VALLEY HEALTH PLAN http:// www. uwz. com 2001
A Health Maintenance
Organization
Serving: West Central Wisconsin
Enrollment in this Plan is
limited; see page 7 for requirements.
Enrollment codes for this Plan:
VH1 Self Only VH2 Self and Family
RI 73-606 1
1 Page
2 3
2001 Valley Health Plan, Inc. 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
...................................................................................................................................
5-6
Service
Area........................................................................................................................................................
7
Section 2. How we change for
2001………………………………………..
.................................................................. 8
Program-wide
changes.......................................................................................................................................
8
Changes to this Plan
...........................................................................................................................................
8
Section 3. How you get care
…………..............................................................................................................................
9
Identification cards
.............................................................................................................................................
9
Where you get covered
care...............................................................................................................................
9
· Plan providers
..............................................................................................................................................
9
· Plan
facilities................................................................................................................................................
9
What you must do to get covered
care..............................................................................................................
9
· Primary care
.................................................................................................................................................
9
· Specialty care
.............................................................................................................................................
10
· Hospital care
..............................................................................................................................................
10
Circumstances beyond our
control..................................................................................................................
11
Services requiring our prior
approval..............................................................................................................
11
Section 4. Your costs for covered
services.......................................................................................................................
12
·
Copayments................................................................................................................................................
12
·
Coinsurance................................................................................................................................................
12
Your out-of-pocket
maximum.........................................................................................................................
12
Section 5.
Benefits…………………………………………………………
................................................................. 13
Overview...........................................................................................................................................................
13
(a) Medical services and supplies provided by physicians and other health
care professionals............ 14
(b) Surgical and anesthesia services
provided by physicians and other health care professionals........ 22
(c)
Services provided by a hospital or other facility, and ambulance services
....................................... 26
(d) Emergency services/
accidents..............................................................................................................
29
(e) Mental health and substance abuse
benefits........................................................................................
31
(f) Prescription drug
benefits.....................................................................................................................
33
(g) Special
features......................................................................................................................................
35
(h) Dental
benefits.......................................................................................................................................
36
Section 6. General exclusions --things we don't
cover..................................................................................................
37 <
Section 7. Filing a claim for covered
services..................................................................................................................
38 2
2 Page 3 4
2001 Valley Health Plan, Inc. Table of Contents 3
Section 8. The disputed claims process
......................................................................................................................
39-40
Section 9. Coordinating benefits with other
coverage.....................................................................................................
41
When you have…
·Other health
coverage...............................................................................................................................
41
·Original Medicare
.....................................................................................................................................
41
·Medicare managed care
plan....................................................................................................................
43
TRICARE/ Workers' Compensation/ Medicaire
........................................................................................
43-44
Other Government
agencies............................................................................................................................
44
When others are responsible for injuries
........................................................................................................
44
Section 10. Definitions of terms we use in this
brochure................................................................................................
45
Section 11. FEHB
facts......................................................................................................................................................
47
Coverage
information........................................................................................................................................
· No pre-existing condition limitation
.......................................................................................................
· Where you get information about enrolling in the FEHB
Program.......................................................
·
Types of coverage available for you and your family
............................................................................
· When benefits and premiums
start...........................................................................................................
· Your medical and claims records are
confidential..................................................................................
· When you
retire........................................................................................................................................
When you lose
benefits.....................................................................................................................................
· When FEHB coverage ends
.....................................................................................................................
· Spouse equity coverage
...........................................................................................................................
· Temporary Continuation of Coverage
(TCC)........................................................................................
· Enrolling in
TCC......................................................................................................................................
· Converting to individual
coverage..........................................................................................................
· Getting a Certificate of Group Health Plan
Coverage...........................................................................
Inspector General advisory
..............................................................................................................................
49
Index..................................................................................................................................................................
50
Summary of
Benefits........................................................................................................................................
51
Rates……………………………………………………………………………………………..
Back cover 3
3 Page
4 5
2001 Valley Health Plan, Inc. 4
Introduction/ Plain Language
Introduction
Valley Health
Plan, Inc.
2270 EastRidge Center
Eau Claire, WI 54701
This brochure describes the benefits of Valley Health Plan, Inc. under our
contract (CS 2669) 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 8. 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
Valley Health Plan, Inc.
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 Valley Health Plan, Inc. 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and
other providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay
the copayments, 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?
Valley Health Plan is a group model
HMO providing pre-paid health care. Services are providedby over 300
physicians in 35 different specialties and subspecialties including
physicians at Midelfort Clinic -Mayo Health System,
Eau Claire's largest multi-specialty group medical practice. Our clinics are
located throughout a 15 county service
area.
Families must choose to
receive their care from one of four options -Midelfort Option, Red Cedar Option,
Cumberland
Option, or Indianhead Option. All family members must belong
to the same option and are encouraged to choose a
primary care physician
from within their chosen option. Each family member may have a different primary
care
physician within their chosen option. Primary care physicians are those
with a specialty in Internal Medicine,
Pediatrics, and Family Practice.
Patients' Bill of Rights
Valley Health Plan has made a commitment
to you by teaming up with our health care providers and support staff to
Provide you with care for your health services. As part of the team, you
work with the other players to get the care
you need. Each team member has
rights and responsibilities to make sure the best care is available. Take time
to
learn the roles of everyone on your health care team.
Your role as a Valley Health Plan Member:
· Use your Member Benefit Handbook as a guide to understanding what is
and is not covered by Valley Health Plan.
· Call our Member Service
Department to assist you in determining coverage or voicing concerns about the
Plan or VHP providers (1-800-472-5411).
· Be active in all areas of
your health and that of your family. · Select and establish a
relationship with one of the health plan's network of physicians.
·
Make choices that help to maintain your health and prevent illness. · Ask
questions of your provider so you understand your health or illness.
· Follow the treatment plan agreed upon by your provider. 5
5 Page 6 7
2001 Valley Health Plan, Inc. 6 Section 1
· Keep your appointment or give reasonable notice to the provider
if you must cancel. · Provide, to the extent necessary, information that
Valley Health Plan and your provider need in order to care for
you.
Patients' Bill of Rights (continued)
Your Doctor's Role:
· Get to know you and your health care needs. · Provide or
coordinate your care.
· Maintain quality standards for your care.
· Explain to you treatment options regardless of insurance coverage or
cost.
· Inform you of the risks and benefits of treatment options.
· Encourage you to be active in the decisions about your treatment.
