Government Employees Health Association, Inc. Benefit Plan
(800) 821-6136 http://www.geha.com
2010
A fee-for-service high deductible health plan with a preferred provider organization
Sponsored and administered by: Government Employees Health Association, Inc. For changes in benefits, see page 10.
Who may enroll in this Plan: All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program may become members of GEHA. You must be, or must become a member of Government Employees Health Association, Inc. To become a member: You join simply by signing a completed Standard Form 2809, Health Benefits Registration Form, evidencing your enrollment in the Plan. Membership dues: There are no membership dues for the Year 2010.
Enrollment codes for this Plan: 341 High Deductible Health Plan (HDHP) - Self Only 342 High Deductible Health Plan (HDHP) - Self and Family
URAC accreditation: GEHA for Health Network URAC UM accreditation: InforMed for Health Utilization Management JCAHO accreditation: Medco for Home Care Pharmacy Dispensing Services
RI 71-014
Important Notice from Government Employees Health Association, Inc. About Our Prescription Drug Coverage and Medicare OPM has determined that the Government Employees Health Association, Inc. prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage. Thus you do not need to enroll in Medicare Part D and pay extra for prescription drug benefit coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage. However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB plan will coordinate benefits with Medicare. Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.
Please be advised
If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that's at least as good as Medicare's prescription drug coverage, your monthly premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You'll have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordinated Election Period (November 15th through December 31st) to enroll in Medicare Part D.
Medicare's Low Income Benefits
For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at (800) 772-1213, (TTY (800) 325-0778).
You can get more information about Medicare prescription drug plans and the coverage offered in your area from these places: Visit www.medicare.gov for personalized help, Call (800) MEDICARE (800) 633-4227. (TTY (877) 486-2048).
Table of Contents
Important Notice ...........................................................................................................................................................................1 Introduction ...................................................................................................................................................................................3 Plain Language ..............................................................................................................................................................................3 Stop Health Care Fraud! ...............................................................................................................................................................4 Preventing Medical Mistakes ........................................................................................................................................................5 Section 1. Facts about this fee-for-service Plan ............................................................................................................................7 General features of our High Deductible Health Plan (HDHP) ..........................................................................................7 How we pay providers ........................................................................................................................................................7 Your rights ...........................................................................................................................................................................9 Your medical and claims records are confidential ..............................................................................................................9 Section 2. How we change for 2010 ...........................................................................................................................................10 Program-wide changes ......................................................................................................................................................10 Changes to this Plan ..........................................................................................................................................................10 Section 3. How you get care .......................................................................................................................................................11 Identification cards ............................................................................................................................................................11 Where you get covered care ..............................................................................................................................................11 Covered providers .........................................................................................................................................................11 Covered facilities ..........................................................................................................................................................11 What you must do to get covered care ..............................................................................................................................12 Transitional care ...........................................................................................................................................................12 If you are hospitalized when your enrollment begins...................................................................................................12 How to get approval for… ................................................................................................................................................13 Your hospital stay .........................................................................................................................................................13 Radiology/Imaging procedures precertification ...........................................................................................................14 Other services ...............................................................................................................................................................15 Section 4. Your costs for covered services ..................................................................................................................................16 Cost-sharing ......................................................................................................................................................................16 Deductible .........................................................................................................................................................................16 Coinsurance .......................................................................................................................................................................16 If your provider routinely waives your cost ......................................................................................................................16 Waivers ..............................................................................................................................................................................16 Differences between our allowance and the bill ................................................................................................................-1 Your catastrophic protection out-of-pocket maximum for deductibles and coinsurance..................................................17 Carryover ..........................................................................................................................................................................18 If we overpay you .............................................................................................................................................................18 When Government facilities bill us ..................................................................................................................................18 When you are age 65 or over and do not have Medicare ..................................................................................................19 When you have the Original Medicare Plan (Part A, Part B, or both) ..............................................................................20 Section 5. High Deductible Health Plan Benefits .......................................................................................................................21 High Deductible Health Plan Benefits ..............................................................................................................................21 Non-FEHB benefits available to Plan members ...............................................................................................................74 Section 6. General exclusions – things we don't cover ..............................................................................................................74 Section 7. Filing a claim for covered services ............................................................................................................................76 Section 8. The disputed claims process.......................................................................................................................................78 Section 9. Coordinating benefits with other coverage ................................................................................................................80 When you have other health coverage or auto insurance..................................................................................................80
