Enclosure 2A - Fee-for-Service brochure examples
This is the key for the "Print size" and "Print style". Follow the visual in making
text: bold, bold-italicized, and italicized, and for shading degrees.
Times New Roman, 32-point
Times New Roman, 14-point
Times New Roman, 16-point
Times New Roman, 13-point
Times New Roman, 10 point
〉 {{Use Graphic for logo AND its text}}
∫ Times New Roman, 11-point
⌠ Times New Roman, 12-point
Tahoma, 14-point (or equivalent)
FFS Plan name
http://www.planAddress.org
2004
A fee-for-service plan
with a preferred provider organization
〉
Sponsored and administered by: {insert sponsoring organization name}
Who may enroll in this Plan: {plan specific}
To become a member or associate member: {plan specific}
Xxxxxxx
Xxxxxx
If you are a non-postal employee/annuitant, you will automatically become an associate
member of {organization name} upon enrollment in the {Plan name}.
Annuitants (retirees) may {may not} enroll in this Plan. {plan specific}
Membership dues: $xx per year for an associate membership. {Organization name} will
bill new associate members for the annual dues when it receives notice of enrollment.
{Organization name} will also bill continuing associate members for the annual
membership. Active and retired Postal Service employee's membership dues vary by
{organization{ local. {Plan specific}
Enrollment codes for this Plan:
001 High Option - Self Only
002 High Option - Self and Family
004 Standard Option - Self Only
005 Standard Option - Self and Family
〉
〉
Attach
Your
Logo
For changes
in benefits
see page xx.
RI 71-xxx
Add logo for any accreditation you have
and say below it:
This Plan has _____ accreditation from
the ______. See the 2002 Guide for more
in
f
ormation on accreditation.
2003{Insert FFS Plan name} 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………....................................................... xx
Plain Language……………………………………………………………….......................................................... xx
Preventing medical mistakes ................................................................................................................................... xx
Stop Health Care Fraud!........................................................................................................................................... xx
Section 1. Facts about this fee-for-service plan...................................................................................................... xx
Section 2. How we change for 2004……………………………………….. .......................................................... xx
Section 3. How you get care …………................................................................................................................... xx
Identification cards ................................................................................................................................. xx
Where you get covered care ................................................................................................................... xx
• Covered providers .......................................................................................................................... xx
• Covered facilities............................................................................................................................ xx
What you must do to get covered care.................................................................................................... xx
How to get approval for… ................................................................................................................... xx
• Your hospital stay (precertification)............................................................................................... xx
• Other services................................................................................................................................. xx
Section 4. Your costs for covered services............................................................................................................... xx
• Copayments.................................................................................................................................... xx
• Deductible ...................................................................................................................................... xx
• Coinsurance.................................................................................................................................... xx
• Differences between our allowance and the bill............................................................................. xx
Your out-of-pocket maximum ................................................................................................................ xx
When Government facilities bill us… ................................................................................................. xx
If we overpay you................................................................................................................................... xx
When you are age 65 or over and you do not have Medicare ................................................................ xx
When you have Medicare ....................................................................................................................... xx
Should I enroll in Medicare? .................................................................................................................. xx
Section 5. Benefits………………………………………………………… ........................................................... xx
Overview ................................................................................................................................................ xx
(a) Medical services and supplies provided by physicians and other health care professionals ........... xx
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ xx
(c) Services provided by a hospital or other facility, and ambulance services...................................... xx
(d) Emergency services/accidents ......................................................................................................... xx
(e) Mental health and substance abuse benefits .................................................................................... xx
(f) Prescription drug benefits................................................................................................................ xx
(g) Special features................................................................................................................................ xx
2003{Insert FFS Plan name} 3 Table of Contents
• Flexible benefits option
• {bullet list your other features}
(h) Dental benefits {do not remove this--in benefit section show "no benefit" if you don't have dental}xx
(i) Point of Service Product {remove this & renumber next if you don't have POS benefits} ..............xx
(j) Non-FEHB benefits available to Plan members {remove this if you don't have non-FEHB benefits}xx
Section 6. General exclusions -- things we don't cover......................................................................................xx
Section 7. Filing a claim for covered services .........................................................................................................xx