Valley Health Plan's Role:
· Provide identification cards and a
benefit handbook. · Provide information to explain what is covered and
what is not covered under your policy.
· Provide assistance to help
you understand your coverage. · Tell you about the doctors, clinics, and
hospitals that make up the provider network for Valley Health Plan.
·
Ensure high quality of care. · Manage your bills and claims.
·
Allow you to voice concerns or problems you may have with Valley Health Plan or
our providers by calling our Member Service Department.
· Allow you
to appeal a decision you do not agree with.
Your Employer's Role:
· Select a health plan for employees. · Provide help for you to
understand your health plan.
· Communicate with Valley Health Plan if
there are any problems.
Shared Responsibilities:
· Valley Health Plan will treat you with respect and dignity
regardless of your race, age, sex or creed. We require our providers and their
staff to do the same.
· We ask our members to also show respect and
consideration to health care providers, provider staff, nurses, receptionists,
etc., and to the staff at Valley Health Plan.
· We will ensure that
information about your health and other information will be kept confidential to
the extent required by the law.
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.
If you want more information about us, call 715/ 836-1254 or 800/ 472-5411,
or write to Valley Health Plan, Inc., PO
Box 3128, Eau Claire, WI
54702-3128. You may also contact us by fax at 715/ 836-1298. 6
6 Page 7 8
2001 Valley Health Plan, Inc. 7 Section 1
Service Area
To enroll with us, you must live in our service
area. This is where our providers practice. Our service area is:
The
Wisconsin counties of Chippewa, Dunn, and Eau Claire.
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. 7
7 Page 8 9
2001 Valley Health Plan, Inc. 8 Section 2
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 shorter
day or
visit limitations 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 our Member Service Department at 715/
836-1254 or 800/ 472-5411 or checking
our website www. uwz. 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 68.8% for Self only or 54.3% for Self and Family. ·
Valley Health Plan has reduced the service area to the following Wisconsin
counties: Chippewa, Dunn and
Eau Claire.
· Prescription Drugs: You pay a $10 copayment for
brand name drugs and a $5 copayment for generic name drugs per prescription unit
or refill. 8
8 Page
9 10
2001 Valley Health Plan, Inc.
Section 3 9
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
715/
836-1254 or 800/ 472-5411, extension 1254.
Where you get covered care You get care from "Plan
providers" and "Plan facilities." You will only pay copayments
and/ or coinsurance, and you will not have to file claims.
· · Plan providers Plan providers are physicians and
other health care professionals in our service area that we contract with to
provide covered services to our
members. We credential Plan providers
according to national standards.
We list Plan providers in the provider
directory, which we update
periodically.
· ·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.
What you must do to get covered 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.
· ·Primary care Your primary care physician can be an
internists, pediatrician, family practitioner or gynecologist. 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. 9
9 Page 10 11
2001 Valley Health Plan, Inc. Section 3 10
· · Specialty care Referrals to a participating
provider of the Plan for specialty care do not require prior written
authorization from Valley Health Plan. A woman
may see her plan gynecologist
for her annual routine exam without a
referral. Prior written authorization
from Valley Health Plan is required
when receiving care through providers
not affiliated with Valley Health
Plan except in the case of an emergency.
Here are other things you should know about specialty care:
· If
you need to see a specialist frequently because of a chronic, complex, or
serious medical condition, your primary care physician
will develop a
treatment plan that allows you to see your Plan specialist without a referral.
· 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 usor, 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 715/ 836-1254 or 800/
472-5411, extension 1254. If you are new to the FEHB Program, we
will arrange for you to receive care. 10
10
Page 11 12
2001
Valley Health Plan, Inc. Section 3 11
Hospital Care (continued)
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.
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 physician must get our
approval before referring you to a non-Plan specialist. Before giving approval,
we consider if the service is
medically necessary, and if it follows generally accepted medical
practice. 11
11 Page
12 13
2001 Valley Health Plan, Inc.
Section 5 12
Section 4. Your costs for covered services
You
must share the cost of some services. You are responsible for:
·
· Copayments A copayment is a fixed amount of money you pay to the
provider when you receive services.
Example: When you see your primary care physician you pay a
copayment of
$10 per office visit and when you go to the emergency room,
you pay a $25
copayment. You have a $5 copay for generic prescriptions
and $10 copay for
brand name prescriptions.
· ·Coinsurance Coinsurance is the percentage of our negotiated
fee that you must pay for your care.
Example: In our Plan, you pay 20% per
purchase or rental on durable
medical equipment and diabetic supplies up to
your maximum out-of-pocket
of $500. Benefits are provided for ambulance
transportation
ordered or authorized by a Plan doctor up to $300 per
occurrence, then
20% member coinsurance. Air ambulance is paid in full up to
$1000 per
occurrence, then 20% member coinsurance.
Your out-of-pocket maximum for coinsurance After your coinsurance for
Durable Medical Equipment (DME) and
Diabetic Supplies total $500 per person
in any calendar year, you do not
have to pay any more for covered services.
Be sure to keep accurate records of your coinsurance since you are
responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 Valley Health Plan, Inc. Section 5 13
Section 5. Benefits --OVERVIEW
(See page 8 for how our
benefits changed this year and page 51 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to the
benefits in the
following subsections. To obtain claims forms, claims filing
advice, or more information about our benefits, contact us
at 715/ 836-1254.
(a) Medical services and supplies provided by physicians and other health
care professionals ....................................... 14-21
·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
·Alternative treatments
·Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals......................... 22-25
·Surgical
procedures ·Reconstructive surgery ·Oral and maxillofacial surgery
·Organ/ tissue transplants
·Anesthesia
(c) Services
provided by a hospital or other facility, and ambulance
services........................................................ 26-28
·Inpatient hospital ·Outpatient hospital or ambulatory surgical
center
·Extended care benefits/ skilled nursing care facility
benefits
·Hospice care ·Ambulance
(d) Emergency services/ accidents
..............................................................................................................................
29-30
·Medical emergency ·Ambulance
(e) Mental health and substance abuse
benefits........................................................................................................
31-32
(f) Prescription drug
benefits......................................................................................................................................
33-34
(g) Special features
............................................................................................................................................................
35
(h) Dental
benefits..............................................................................................................................................................
36
Summary of benefits
...........................................................................................................................................................