2010 Government Employees Health Association, Inc. Benefit Plan
1
Table of Contents
What is Medicare ............................................................................................................................................................80 Should I enroll in Medicare ........................................................................................................................................81 The Original Medicare Plan (Part A or Part B).............................................................................................................81 Tell us about your Medicare coverage ..........................................................................................................................81 Private contract with your physician ............................................................................................................................81 Medicare Advantage (Part C) .......................................................................................................................................82 Medicare prescription drug coverage (Part D) .............................................................................................................82 TRICARE and CHAMPVA ..............................................................................................................................................84 Workers' Compensation ....................................................................................................................................................84 Medicaid............................................................................................................................................................................84 When other Government agencies are responsible for your care .....................................................................................84 When others are responsible for injuries...........................................................................................................................84 When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) ..........................................................85 Clinical trials .....................................................................................................................................................................85 Section 10. Definitions of terms we use in this brochure ...........................................................................................................86 Section 11. FEHB Facts ..............................................................................................................................................................91 Coverage information .......................................................................................................................................................91 No pre-existing condition limitation.............................................................................................................................91 Where you can get information about enrolling in the FEHB Program .......................................................................91 Types of coverage available for you and your family ..................................................................................................91 Children's Equity Act ...................................................................................................................................................92 When benefits and premiums start ...............................................................................................................................92 When you retire ............................................................................................................................................................92 When you lose benefits .....................................................................................................................................................92 When FEHB coverage ends ..........................................................................................................................................92 Upon divorce ................................................................................................................................................................93 Temporary Continuation of Coverage (TCC) ...............................................................................................................93 Converting to individual coverage ...............................................................................................................................93 Getting a Certificate of Group Health Plan Coverage ..................................................................................................93 Section 12. Three Federal Programs complement FEHB benefits .............................................................................................94 The Federal Flexible Spending Account Program – FSAFEDS .......................................................................................94 The Federal Employees Dental and Vision Insurance Program – FEDVIP......................................................................94 The Federal Long Term Care Insurance Program – FLTCIP ............................................................................................95 Index............................................................................................................................................................................................96 Summary of benefits for the HDHP of the Government Employees Health Association, Inc. 2010 .........................................98 2010 Rate Information for Government Employees Health Association, Inc. (GEHA) Benefit Plan ......................................100
2010 Government Employees Health Association, Inc. Benefit Plan
2
Table of Contents
Introduction
This brochure describes the benefits of Government Employees Health Association, Inc. under our contract (CS 1063) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. This Plan is underwritten by Government Employees Health Association, Inc. The address for the Government Employees Health Association, Inc. administrative offices is: Government Employees Health Association, Inc. P.O. Box 4665 Independence, Missouri 64051-4665 This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits. If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2010, unless those benefits are also shown in this brochure. OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2010, and changes are summarized on page 10. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member, "we"
means Government Employees Health Association, Inc.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office
of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit OPM's "Rate Us" feedback area at www.opm.gov/insure or e-mail OPM at fehbwebcomments@opm.gov. You may also write to OPM at the U.S. Office of Personnel Management, Insurance Services Programs, Program Planning & Evaluation Group, 1900 E Street, NW, Washington, DC 20415-3650.
2010 Government Employees Health Association, Inc. Benefit Plan
3
Introduction/Plain Language/Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program premium. OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program regardless of the agency that employs you or from which you retired. Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:
Do not give your plan identification (ID) number over the telephone or to people you do not know, except for your health care
provider, authorized health benefits plan, or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid. Carefully review explanations of benefits (EOBs) statements that you receive from us. Please review your claims history periodically for accuracy to ensure services are not being billed to your accounts that were never
rendered.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following: Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at (800) 821-6136 and explain the situation. If we do not resolve the issue:
CALL - THE HEALTH CARE FRAUD HOTLINE 202-418-3300 OR WRITE TO: United States Office of Personnel Management Office of the Inspector General Fraud Hotline 1900 E Street NW Room 6400 Washington, DC 20415-1100
Do not maintain as a family member on your policy:
Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or Your child over age 22 (unless he/she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your
retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try
to obtain services for someone who is not an eligible family member or who is no longer enrolled in the Plan.
2010 Government Employees Health Association, Inc. Benefit Plan
4
Introduction/Plain Language/Advisory
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps: 1. Ask questions if you have doubts or concerns.
