Administration investigational services (FDA) or is labeled
experimental or investigational on the protocol the
Plan considers the
service experimental or investigational.
Medical necessity Means a
service or item (intervention) that is delivered or undertaken primarily to
prevent, diagnose, treat or palliate a disease, illness or injury,
genetic
or congenital defect, pregnancy, or psychological condition that lies outside
the range of normal, age appropriate human variation.
Interventions must be:
· Effective for the patient's medical condition and indications,
which is determined by scientific evidence consisting primarily of
controlled clinical trails that demonstrate the effect of the intervention on
health outcomes. If clinical trails have not been
conducted, effectiveness
is evaluated on the basis of professional
standards of care or expert
opinion.
· Expected to produce the intended results and have expected
outcomes that outweigh potential harmful effects.
· Measurable by positive changes in the patient's health status as
determined by length or quality of life.
· Appropriate for the
patient's medical condition and indications. The
expected outcome relative
to cost must represent an economically efficient use of resources.
· Performed in the proper setting, at the proper time, in the proper
amounts, and by the proper provider of care relative to the patient's
condition.
· Recommended by the PCP and treating physician and determined by the
Health Plan medical director to meet the above criteria.
Us/ We Us and we refer to Preferred Plus of Kansas
You You
refers to the enrollee and each covered family member. 41
41 Page 42 43
2001 Preferred Plus of Kansas 42 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:
· 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. 42
42 Page
43 44
2001 Preferred Plus of Kansas
43 Section 11
When benefits and The benefits in this
brochure are effective on January 1. If you are new premiums start to
this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on
January 1.
Your medical and claims We will keep your medical and
claims information confidential. Only records are confidential the
following will have access to it:
· OPM, this Plan, and subcontractors when they administer this
contract;
· This Plan, and appropriate third parties, such as other
insurance plans
and the Office of Workers' Compensation Programs (OWCP),
when coordinating benefit payments and subrogating claims;
· Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;
· OPM and the General Accounting Office when conducting audits;
· Individuals involved in bona fide medical research or education
that
does not disclose your identity; or
· OPM, when reviewing a disputed claim or defending litigation about a
claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the last
five years of your
Federal service. If you do not meet this requirement, you
may be eligible for other forms of coverage, such as temporary continuation of
coverage (TCC).
When you lose benefits
· ·When FEHB coverage ends
You will receive an additional 31 days of coverage, for no additional
premium, when:
·· Your enrollment ends, unless you cancel your enrollment, or
·· You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary Continuation of
Coverage.
· · Spouse equity If you are divorced from a Federal
employee or annuitant, you may not coverage continue to get benefits
under your former spouse's enrollment. But, you
may be eligible for your own
FEHB coverage under the spouse equity
law. If you are recently divorced or
are anticipating a divorce, contact your ex-spouse's employing or retirement
office to get RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.
· · TCC If you leave Federal service, or if you lose
coverage because you no longer qualify as a family member, you may be eligible
for Temporary
Continuation of Coverage (TCC). For example, you can receive
TCC if
you are not able to continue your FEHB enrollment after you retire.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct.
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. 43
43 Page 44 45
2001 Preferred Plus of Kansas 44 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 If you leave the FEHB Program, we will give
you a Certificate of Group
Group Health Plan Coverage Health Plan
Coverage that indicates how long you have been enrolled with us. You can use
this certificate when getting health insurance or other health care coverage.
Your new plan must reduce or eliminate waiting periods, limitations, or
exclusions
for health related conditions based on the information in the
certificate, as long as you enroll within 63 days of losing coverage under this
Plan.
If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate
from those plans.
Inspector General Advisory Stop health care fraud! Fraud increases the
cost of health care for everyone. If you suspect that a physician, pharmacy, or
hospital has
charged you for services you did not receive, billed you twice
for the same service, or misrepresented any information, do the following:
· Call the provider and ask for an explanation. There may be an error.
·
If the provider does not resolve the matter, call us at
(316)-609-2390
or 1-( 800)-660-8114 and explain the situation.
·
If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--202/
418-3300 or write to: The United States Office of
Personnel Management, Office of the Inspector General Fraud Hotline, 1900 E
Street, NW, Room 6400, Washington, DC 20415.
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be
prosecuted for fraud. Also, the Inspector General
may investigate anyone who uses an ID card if the person tries to obtain
services for
someone who is not an eligible family member, or is no longer enrolled in the
Plan and tries to obtain benefits. Your agency may also take
administrative
action against you. 44
44 Page
45 46
2001 Preferred Plus of Kansas
45 Index
Index
Do not rely on this page; it is for
your convenience and does not explain your benefit coverage.