51 13
13 Page 14
15
2001 Valley Health Plan, Inc. 14 Section
5( b)
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
· Physician's home visit
$10 per office visit
$20 per visit
Professional services of physicians
· In an urgent care center
· Office medical consultations
· Second surgical opinion
$10 per office visit
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap
tests
· Pathology
· X-rays
· Non-routine
Mammograms
· Cat Scans/ MRI (MRI's may require prior written VHP
authorization,
please contact VHP's Member Service Department)
· Ultrasound
· Electrocardiogram and EEG
Nothing if you receive these
services during your office visit;
otherwise, $10 per office visit
Preventive care, adult You pay
Routine annual examination to
include:
· Prostate Specific Antigen (PSA test) – one annually
· Routine pap test
· Routine mammogram
$10 per office visit
Preventive care, adult – continued on next page 14
14 Page 15 16
2001 Valley Health Plan, Inc. 15 Section 5(
b)
Preventive care, adult (Continued) You pay
Not covered: Physical exams required for obtaining or continuing
employment or insurance, pilot license, attending schools or camp, or
travel.
All charges.
Routine Immunizations, limited to:
· Tetanus-diphtheria (Td)
booster – once every 10 years
· Influenza/ Pneumococcal
vaccines, annually
$10 copay will apply to associated
visit
Preventive care, children You pay
Well-child care charges for
routine examinations, immunizations and care (through age 22) $10 per office
visit
Maternity care You pay
Complete maternity (obstetrical) care, such
as:
· Routine Prenatal care
· Delivery
·
Postnatal care
Note: Here are some things to keep in mind:
· You do not need to precertify your normal delivery.
· 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 for routine prenatal care
$10 per office visit for non-routine
prenatal visits due to
complications
Not covered:
· Tests solely for determination of fetal
sex · Medical and hospital costs resulting from a normal full-term
delivery of a
baby outside of the VHP service area.
All charges
Family planning You pay
· Voluntary sterilization
· Surgically implanted contraceptives (eg: Norplant)
·
Injectable contraceptive drugs (eg: Depo-Provera)
· Intrauterine
devices (eg: IUDs)
· Genetic counseling
$10 copay will apply to associated
visit
Family Planning – continued on next page 15
15 Page 16 17
2001 Valley Health Plan, Inc. 16 Section 5(
b)
Family planning (Continued) You pay
Not
covered: reversal of voluntary surgical sterilization, All charges.
Infertility services You pay
Diagnosis and treatment of
infertility, such as:
· Artificial insemination:
··intravaginal insemination (IVI)
··intracervical insemination (ICI)
··intrauterine insemination (IUI)
$10 per office visit
Not covered:
· Fertility drugs
·
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
All charges.
Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit
Allergy serum Nothing
Not covered: provocative food testing and
sublingual allergy
desensitization
All charges
Treatment therapies You pay
· Chemotherapy and radiation
therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/
Tissue Transplants on page 27.
· Respiratory and inhalation therapy
· Dialysis –
Hemodialysis and peritoneal dialysis
Nothing
Treatment Therapies – continued on next page 16
16 Page 17 18
2001 Valley Health Plan, Inc. 17 Section 5(
b)
Treatment therapies (Continued) You pay
· Growth hormone therapy (GHT)
Note: – We will only
cover GHT when we preauthorize the treatment.
ask your VHP physician to
submit information that establishes that the
GHT is medically necessary. Ask
us to authorize GHT before you
begin treatment; otherwise, we will only
cover GHT services from the date approved by VHP. 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.
Prescription drug copays apply
(See 5 (f), pages 33-34)
· Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic
therapy – Covered under Durable Medical Equipment benefit. $10 copay per
visit
Rehabilitative therapies You pay
Short-term rehabilitative
therapy (physical therapy, occupational therapy and speech therapy ) using
qualified physical therapists,
speech therapists and occupational
therapists.
· Provided on an inpatient or outpatient basis for up to
two months per condition if significant improvement can be expected within two
months. Speech therapy is limited to treatment of certain speech
impairments of organic origin. Occupational therapy is limited to
services that assist the member to achieve and maintain self-care
and
improved functioning in other activities of daily living.
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.
· Phase I (inpatient) and Phase II (outpatient) Cardiac
rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction. Phase II rehabilitation is covered three
sessions
a week for up to 12 weeks.
$10 per office visit
Not covered:
· long-term rehabilitative therapy
· exercise programs
· phase III cardiac
rehabilitation
All charges. 17
17 Page 18 19
2001 Valley
Health Plan, Inc. 18 Section 5( b)
Hearing services (testing,
treatment, and supplies) You pay
· Hearing testing for medical
diagnosis only
· Hearing testing for children through age 17 (see
Preventive care, children)
$10 per office visit
Not covered:
· all other hearing testing (eg: for the
purpose of hearing aids) · hearing aids, testing and examinations
for them
All charges.
Vision services (testing, treatment, and supplies) You pay
One
routine vision exam per calendar year
· Annual eye refractions
$10 per office visit
Not covered:
· Eyeglasses, contact lenses and fittings
· Internal Ocular Photographs
· Vision
therapy
· Eye exercises and orthoptics
·
Radial keratotomy and other refractive surgery( corrective eye surgeries)
All charges.
Foot Care You pay
Routine foot care when you are under active
treatment for a metabolic
or peripheral vascular disease, such as diabetes.
$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. 18
18 Page 19 20
2001 Valley
Health Plan, Inc. 19 Section 5( b)
Orthopedic and prosthetic
devices You pay
· Artificial limbs and eyes; stump hose
· Externally worn breast prostheses (one every two years) and
surgical bras (four per year), following a mastectomy
· Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
· Custom
made orthotics
· Elastic support hose (four pair per year)
· Corsets
· Internal prosthetic devices, such as artificial joints, pacemakers,
and surgically implanted breast implant following mastectomy. Note:
We pay
internal prosthetic devices as hospital benefits; see Section 5 (c) for payment
information. See 5( b) for coverage of the surgery
to insert the device.
Note: – We will only cover Orthopedic and prosthetic devices when
you receive prior written VHP authorization. Ask your VHP physician
to
submit information that establishes that the device is medically
necessary.
Ask us to authorize the device before you begin treatment;
otherwise, we
will only cover services from the date the device is
authorized. If the
device is not medically necessary, we will not cover
the device or related
services and supplies.
You pay 20% up to a $500 annual
maximum.
Not covered:
· Over-the-counter supplies/ devices, even
if purchased with a prescription
· Cochlear implants
· Over-the-counter orthopedic
and corrective shoes
· arch supports
·
over-the-counter foot orthotics
· heel pads and heel cups
· lumbosacral support
· trusses ·
prosthetic replacements provided less than 3 years after the last one
covered by VHP
All charges. 19
19 Page 20 21
2001 Valley
Health Plan, Inc. 20 Section 5( b)
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.