Ask questions and make sure you understand the answers. Choose a doctor with whom you feel comfortable talking. Take a relative or friend with you to help you ask questions and understand answers.
2. Keep and bring a list of all the medicines you take.
Bring the actual medicines or give your doctor and pharmacist a list of all the medicines that you take, including non-prescription
(over-the-counter) medicines.
Tell them about any drug allergies you have. Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or
pharmacist says.
Make sure your medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than
you expected.
Read the label and patient package insert when you get your medicine, including all warnings and instructions. Know how to use your medicine. Especially note the times and conditions when your medicine should and should not be taken. Contact your doctor or pharmacist if you have any questions.
3. Get the results of any test or procedure.
Ask when and how you will get the results of tests or procedures. Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail. Call your doctor and ask for your results. Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose
from to get the health care you need.
Be sure you understand the instructions you get about follow-up care when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation. Ask your doctor, "Who will manage my care when I am in the hospital " Ask your surgeon:
- Exactly what will you be doing - About how long will it take - What will happen after surgery - How can I expect to feel during recovery
2010 Government Employees Health Association, Inc. Benefit Plan
5
Introduction/Plain Language/Advisory
 Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications you are taking.
Beginning January 1, 2010, you will no longer be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient services needed to correct never events, if you use Arizona Foundation for Medical Care, FCHN, Freedom Network, PPO USA, Providence Preferred and SuperMed Network preferred providers. This new policy will help protect you from preventable medical errors and improve the quality of care you receive. When you enter the hospital for treatment of one medical problem, you don't expect to leave with additional injuries, infections or other serious conditions that occur during the course of your stay. Although some of these complications may not be avoidable, too often patients suffer from injuries or illnesses that could have been prevented if the hospital had taken proper precautions. We are adopting a benefit payment policy that will encourage hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores and fractures; and reduce medical errors that should never happen called "Never Events". When a Never Event occurs neither your FEHB plan or you will incur cost to correct the medical error. Visit these Web sites for more information about patient safety. - www.ahrq.gov/path/beactive.htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive. - www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and your family. - www.talkaboutrx.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medicines. - www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care. - www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety. - www.quic.gov/report. Find out what federal agencies are doing to identify threats to patient safety and help prevent mistakes in the nation's health care delivery system.
2010 Government Employees Health Association, Inc. Benefit Plan
6
Introduction/Plain Language/Advisory
Section 1. Facts about this fee-for-service Plan
This Plan is a fee-for-service (FFS) plan. You can choose your own physicians, hospitals, and other health care providers. We reimburse you or your provider for your covered services, usually based on a percentage of the amount we allow. The type and extent of covered services, and the amount we allow, may be different from other plans. Read brochures carefully.
General features of our High Deductible Health Plan (HDHP)
HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB Program HDHPs also offer health savings accounts or health reimbursement arrangements. Please see below for more information about these savings features. We have a Preferred Provider Organization (PPO) Our fee-for-service plan offers services through a PPO. This means that certain hospitals and other health care providers are "preferred providers". When you use our PPO providers, you will receive covered services at reduced cost. Government Employees Health Association, Inc. is solely responsible for the selection of PPO providers in your area. Contact us for the names of PPO providers and to verify their continued participation. You can also go to our Web page, which you can reach through the FEHB Web site, www.opm.gov/insure. Contact Government Employees Health Association, Inc.to request a PPO directory. We have entered into arrangements with Arizona Foundation for Medical Care; Coventry Health Care of Georgia; FCHN; First Health; Freedom Network; Health America Pennsylvania; HealthCare Preferred; HealthLink; Health Partners of Kansas; MedSolutions; MultiPlan; OneNet PPO; PPO USA; Private Healthcare Systems; Providence Preferred; SuperMed Network and WellPath which are Preferred Providers or networks of hospitals and/or doctors in all states. The doctors and hospitals participating in these networks have agreed to provide services to Plan members. You always have the right to choose a PPO provider or a non-PPO provider for medical treatment. PPO networks are now available in many metropolitan areas and additional coverage areas will be added throughout the year. Enrollees residing in a PPO network area may request a directory of the PPO providers in their service area. These providers are required to meet licensure and certification standards established by State and Federal authorities, however, inclusion in the network does not represent a guarantee of professional performance nor does it constitute medical advice. To locate a participating provider in your area, call (800) 296-0776 or visit the GEHA Web site at www.geha.com. When you phone for an appointment, please remember to verify that the physician is still a PPO provider. The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. We cannot guarantee the availability of every specialty in all areas. If no PPO provider is available, or you do not use a PPO provider, the standard non-PPO benefits apply. However, if the services are rendered at a PPO hospital, we will pay up to the Plan allowable for services of radiologists, anesthesiologists, emergency room physicians and pathologists who are not preferred providers at the preferred provider rate. In addition, providers outside the United States will be paid at the PPO level of benefits. Georgia, North Carolina, Pennsylvania and South Carolina We have entered into an agreement with Coventry Health Care, Inc. Coventry's open access health network will be available to our members. Benefits described above will be the same. You have the right to choose in network or out of network providers for your care. By receiving care from an in-network provider, you receive a higher level of benefit coverage. Also, in-network providers will file claims for you and are responsible for obtaining any needed precertifications required by the Plan. Out-of-network providers, unlike your in-network providers, are not obligated to obtain any needed certifications and therefore the member is responsible for obtaining the certification. In the local markets, Coventry is referred to as Coventry Health Care of Georgia, WellPath in the Carolinas and Health America Pennsylvania or HAPA. Members still call GEHA for all concerns or questions.