Accidental injury 32
Allergy tests 14 Alternative treatment 18
Ambulance 26 Anesthesia 22
Autologous bone marrow transplant 21
Biopsies 19
Blood and blood plasma 23 Breast cancer screening 12
Casts 19 Changes for 2001 6
Chemotherapy 15 Childbirth 13
Cholesterol
tests 12 Claims 34
Colorectal cancer screening 12 Congenital anomalies 19
Contraceptive devices and drugs 13,29 Coordination of benefits 37
Covered providers 7
Crutches 17 Definitions 41
Dental care 32 Developmental therapy 15
Diagnostic services 11 Disputed claims review 35
Donor expenses
(transplants ) 21 Dressings 24
Durable medical equipment (DME) 17
Educational classes and programs 18 Effective date of enrollment 43
Emergency 25 Experimental or
investigational 33 Eyeglasses 16
Family planning 13
Fecal occult blood test 12 General Exclusions 33
Hearing
services 16 Home health services 18
Hospice care 24 Home nursing care 18
Hospital 23 Immunizations 12
Infertility 14 Inhospital physician
care 23
Inpatient Hospital Benefits 23 Insulin 30
Laboratory and
pathological
services 11 Machine diagnostic tests 11
Magnetic Resonance Imagings (MRIs) 11
Mail Order Prescription Drugs 29
Mammograms 12
Maternity Benefits 13 Medicaid 40
Medicare 37 Mental
Conditions/ Substance
Abuse Benefits 27 Neurological testing 11
Newborn care 13 Nursery charges 13
Obstetrical care 13
Occupational therapy 15 Office visits 11
Oral and maxillofacial surgery 20 Orthopedic devices 17
Out-of-pocket
expenses 9 Outpatient facility care 24
Oxygen 17 Pap test 12
Physical examination 12 Physical therapy 15
Physician 7
Pre-admission testing 11 Precertification 9
Preventive care, adult 12
Preventive care, children 12
Prescription drugs 29 Preventive services 12
Prior approval 9 Prostate cancer screening 12
Prosthetic devices 17
Psychotherapy 27
Radiation therapy 15
Rehabilitation therapies 15
Renal dialysis 15
Room and board 23 Second surgical opinion 11
Skilled nursing
facility care 24 Smoking cessation 31
Speech therapy 15 Sterilization
procedures 13
Substance abuse 27 Surgery 19
· Anesthesia 22
· Oral 20
· Outpatient 24 · Reconstructive 20
Syringes 30 Temporary continuation of
coverage 43 Transplants 21
Treatment therapies 15 Vision services 16
Well child care
12
Wheelchairs 17 Workers' compensation 40
X-rays 11 45
45 Page
46 47
2001 Preferred Plus of Kansas
46 Notes
NOTES: 46
46 Page 47 48
2001 Preferred
Plus of Kansas 47 Summary
Summary of benefits for the
Preferred Plus of Kansas -2001
· Do not rely on this chart
alone. All benefits are provided in full unless indicated and are subject to
the
definitions, limitations, and exclusions in this brochure. On this page
we summarize specific expenses we cover; for more detail, look inside.
· If you want to enroll or change your enrollment in this Plan, be
sure to put the correct enrollment code from the
cover on your enrollment
form.
· We only cover services provided or arranged by Plan physicians,
except in emergencies.
Benefits You Pay Page
Medical services provided by physicians:
· Diagnostic and treatment services provided in the office
................... Office visit copay: $10 primary care; $10 specialist 11
Services provided by a hospital:
·
Inpatient.......................................................................................................
·
Outpatient....................................................................................................
Nothing 23
24
Emergency benefits:
· In-area
.........................................................................................................
· Out-of-area
.................................................................................................
$50 per visit
$50 per visit
26
26
Mental health and substance abuse
treatment............................................ Regular cost sharing 27
Prescription
drugs...........................................................................................
$5 generic copay; $15 name brand copay; $10 mail-order copay 29
Dental
Care...................................................................................................
Accidental injury benefit; $10 copay per visit 32
Vision
Care...................................................................................................
No benefit. 16 47
47 Page
48
2001 Rate Information for
Preferred Plus of Kansas
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category,
refer to the FEHB Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB
Guide for United States Postal Service Employees,
RI 70-2. Different postal rates apply and special FEHB guides are published for
Postal Service Nurses and Tool & Die employees (see RI
70-2B); and for Postal Service Inspectors and Office of Inspector General
(OIG) employees (see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal employee organization. Refer to the applicable
FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type
of Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your
Share
Self Only VA1 $85.28 $28.43 $184.78 $61.59 $100.92 $12.79
Self and
Family VA2 $195.82 $106.63 $424.28 $231.03 $231.17 $71.28 48