Prior
written VHP authorization is required for some equipment, please
contact VHP's Member Service Department to determine if prior
authorization is required. Equipment may be subject to review to assure
condition meets VHP's criteria. Under this benefit, we also cover:
· oxygen and dialysis equipment
· nebulizers;
·
bi-pap and c-pap machines;
· hospital beds;
· standard
manual wheelchairs;
· crutches;
· walkers;
·
blood glucose monitors;
· insulin pumps;
· diabetic
supplies, including insulin syringes, needles, gluose test tablets and tape,
Benedict's solution or equivalent and acetone test
tablets;
· disposable needles and syringes needed to inject
covered prescribed medication
Note: –Ask us to authorize the device before you begin treatment;
otherwise, we will only cover services from the date the DME is
authorized. If the DME is not medically necessary, we will not cover
the
DME or related services and supplies.
You pay 20% up to a $500 annual
maximum
Not covered:
· Motorized wheelchairs and scooters
· Motor vehicles (e. g. cars, vans) or customization of vehicles,
lifts
for wheelchairs and scooters, and stair lifts
·
Whirlpools
· Batteries or battery chargers
·
Over-the-counter equipment, even if purchased with a prescription
· Eyeglasses or contact lenses expect as specified in this
contract
· Dentures
· Medical supplies and
durable medical equipment for comfort, person hygiene, and convenience items,
such as, but not limited to,
air conditioners, air cleaners, humidifiers; or physical fitness
equipment; physicians equipment; disposable supplies; alternative
communication devices; and self-help devices not medical in
nature.
· Equipment, models, or devices which have features over and above
that which are medically necessary for the participant will be
limited to the standard model as determined by VHP.
All charges. 20
20 Page 21 22
2001 Valley
Health Plan, Inc. 21 Section 5( b)
Home health services You
pay
· Home health care ordered by a Plan physician and provided
by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed
vocational nurse (L. V. N.), or home health aide.
· Services
include oxygen therapy, intravenous therapy and medications.
Note: – We will only cover home health services when you receive
prior written VHP authorization. Ask your VHP physician to submit
information that establishes that the home health services are medically
necessary. Ask us to authorize the services before you begin treatment;
otherwise, we will only cover services from the date the home health
services are authorized. If the services are not medically necessary, we
will not cover the home health services or related charges.
$10 per home visit
Not covered:
· nursing care requested by, or for the
convenience of, the patient or the patient's family;
· nursing care primarily for hygiene, feeding, dressing,
exercising, moving the patient, homemaking, companionship or giving oral
medication.
All charges.
Alternative treatments You pay
· chiropractic services
· biofeedback, prior written VHP authorization required
$10 per office visit
Not covered:
· Acupuncture; · dry
needling;
· naturopathic services; · hypnotherapy;
· massage therapy; · rolfing;
·
music therapy; · recreational therapy;
·
sensory integration treatment/ therapy; · prolotherapy;
· yoga therapy
All charges.
Educational classes and programs You pay
Coverage is limited to:
· Diabetes self-management $10 per office visit 21
21 Page 22 23
2001 Valley Health Plan, Inc. 22 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 charge (i. e. hospital,
surgical center, etc.).
· YOU MUST GET PRECERTIFICATION OF SOME
SURGICAL PROCEDURES. Please contact VHP's Member Service Department.
I M
P O
R T
A N
T
Benefit Description You pay
…
Surgical procedures You Pay
· 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. Prior written VHP authorization
is required.
· Insertion of internal prosthetic devices. See 5( a) –
Orthopedic braces and prosthetic devices for device coverage information.
Nothing, if services are provided in
a hospital or outpatient surgical
facility.
$10 per office visit
· Voluntary sterilization · Norplant (a surgically implanted
contraceptive) and intrauterine
devices (IUDs)
· 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.
Not covered:
· Reversal of voluntary sterilization
· Routine treatment of conditions of the foot; see Foot care.
All charges. 22
22 Page
23 24
2001 Valley Health Plan, Inc.
23 Section 5( b)
Reconstructive surgery You pay
· Surgery to correct a functional defect
· Surgery to
correct a condition caused by injury or illness if:
··the
condition produced a major effect on the member's appearance and
··the condition can reasonably be expected to be corrected by
such surgery
Surgery to correct a condition that existed at or from birth
and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.
Nothing, if services are provided in
a hospital or outpatient surgical
facility.
· 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.
.
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 You pay
Oral surgical procedures,
limited to:
· Reduction of fractures of the jaws or facial bones;
· Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
· Removal of stones from salivary ducts; ·
Excision of leukoplakia or malignancies;
· Excision of cysts and incision of abscesses when done as independent
procedures; and
· Other surgical procedures that do not involve the teeth or their
supporting structures.
$10 per office visit
Not covered:
· Oral implants and transplants
· Procedures that involve the teeth or their supporting structures
(such
as the periodontal membrane, gingiva, and alveolar bone)
·
Periodontic care
· General dental care
·
Orthodontics
All charges. 23
23 Page 24 25
2001 Valley
Health Plan, Inc. 24 Section 5( b)
Temporomandibular Joint
Dysfunction (TMJ) You pay
Diagnostic procedures and non-surgical
treatment including:
· Evaluations
· Physical therapy
· Chiropractic services
Note: prior written VHP authorization is
not required for the above TMJ services.
$10 copay per office visit
· Biofeedback, prior written VHP authorization required $10 copay per
office visit
· Splint therapy
Note: prior written VHP
authorization is required.
You pay 20% up to a $500 annual
maximum.
· Surgical treatment
Note: prior written VHP authorization is
required.
Covered under the hospital benefit,
you pay nothing, coverage is 100%
Not covered:
· Orthodontics · Periodontic
care
· General dental care
All charges. 24
24 Page 25 26
2001 Valley
Health Plan, Inc. 25 Section 5( b)
Organ/ tissue transplants
You pay
Limited to:
· Cornea
· Heart
·
Heart/ lung
· Parathyroid and musculoskeletal
· Kidney
· Kidney/ Pancreas
· Liver
· Lung: Single
–Double
· Pancreas
· Allogeneic (donor) bone marrow
transplants
· Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma;
advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer;
multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
· National Transplant Program (NTP) -Note:
Prior written VHP
authorization is required. Coverage is limited
to one transplant per organ
per lifetime, except kidney. We cover
related medical and hospital expenses
of the donor when we cover the
recipient.