How we pay providers
Fee-for-service plans reimburse you or your provider for covered services. They do not typically provide or arrange for health care. Fee-for-service plans let you choose your own physicians, hospitals and other health care providers.
2010 Government Employees Health Association, Inc. Benefit Plan
7
Section 1
The FFS plan reimburses you for your health care expenses, usually on a percentage basis. These percentages, as well as deductibles, methods for applying deductibles to families and the percentage of coinsurance you must pay vary by plan. We offer a preferred provider organization (PPO) arrangement. This arrangement with health care providers gives you enhanced benefits or limits your out-of-pocket expenses. We reserve the right to audit medical expenses. Preventive care services Preventive care services rendered by a preferred provider are paid as first dollar coverage. Annual deductible The annual deductible must be met before Plan benefits are paid for care other than preventive care services. Health Savings Account (HSA) You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP (including a spouse's health plan, but does not include specific injury insurance and accident, disability, dental care, vision care, or long-term coverage), not enrolled in Medicare, not have received VA benefits within the last three months, not covered by your own or your spouse's flexible spending account (FSA), and are not claimed as a dependent on someone else's tax return.
You may use the money in your HSA to pay all or a portion of the annual deductible, coinsurance, or other out-of-pocket costs that
meet the IRS definition of a qualified medical expense.
Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they
are not covered by an HDHP.
You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax
and, if you are under 65 years old, an additional 10% penalty tax on the amount withdrawn.
For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the
health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.
You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the
HSA with you if you leave the Federal government or switch to another plan. Health Reimbursement Arrangement (HRA) If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.
An HRA does not earn interest. An HRA is not portable if you leave the Federal government or switch to another plan.
Catastrophic protection We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for covered services, including deductibles and coinsurance, cannot exceed $5,000 for Self Only enrollment, or $10,000 family coverage. Health education resources and accounts management tools Our Web site at www.geha.com offers access to the Health e-Report Newsletter and our Wellness Center for information on general health topics, health care news, cancer and other specific diseases, drugs/medication interactions, children's health and patient safety information. You will find facts and frequently asked questions about health savings accounts and health reimbursement arrangements on our Web site at www.geha.com. You can access your HSA and HRA account balance in addition to complete claim payment history through our Web site.
2010 Government Employees Health Association, Inc. Benefit Plan
8
Section 1
Your rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM's FEHB Web site (www.opm.gov/insure) lists the specific types of information that we must make available to you. Some of the required information is listed below.
Government Employees Health Association, Inc. was founded in 1937 as the Railway Mail Hospital Association. For over
70 years now, GEHA has provided health insurance benefits to federal employees and retirees.
GEHA is incorporated as a General Not-For-Profit Corporation pursuant to Chapter 355 of the Revised Statutes of the State
of Missouri.
GEHA's provider network includes more than 4,600 hospitals and more than 850,000 participating physician locations throughout
the United States. In circumstances where there is limited access to network providers, GEHA may negotiate discounts with some providers, which will reduce your overall out-of-pocket expenses. If you want more information about us, call (800) 821-6136, or write to GEHA, P. O. Box 4665, Independence, MO 64051-4665. You may also contact us by fax at (816) 257-3233 or visit our Web site at www.geha.com.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
2010 Government Employees Health Association, Inc. Benefit Plan
9
Section 1
Section 2. How we change for 2010
Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.