Section 8. The disputed claims process ...................................................................................................................xx
Section 9. Coordinating benefits with other coverage .............................................................................................xx
When you have other health coverage .................................................................................................... xx
What is Medicare? .................................................................................................................................. xx
Medicare + Choice..................................................................................................................................xx
TRICARE and CHAMPVA ...................................................................................................................xx
Workers Compensation ..........................................................................................................................xx
Medicaid .................................................................................................................................................xx
When other Government agencies are responsible for your care............................................................xx
When others are responsible for injuries.................................................................................................xx
Section 10. Definitions of terms we use in this brochure ........................................................................................ xx
Section 11. FEHB facts ..........................................................................................................................................xx
Coverage information ...........................................................................................................................xx
• No pre-existing condition limitation............................................................................................... xx
• Where you can get information about enrolling in the FEHB Program .........................................xx
• Types of coverage available for you and your family ....................................................................xx
• Children's Equity Act.................................................................................................................... xx
• When benefits and premiums start ................................................................................................. xx
• Your medical and claims records are confidential..........................................................................xx
• When you retire .............................................................................................................................. xx
When you lose benefits.........................................................................................................................xx
• When FEHB coverage ends............................................................................................................xx
• Spouse equity coverage ................................................................................................................. xx
• Temporary Continuation of Coverage (TCC)................................................................................xx
• Converting to individual coverage.................................................................................................xx
• Getting a Certificate of Group Health Plan Coverage ................................................................... xx
Two new Federal Programs complement FEHB benefits......................................................................................... xx
The Federal Flexible Spending Account Program - FSAFEDS ..............................................................xx
The Federal Long Term Care Insurance Program...................................................................................xx
Index ...........................................................................................................................................................xx
Summary of benefits................................................................................................................................................. xx
2003{Insert FFS Plan name} 4 Table of Contents
Rates…………………………………………………………………………………………………………..Back cover
2003 {insert FFS Plan name} 6 Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits. {Plan - add from below all that apply, along with your changes.}
Program-wide changes
•
Changes to this Plan
•
2003 {insert FFS Plan name} 7 Section 4
Section 3. How you get care
⌠Identification cards We will send you an identification (ID) card. 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 xxx-xxx-
xxxx. {Plan specific} or write to us at {Plan address}. You may also
request replacement cards through our Website: {Plan Web address}.
Where you get covered care You can get care from any “covered provider” or “covered facility.”
How much we pay – and you pay – depends on the type of covered
provider or facility you use. If you use our preferred providers, or our
point-of-service program, you will pay less.
• Covered providers We consider the following to be covered providers when they perform
services within the scope of their license or certification: {Insert your
list}
Medically underserved areas. Note: We cover any licensed medical
practitioner for any covered service performed within the scope of that
license in states OPM determines are "medically underserved." For
2004, the states are: Alabama, Idaho, Kentucky, Louisiana, Maine,
Mississippi, Missouri, Montana, New Mexico, North Dakota, South
Carolina, South Dakota, Texas, Utah, West Virginia and Wyoming.
{Reminder: These providers must now include pastoral counselors--see
Carrier Letter 2000-45}
• Covered facilities Covered facilities include: {Plan specific definitions}
•Hospital
•xxxxxxx
What you must do to It depends on the kind of care you want to receive. You can go to any
get covered care provider you want, but we must approve some care in advance.
Transitional care: Specialty care: If you have a chronic or disabling condition and
• lose access to your specialist because we drop out of the Federal
Employees Health Benefits (FEHB) Program and you enroll in
another FEHB Plan, or
• lose access to your PPO specialist because we terminate our contract
with your specialist for other than cause,
you may be able to continue seeing your specialist and receiving any
PPO benefits for up to 90 days after you receive notice of the change.
Contact us or, if we drop out of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
2003 {insert FFS Plan name} 14 Section 4
⌠When you are age 65 or over and you do not have Medicare
Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those benefits
you would be entitled to if you had Medicare. And, your physician and hospital must follow Medicare rules and
cannot bill you for more than they could bill you if you had Medicare. You and the FEHB benefit from these payment
limits. Outpatient hospital care is not covered by this law; regular Plan benefits apply. The following chart has more
information about the limits.