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
Anesthesia You pay
Professional services provided in –
· Hospital (inpatient)
Nothing
Professional services provided in –
· Hospital outpatient
department · Skilled nursing facility
· Ambulatory surgical
center · Office
Nothing 25
25 Page
26 27
2001 Valley Health Plan, Inc.
26 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).
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
Inpatient hospital – continued on next page 26
26 Page 27 28
2001 Valley Health Plan, Inc. 27 Section 5(
c)
Inpatient hospital (Continued) You pay
Other
hospital services and supplies, such as:
· Operating, recovery,
maternity, and other treatment rooms · Prescribed drugs and medicines
· Diagnostic laboratory tests and X-rays · 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
· Medical supplies,
appliances, medical equipment, and any covered items used during a hospital
confinement
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.
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,
subject to VHP criteria Prior written VHP authorization is required. We
do not cover the dental procedures.
Nothing
lExtended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF): 120 days per calendar year when
full-time
skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate.
Note: Prior written VHP authorization is required.
Nothing
Not covered: custodial care All charges 27
27 Page 28 29
2001 Valley Health Plan, Inc. 28 Section 5(
c)
Hospice care You pay
Covers hospice care if the primary
care provider certifies that the
participants life expectancy is six months
or less, the care is palliative in
nature and authorized by VHP. Hospice
care is provided by an inter-disciplinary
team consisting of, but not
limited to: registered nurses,
home health or hospice aids, LPNs, and
counselors. Hospice care
includes, but is not limited to, medical supplies
and services,
counseling, bereavement counseling for one year after the
participants death, durable medical equipment rental, home visits, and emergency
transportation. Coverage may be continued beyond a six month period
if
authorized by VHP. Facility hospice does not include coverage for
the room
and board charges.
Note: Prior written VHP authorization is required.
Nothing
Not covered: Independent nursing, homemaker services All charges
Ambulance You pay
Non-emergency ambulance transfers from one
facility to another may
be eligible for coverage by VHP, prior written VHP
authorization is
required.
Ground ambulance; You pay 20%
of all charges over the first $300
Air ambulance; You pay 20% of
all charges over the first
$1,000
Not covered: Non-emergency ambulance services (eg: non-emergency
van
transportation, ambulance services where medical attention is not
required
en route)
All charges 28
28 Page 29 30
2001 Valley
Health Plan, Inc. 29 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.
· 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:
Seek emergency care from a VHP hospital provider whenever possible. If the
emergency is life-threatening, go to the closest facility. You or a family
member
must notify VHP, unless it is not reasonably possible to do so,
within 48 hours of the services, 715-836-
1254 or 1-800-472-5411.
Emergencies outside our service area: Seek emergency care from the
closest facility. You or a family member must notify VHP, unless it is not
reasonably possible to do so, within 48 hours of the
services, 715-836-1254
or 1-800-472-5411.
Follow-up care:
Follow-up care to an emergency
needs to be provided by VHP providers to be covered by VHP.
Benefit Description You pay
Emergency within our service area You pay
· Emergency care at a doctor's office
· Emergency care at
an urgent care center
$10 per office visit
· Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
Note: *Waived if admitted as an inpatient
directly from the ER.
$25 Emergency room copay per visit.*
Not covered: Elective care or non-emergency care with a non-VHP
provider inside our service area.
All charges. 29
29 Page 30 31
2001 Valley Health Plan, Inc. 30 Section 5(
d)
Emergency outside our service area You pay
·
Emergency care at a doctor's office · Emergency care at an urgent care
center $10 per office visit
· Emergency care as an outpatient or inpatient at a hospital,
including doctors' services
Note: *Waived if admitted as an inpatient directly from the ER.
$25
Emergency room
copay 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
· Follow-up to
emergency care received with non-VHP providers
All charges.
Ambulance You pay
Professional ambulance service when medical
attention is required en
route.
See 5( c) for non-emergency service.
Ground ambulance-You
pay 20% of all
charges over the first
$300
Air ambulance; You pay
20% of all charges
over the first $1,000
Not covered: ambulance services where medical attention is not required en
route All charges. 30
30 Page 31 32
2001 Valley
Health Plan, Inc. 31 Section 5( f)
Section 5 (e). Mental
health and substance abuse benefits
I M
P O
R T
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.
I M
P O
R T
A N
T
Benefit Description You pay
Mental Health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan
provider
and contained in a treatment plan that we approve. The
treatment plan may
include services, drugs, and supplies
described elsewhere in this brochure.
Note: Plan benefits are payable only when we determine the
care is
clinically appropriate to treat your condition and only
when you receive the
care as part of a treatment plan that we approve.
Your cost sharing responsibilities are no
greater than for other illness
or conditions.
· Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical
social
workers
· Medication management
Outpatient visits -$10 copayment per visit
Transitional Care – 100%
coverage, prior
written VHP authorization is required when
using non-VHP
provider
Inpatient Care – 100% coverage, prior written
VHP authorization is
required when using non-VHP provider
· Diagnostic tests $10 copay will apply to associated visit.
Mental Health and substance abuse benefits – continued on next page
31
31 Page 32
33
2001 Valley Health Plan, Inc. 32 Section
5( f)
Mental Health and substance abuse benefits (Continued)
You
pay
· Services provided by a Plan hospital or other Plan facility
· Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment
Nothing
Not covered: Services we have not approved.
Note: OPM will base its
review of disputes about treatment
plans on the treatment plan's clinical
appropriateness. OPM
will generally not order us to pay or provide one
clinically appropriate treatment plan in favor of another.
All charges.
Preauthorization To be eligible to receive these mental health and
substance abuse benefits you must follow your treatment plan and all of our
network authorization
processes. This includes:
Any Services with
non-VHP providers require prior written VHP
authorization. VHP is an HMO, in
order for benefits to apply, you need to
use VHP providers. If your VHP
provider refers you to a non-VHP
provider, you are responsible for obtaining
prior authorization from VHP.
To do this, contact the referring VHP provider
and ask that they forward a
request for authorization for services to VHP.
We will review and will
notify you in writing of the decision.
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 for reasons other than
retirement, move from our service area, or misconduct, you may continue
to receive care for up to 90 days.
If this condition applies to you, we will allow you reasonable time to
transfer
your care to a network mental health or substance abuse
professional
provider. During the transitional period, you may continue to
see your
treating provider. This transitional period will begin with our
notice to you.
The transitional period will last for up to 90 days from the
date you receive
our notice. You may receive this notice prior to
January 1, 2001, and the 90 day period begins with receipt of the notice.
Limitation We may limit your benefits if you do not follow your
treatment plan. 32
32 Page
33 34
2001 Valley Health Plan, Inc.
33 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.
· There is not a calendar year deductible for
prescriptions.
· Some medications may require prior written VHP
authorization, please check with VHP's Member Service Department if you have any
questions.
· Be sure to read Section 4, Your costs for covered services
for valuable information about how cost sharing works. Also read Section 9
about coordinating benefits with other
coverage, including with Medicare.
I M
P O
R T
A N
T
There are important features you should be aware of. These include:
· Who can write your prescription. A plan physician or
licensed dentist must write the prescription .
· Where you can obtain them. You must fill the prescription at
a VHP pharmacy. If you are out of the VHP service area and have an emergency
care visit, we will cover the initial fill at a non-VHP
pharmacy
written by that emergency care provider.
· We use a formulary. VHP's drug formulary is used by our
network providers. The formulary includes a large enough range of drugs, with
sufficient information about them to enable health
practitioners,
physicians, and nurse practitioners to prescribe treatment that is medically
appropriate.
The drug formulary is the cornerstone of drug therapy quality
assurance and cost containment
efforts. The drug formulary process has been
successfully used by hospitals and managed care
organizations to provide
comprehensive, cost-effective pharmacy services. Non-Formulary drugs
will be
dispensed if medically necessary and the formulary drugs are not suitable for
the participant
as determined by the VHP physician. Non-formulary drugs must
be prior authorized by VHP. The
formulary may be revised as deemed necessary
by VHP.
· These are the dispensing limitations. A 34 day supply may be
dispensed for a $5/ generic or $10/ brand copayment. VHP does have a limited
maintenance drug list where a three-month supply
may be obtained for one $5/ generic or $10/ brand copayment. Not all
maintenance drugs are included
on the maintenance drug listing. VHP
determines the list by usage and cost factors. VHP does
reserve the right to
alter the maintenance drug listing or eliminate it at any time.
· When you have to file a claim. Eligible prescriptions written
by VHP providers and filled at a VHP pharmacy will be submitted to us by the VHP
pharmacy. You will be responsible for your
copayment. If you have a receipt for an initial prescription fill as the
result of emergency care
received out of the VHP service area, please submit
that receipt to VHP for reimbursement, less the
appropriate copayment.
Again, VHP will only cover the initial fill of a prescription from out-of-area
emergency care, refills must be rewritten by your VHP physician and filled
at a VHP pharmacy to be eligible for coverage.
Prescription drug benefits begin on the next page. 33
33 Page 34 35
2001 Valley Health Plan, Inc. 34 Section 5(
f)
Benefit Description You pay After the calendar year deductible
Covered medications and supplies You pay
We cover the following
medications and supplies prescribed by a Plan
physician and obtained from a
Plan pharmacy:
· Drugs and medicines that by Federal law of the United States require
a physician's prescription for their purchase, except as excluded below.
· Insulin · Drugs for sexual dysfunction (dosage limits apply,
you pay applicable
copayment up to the dosage limit established by VHP)
· Contraceptive drugs
Note: If there is no generic equivalent available, you will still have to
pay the brand name copay.
$5 per 34 day supply of generic
medications
$10 per 34 day supply of brand
medications
· Disposable needles and syringes for the administration of covered
medications (See Section 5 (b), page 20). Covered under the DME benefits.
You pay 20% up to a $500 annual
maximum.
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 name brand. If you receive a
name
brand drug when a Federally-approved generic drug is
available, and your
physician has not specified Dispense as Written
for the name brand drug, you
have to pay the difference in cost
between the name brand drug and the
generic.
· We have an open formulary. If your physician believes a name brand
product is necessary or there is no generic available, your
physician may
prescribe a name brand drug from a formulary list.
This list of name brand
drugs is a preferred list of drugs that we
selected to meet patient needs at
a lower cost.
Not covered:
· Appetite suppressants
·
Costs of any medication that exceeds VHP's dosage limitation
·
Replacement of lost, stolen, forgotten or destroyed prescriptions
· Drugs and supplies for cosmetic purposes
·
Vitamins, nutrients and food supplements even if a physician prescribes or
administers them
· Nonprescription medicines
· Medications that
have an over-the-counter equivalent available
All Charges 34
34 Page 35 36
2001 Valley
Health Plan, Inc. 35 Section 5( g)
Section 5 (g). Special
Features
Feature Description
24 hour line For any of your health
concerns, 24 hours a day, 7 days a week, you may call the on-call physician at
your clinic. Please contact your
clinic for on-call phone numbers.
Travel benefit/ services
overseas
Valley Health Plan provides coverage world-wide for initial
emergency
care. Please contact VHP as soon as possible if you have
an emergency out of
our service area. 35
35 Page
36 37
2001 Valley Health Plan, Inc.
36 Section 5( h)
Section 5 (h). Dental benefits
I M
P
O
R T
A N
T
Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the
definitions, limitations, and exclusions in this brochure and are payable only
when we determine they are medically necessary.
· Plan dentists must provide or arrange your care.
·
Benefit: preventive dental benefit for children ages 11 and under. Coverage
includes annual oral exam, prophylaxis (cleaning) , annual topical application
of fluoride, preventive
dental instructions, bitewing x-rays.
· 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. Subject to VHP criteria Prior written VHP authorization is
required. We do not cover the dental procedures.
I M
P O
R T
A N
T
Accidental injury benefit
Dental services rendered by a VHP
Network Provider or with prior written VHP authorization to promptly repair,
but not to replace, sound natural teeth., if the dental services are
required as the result of non-occupational accidental
injury. If services
are required following the original emergency visit, a pretreatment estimate
must be submitted to
VHP for approval. Services completed within six months
of the accident will be covered by VHP. Excludes
coverage for damage done to
natural teeth as a result of biting or eating. Sound natural teeth are those
teeth without fillings or crowns, with a healthy viable root. You pay 20% of the
first $500 in charges, nothing thereafter.
Dental Benefits
Service You pay
Preventive dental for children ages 11 and under
including:
· Annual oral exam
· Prophylaxis (cleaning)
·
Annual topical application of fluoride
· Preventive dental
instruction
· Bitewing x-rays
$10 per office visit
Not Covered:
· No other dental services are covered.