⌠If you…
• are age 65 or over, and
• do not have Medicare Part A, Part B, or both; and
• have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former
spouse; and
• are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this
applies.)
⌠Then, for your inpatient hospital care,
• the law requires us to base our payment on an amount -- the "equivalent Medicare amount" -- set by
Medicare’s rules for what Medicare would pay, not on the actual charge;
• you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;
• you are not responsible for any charges greater than the equivalent Medicare amount; we will show that
amount on the explanation of benefits (EOB) form that we send you; and
• the law prohibits a hospital from collecting more than the Medicare equivalent amount.
⌠And, for your physician care,the law requires us to base our payment and your coinsurance on…
• an amount set by Medicare and called the "Medicare approved amount," or
• the actual charge if it is lower than the Medicare approved amount.
If your physician… Then you are responsible for…
Participates with Medicare or accepts
Medicare assignment for the claim and
is a member of our PPO network,
your deductibles, coinsurance, and copayments;
Participates with Medicare and is not in
our PPO network,
your deductibles, coinsurance, copayments, and
any balance up to the Medicare approved
amount;
Does not participate with Medicare, your deductibles, coinsurance, copayments, and
any balance up to 115% of the Medicare
approved amount
It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are
permitted to collect only up to the Medicare approved amount.
Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If
your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the
charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us.
2003 {insert FFS Plan name} 15 Section 4
2003 {insert FFS Plan name} 16 Section 5
Section 5. Benefits -- OVERVIEW
⌠(See page xx for how our benefits changed this year and page xx 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 claim forms, claims filing advice, or more information about
our benefits, contact us at {phone number} or at our Web site at www.
{insert Web address}.
(a) Medical services and supplies provided by physicians and other health care professionals ..................... xx-xx
{page numbers of section}
• Diagnostic and treatment services
• Lab, X-ray, and other diagnostic tests
• Preventive care, adult
• Preventive care, children
• Maternity care
• Family planning
• Infertility services
• Allergy care
• Treatment therapies
• Physical and occupational therapy
• Speech therapy
• Speech therapy
• Hearing services (testing, treatment, and
supplies)
• Vision services (testing, treatment, and
supplies)
• Foot care
• Orthopedic and prosthetic devices
• Durable medical equipment (DME)
• Home health services
• Chiropractic
• Alternative treatments
• Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health care professionals.................... xx-xx
• Surgical procedures
• Reconstructive surgery
• Oral and maxillofacial surgery
• Organ/tissue transplants
• Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ................................................. xx-xx
• Inpatient hospital
• Outpatient hospital or ambulatory surgical
center
• Extended care benefits/Skilled nursing care
facility benefits
• Hospice care
• Ambulance
(d) Emergency services/Accidents.................................................................................................................... xx-xx
• Accidental injury
• Medical emergency
• Ambulance
(e) Mental health and substance abuse benefits................................................................................................ xx-xx
(f) Prescription drug benefits............................................................................................................................ xx-xx
(g) Special features ........................................................................................................................................... xx-xx
• Flexible benefits option
• {bullet list your features}
(h) Dental benefits {do not remove this--in benefit section show "no benefit" if you don't have dental}.......... xx-xx
(i) Point of Service benefits {remove this & renumber next, if you don't have POS benefits}.......................... xx-xx
(j) Non-FEHB benefits available to Plan members {remove this if you don't have non-FEHB benefits} ........ xx-xx
SUMMARY OF BENEFITS ............................................................... xx{page # from summary at back of brochure}
2003 {insert FFS Plan name} 17 Section 5(a)
Section 5 (a). Medical services and supplies provided by physicians and other
health care professionals
∫
I
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Here are some important things you should keep in mind about these benefits:
•
Please remember that all benefits are subject to the definitions, limitations, and
exclusions in this brochure and are payable only when we determine they are
medically necessary.
•
The calendar year deductible is: $275 per person ($550 per family). The calendar
year deductible applies to almost all benefits in this Section. We added “(No
deductible)” to show when the calendar year deductible does not apply. {If you
want, you can say, "We added asterisks - * - to show when the calendar year
deductible does not apply."}
•
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply
only when you use a PPO provider. When no PPO provider is available, non-PPO
benefits apply.