36
36 Page 37
38
2001 Valley Health Plan, Inc. Section 6 37
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;
· Services, drugs, or supplies you receive from a
provider or facility barred from the FEHB Program;
· Services, drugs,
or supplies for cosmetic or beautifying purposes;
· Therapies, as
determined by VHP, for the evaluation, diagnosis or treatment of educational
problems; or
· Hospital stays which are extended for reasons other than medical
necessity, i. e. lack of transportation, lack of care-giver, inclement weather
or other like reasons. 37
37 Page 38 39
2001 Valley
Health Plan, Inc. 38 Section 7
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or obtain your prescription drugs at Plan pharmacies,
you will not have to file claims. Just present your identification card and pay
your copayment,
coinsurance, or deductible.
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 and 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 715/ 836-1254 or 800/ 472-5411,
extension 1254.
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: Valley Health Plan PO Box 3128
Eau Claire, WI 54702-3128
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim within 12 months of the
date of service, unless
timely filing was prevented by administrative
operations of Government
or legal incapacity, provided the claim was
submitted as soon as
reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 38
38 Page
39 40
2001 Valley Health Plan, Inc.
39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on
your claim or request for
services, drugs, or supplies – including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. Write to us
at: 2270 EastRidge Center, PO Box 3128, Eau Claire, WI 54702-3128. You must:
(a) Write to us within 6 months from the date of our decision; and
(b)
Send your request to us at: Valley Health Plan, Inc., 2270 EastRidge Center, PO
Box 3128, Eau
Claire, WI 54702-3128.; and
(c) Include a statement about why you believe our initial decision was wrong,
based on specific
benefit provisions in this brochure; and
(d) Include copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our request— go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days. If we do
not receive the information within 60 days, we will decide within 30 days of the
date the
information was due. We will base our decision on the information
we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
· 90 days after the date of our letter
upholding our initial decision; or
· 120 days after you first wrote
to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division III, P. O. Box 436, Washington, D. C. 20044-0436.
39
39 Page 40 41
2001 Valley Health Plan, Inc. 40 Section 8
The Disputed Claims process (Continued)
Send OPM the following
information:
· A statement about why you believe our decision was
wrong, based on specific benefit provisions in this brochure;
· Copies of documents that support your claim, such as physicians'
letters, operative reports, bills, medical records, and explanation of benefits
(EOB) forms;
· Copies of all letters you sent to us about the claim;
· Copies of all letters we sent to you about the claim; and
· Your daytime phone number and the best time to call.
Note: If
you want OPM to review different claims, you must clearly identify which
documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
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 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services 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
715/ 836-1254 or 800/
472-5411, extension 1254, 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. 40
40 Page 41 42
2001 Valley Health Plan, Inc. 41 Section 9
Section 9. Coordinating benefits with other coverage
When you
have other health coverage You must tell us if you are covered or a family
member is covered under another group health plan or have automobile insurance
that pays health
care expenses without regard to fault. This is called
"double coverage."
When you have double coverage, one plan
normally pays its benefits in
full as the primary payer and the other plan
pays a reduced benefit as the
secondary payer. We, like other insurers,
determine which coverage is
primary according to the National Association of
Insurance Commissioners' guidelines.
When we are the primary payer, we will pay the benefits described in this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance, up
to our
regular benefit. 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. Your care
must continue to be authorized by your Plan PCP, or precertified as
required.
We will not waive any of our copayments, coinsurance, and deductibles.
(Primary payer chart begins on next page.) 41
41 Page 42 43
2001 Valley Health Plan, Inc. 42 Section 9
The following chart illustrates whether Original Medicare or this Plan
should be the primary payer for you according
to your employment status and
other factors determined by Medicare. It is critical that you tell us if you or
a covered
family member has Medicare coverage so we can administer these
requirements correctly.
Primary Payer Chart
Then the primary payer is… A. When either
you --or your covered spouse --are age 65 or over and …
Original Medicare This Plan
1) Are an active employee with the
Federal government (including when you or
a family member are eligible for
Medicare solely because of a disability), 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
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 42
42 Page
43 44
2001 Valley Health Plan, Inc.
43 Section 9
· Claims process You probably will
never have to file a claim form when you have both
our plan and Medicare and
you are using VHP providers.
· 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 715/ 836-1254 or 800/ 472-5411.
· We do not waive costs when you have Medicare.
· · 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 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
our 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, coinsurance, or
deductibles.
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 managed care plan service area.
· · 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. 43
43 Page
44 45
2001 Valley Health Plan, Inc.
44 Section 9
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 When you receive money to compensate you
for
for injuries medical or hospital care for injuries or illness
caused by another person, you must reimburse us for any expenses we paid.
However, we will
cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 44
44 Page 45 46
2001 Valley
Health Plan, Inc. 45 Section 10
Section 10. Definitions of
terms we use in this brochure
Calendar year January 1 through December
31 of the same year. For new enrollees, the calendar year begins on the
effective date of their enrollment and ends on
December 31 of the same year.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 12.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 12.
Covered services Care we provide
benefits for, as described in this brochure.
Custodial care Provision
of room and board, nursing care, or personal care designed to assist an
individual who, in the opinion of a plan physician, has reached
the maximum
level of recovery. In the case of confinement in a Hospital
or nursing
facility, Custodial Care also includes room and board, nursing
care, or such
other care which is provided to an individual for whom it
cannot reasonably
be expected, in the opinion of the Plan physician, that
the medical or
surgical treatment will enable that person to live outside
an institution.
Custodial care also includes rest cures, respite care, and
home care
provided by family members.
Experimental or The use of any service, treatment, procedure,
facility, equipment, drug,
investigational services device or supply
for a participant's illness or injury that, as determined by the Plan: (a)
requires the approval by the appropriate federal or other
governmental agency that has not been granted at the time it is used; or
(b) isn't yet recognized as acceptable medical practice to treat that
illness
or injury for a Participant's illness or injury. The criteria that
the Plan
uses for determining whether or not a service, treatment,
procedure,
facility, equipment, drug, device or supply is considered to be
experimental or investigative include, but are not limited to: (a) whether
the service, treatment, procedure, facility, equipment, drug, device or
supply is commonly performed or used on a widespread geographic
basis;
(b) whether the service, treatment, procedure, facility, equipment,
drug,
device or supply is generally accepted to treat that illness or injury
by
the medical profession in the United States; (c) the failure rate and
side
effects of the service, treatment, procedure, facility, equipment, drug, device
or supply; (d) whether other, more conventional methods of
treating the illness or injury have been exhausted by the Participant; (e)
whether the service, treatment, procedure, facility, equipment, drug,
device or supply is medically indicated; (f) whether the service,
treatment, procedure, facility, equipment, drug, device or supply is
recognized for reimbursement by Medicare, Medicaid and other insurers
and self-funded plans. 45
45 Page 46 47
2001 Valley
Health Plan, Inc. 46 Section 10
Medical necessity A
service, treatment, procedure, equipment, drug, device or supply provided by a
Hospital, physician or other health care provider that is
required to
identify or treat a Participant's illness or injury and which is,
as
determined by the Plan: (1) consistent with the symptom( s) or
diagnosis and
treatment of the Participant's illness or injury; (2)
appropriate under the
standards of acceptable medical practice to treat that illness or injury; (3)
not solely for the convenience of the Participant,
physician, Hospital or other health care provider; (4) the most appropriate
service, treatment, procedure, equipment, drug, device or supply which
can be safely provided to the Participant and accomplishes the desired
end result in the most economical manner.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services. Fee-for-service plans
determine their
allowances in different ways. We determine our allowance as
follows:
An amount for a treatment, service or supply provided by a non-plan
health care provider that is reasonable, as determined by the Plan, when
taking into consideration, among other factors determined by the Plan,
amounts charged by health care providers for similar treatment, services
and supplies when provided in the same general area under similar or
comparable circumstances and amounts accepted by the health care
provider as full payment for similar treatment, services and supplies. In
some cases the amount the Plan determines as reasonable may be less
than
the amount billed. In these situations the Participant is held harmless for the
difference between the billed and paid charge( s), other
than the Copayments or Coinsurance specified on the Schedule of
Benefits,
unless he/ she accepted financial responsibility, in writing, for
specific
treatment or services prior to receiving services. Charges for
Hospital or
other institutional Confinements are incurred on the date of
admission. All
others are incurred on the date a Participant receives the
service or item.
The benefit levels that apply on the Hospital admission
date apply to the
charges for the covered expenses incurred for the entire
Confinement
regardless of changes in benefit levels during the
Confinement.
Us/ We Us and we refer to Valley Health Plan, Inc.
You You
refers to the enrollee and each covered family member. 46
46 Page 47 48
2001 Valley Health Plan, Inc. 47 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. 47
47 Page
48 49
2001 Valley Health Plan, Inc.
48 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 Eligibility 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. 48
48 Page 49 50
2001 Valley Health Plan, Inc. 49 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 715/ 836-1254
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. 49
49
Page 50 51
2001
Valley Health Plan, Inc. 50 Index
Index
Do not rely on
this page; it is for your convenience and does not explain your benefit
coverage.
Accidental injury 36 Allergy Care 16
Alternative
treatment 21 Ambulance 28, 30
Anesthesia 25 Autologous bone marrow
transplant 25 Blood and blood plasma 27
Changes for 2001 8
Chemotherapy 16
Claims 38, 43 Coinsurance 12,45
Contraceptive devices
and drugs 33, 34 Coordination of benefits 41
Definitions 45 Dental
care 36
Diagnostic services 14 Disputed claims review 39,40
Donor
expenses (transplants) 25 Durable medical equipment
(DME) 20 Educational
classes and programs 21
Emergency 29,30 Experimental or investigational
45
Eyeglasses 18 Family planning 15,16
Foot Care 18
General Exclusions 37
Hearing services 18 Home health services 21
Hospice care 28
Immunizations 15
Infertility 16 Inpatient Hospital Benefits 26,27
Insulin 34 Magnetic Resonance Imagings
(MRIs) 14 Maternity
Benefits 15
Medicaid 44 Medically necessary 46
Medicare 41,42,43 Mental
Conditions/ Substance
Abuse Benefits 31,32 Occupational therapy 17
Oral and maxillofacial surgery 23 Orthopedic devices 19
Out-of-pocket
expenses 12 Outpatient facility care 27
Oxygen 20 Pap test 14
Physical therapy 17 Preventive care, adult 14,15
Preventive care,
children 15 Prescription drugs 33,34
Prior approval 11 Prosthetic devices 19
Psychologist 31 Radiation therapy 16
Rehabilitation therapies 17
Second surgical opinion 14
Skilled nursing facility care 27 Speech
therapy 17
Sterilization procedures 15,16 Subrogation 44
Substance abuse
31,32 Surgery 22-24
· Anesthesia 25 · Oral 23
·
Outpatient 27 · Reconstructive 23
Temporomandibular Joint
(TMJ) 24
Temporary continuation of coverage 48
Transplants 25 Treatment therapies
16,17
Vision services 18 Well child care 15
Wheelchairs 20
Workers' compensation 44
X-rays 14 50
50
Page 51 52
51
51 Page 52 53
2001 Valley Health Plan, Inc. 51 Summary of
Benefits
Summary of benefits for the Valley Health Plan – 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 14
Services provided by a hospital:
·
Inpatient.................................................................................................
·
Outpatient..............................................................................................
Nothing. 26-
28
Emergency benefits:
·
In-area..................................................................................................
· Out-of-area
..........................................................................................
(* Emergency room copay is waived, if admitted to the hospital)
$10 for an office visit or *$ 25
copay to the hospital for an
emergency room visit
29-
30
Mental health and substance abuse treatment
....................................... Regular cost sharing. 31-
32
Prescription
drugs.....................................................................................
$5/ generic and $10/ brand 33-
34
Dental Care (Accidental injury
benefit)..............................................
Preventive Dental for
children ages 11 and under.
20% of first $500 in charges.
$10 per office
visit
36
Vision Care (one routine vision exam per calendar year).................. $10
per office visit 18
Special
Features…………………………………………………….
35
Protection against catastrophic costs (your out-of-pocket maximum)
............................................................ Your
out-of-pocket expenses for benefits covered under this Plan
are limited to
the stated copayments/ coinsurance which are
required for a few benefits.
12 52
52 Page
53
2001 Valley Health Plan, Inc. 51 Summary of Benefits
2001 Rate Information for
Valley Health Plan
Non-Postal rates apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the
FEHB Guide for that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United States Postal Service Employees, RI
70-2. Different postal rates apply and special FEHB guides are
published for
Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for
Postal Service
Inspectors and Office of Inspector General (OIG) employees
(see RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal
employee organization. Refer to the
applicable FEHB Guide.
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment
Code Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share
Western Wisconsin
Self Only VH1 $86.59 $63.53 $187.61 $137.65 $102.22 $47.90
Self
and Family VH2 $195.82 $188.49 $424.28 $408.39 $231.17 $153.14 53