• Be sure to read Section 4, Your costs for covered services, for valuable information
about how cost sharing works, with special sections for members who are age 65 or
over. Also read Section 9 about coordinating benefits with other coverage,
including with Medicare.
∫
I
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⌠Benefit Description
⌠You pay
After the calendar year deductible…
Notr: The calendar year deductible applies to almost all benefits in this Section. We say “(No deductible)” when it
does not apply.
⌠Diagnostic and treatment services
Professional services of physicians
• In physician’s office
PPO: $15 copayment (No deductible)
Non-PPO: 30% of the Plan allowance and
any difference between our allowance and
the billed amount
40% shading
10% shading
2003 {insert FFS Plan name} 47 Section 6
Section 6. General exclusions -- things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless we determine it is medically necessary to prevent, diagnose, or treat your illness,
disease, injury, or condition.
We do not cover the following:
• Services, drugs, or supplies you receive while you are not enrolled in this Plan;
• Services, drugs, or supplies that are not medically necessary;
• Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric
practice;
• Experimental or investigational procedures, treatments, drugs or devices;
• Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if
the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest {plan specific—
can vary somewhat; discuss with contracts specialist };
• Services, drugs, or supplies related to sex transformations;
• Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
• Services, drugs, or supplies you receive without charge while in active military service.
{Insert other “General Exclusions” that apply—your contract specialist will help you edit for plain language
and necessity – BE SURE TO PUT “; or” after the next to last entry and then a period after the last entry}
2003 {insert FFS Plan name} 48 Section 7
Section 7. Filing a claim for covered services
⌠How to claim benefits To obtain claim forms or other claims filing advice or answers about
our benefits, contact us at __________, or at our Web site at www.xxx
.
In most cases, providers and facilities file claims for you. Your
physician must file on the form HCFA-1500, Health Insurance Claim
Form. Your facility will file on the UB-92 form. For claims questions
and assistance, call us at xxx.
When you must file a claim -- such as for services you receive overseas
or when another group health plan is primary -- submit it on the HCFA-
1500 or a claim form that includes the information shown below. Bills
and receipts should be itemized and show:
• Name of patient and relationship to enrollee;
• Plan identification number of the enrollee;
• Name and address of person or firm providing the service or
supply;
• Dates that services or supplies were furnished;
• Diagnosis;
• Type of each service or supply; and
• The charge for each service or supply.
Note: Canceled checks, cash register receipts, or balance due
statements are not acceptable substitutes for itemized bills.
In addition:
• You must send a copy of the explanation of benefits (EOB) from
any primary payer (such as the Medicare Summary Notice (MSN))
with your claim.
• Bills for home nursing care must show that the nurse is a registered
or licensed practical nurse.
• Claims for rental or purchase of durable medical equipment;
private duty nursing; and physical, occupational, and speech
therapy require a written statement from the physician specifying
the medical necessity for the service or supply and the length of
time needed.
• Claims for prescription drugs and supplies that are not ordered
through the Mail Service Prescription Drug Program must include
receipts that include the prescription number, name of drug or
supply, prescribing physician’s name, date, and charge.
2003 {insert FFS Plan name} 49
Section 8. The disputed claims process
{NOTE TO PLANS: For step numbers below, sample below is 16pt Tahoma. But as long as the numbers stand out
and look balanced, it won't matter what type face you use.}
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our
decision on your claim or request for services, drugs, or supplies – including a request for preauthorization/prior
approval:
Step
Description
1 Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: {{Plan address}}; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific
benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians' letters, operative
reports, bills, medical records, and explanation of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to:
(a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial -- go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a
copy of our request—go to step 3.
3
You or your provider must send the information so that we receive it within 60 days of our request. We
will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.
We will write to you with our decision.
4
If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days;
or
• 120 days after we asked for additional information.
Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health
Insurance Group x, 1900 E Street, NW, Washington, DC 20415-xxxx. {PO Box discontinued. Use zip+4
extensions. Use: Health Insurance Group 1...20415-3610 or Health Insurance Group 2...20415-3620}
2003 {insert FFS Plan name} 50