Program-wide changes
In Section 10, under Definitions, we have clarified cost categories associated with clinical trials. (see page 86)
Changes to this Plan
Your share of the non-Postal premium will stay the same for Self Only and for Self and Family. (see page 100) Cost sharing and limitations for out-of-network mental health and substance abuse treatments will be no greater than for similar
benefits for other illness and conditions. The separate inpatient and outpatient hospital/intensive day treatment deductible no longer applies. Outpatient visits for psychotherapy visits are no longer limited to 30 visits per calendar year. Inpatient hospital days and inpatient physician hospital visits are no longer limited to 100 per calendar year. Inpatient treatment for alcoholism and drug abuse is no longer limited to 30 lifetime days. Outpatient Intensive Day Treatment is no longer limited to 60 days per calendar year. All benefits are subject to medical necessity review. Admissions to out-of-network Residential Treatment Centers are now covered subject to medical necessity review. Your coinsurance on covered expenses is 25%. (see pages 61 and 62)
Precertification is now required for out-of-network Intensive Day Treatment. (see pages 61 and 62) Licensed Professional Counselors and Licensed Marriage and Family Therapists are now covered providers when services are
performed within the scope of their license. (see pages 11 and 61)
Inpatient confinements at Skilled Nursing Facilities are now covered following transfer from acute inpatient confinements when
skilled care is required. Benefits are limited to $700 per day for a maximum of 14 days. If Medicare pays the first 14 days no benefits are payable. (see page 57)
Routine eye examinations are covered for children under age 22. Benefit is limited to one routine examination per year and will be
paid at 100% of Plan allowance. (see pages 33 and 38)
We have modified the definition of Plan allowance to include we use Medicare participating provider allowance and current
schedule used by Office of Workmen's Compensation. We have also clarified how we determine Plan allowance for overseas claims and for claims which do not include itemized charges. (see pages 89 and 90)
For each month you are eligible for an HSA premium pass through, we will contribute $60 per month to your HSA for a Self Only
enrollment or $120 per month for a Self and Family enrollment. (see pages 23, 27, and 98) We have clarified the following:
All treatment within 120 days following a transplant is subject to the $100,000 limit if a plan designated organ transplant facility is
not used. (see page 53)
We have included updated information on Medco procedures and contact information. (see pages 65 and 67) We have added additional information on requirements and procedures for precertifying physical, occupational and speech therapy.
(see pages 41 and 42)
Admission to skilled nursing facilities, long term acute care facilities and rehabilitation facilities require precertification with
OrthoNet. (see page 13)
Marrow Failure and Related Disorders and Paroxysmal Nocturnal Hemoglobinuria have been added as covered allogeneic
transplants and require precertification. (see page 51)
2010 Government Employees Health Association, Inc. Benefit Plan
10
Section 2
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 electronic enrollment system (such as Employee Express) confirmation letter. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 821-6136 or write to us at GEHA, P. O. Box 4665, Independence, MO 64051-4665. You may also request replacement cards through our Web site: www.geha.com. Where you get covered care You can get care from any "covered provider" or "covered facility". How much we pay – and you pay – depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less. We consider the following to be covered providers when they perform services within the scope of their license or certification: A licensed doctor of medicine (M.D.) or a licensed doctor of osteopathy (D.O.). Other covered providers include a chiropractor, nurse midwife, nurse anesthetist, audiologist, dentist, optometrist, licensed clinical social worker, licensed clinical psychologist, licensed professional counselor, licensed marriage and family therapist, podiatrist, physical, occupational and speech therapist, nurse practitioner/clinical specialist, nursing school administered clinic, physician assistant and Christian Science practitioner. The term "doctor" includes all of these providers when the services are performed within the scope of their license or certification. Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in the states OPM determines are "medically underserved". For 2010, the states are: Alabama, Arizona, Idaho, Illinois, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, and Wyoming. Covered facilities Covered facilities include: Freestanding ambulatory facility A facility which is licensed by the state as an ambulatory surgery center or has Medicare certification as an ambulatory surgical center, has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional. Christian Science nursing organization/facilities that are accredited by The Commission for Accreditation of Christian Science Nursing Organization/Facilities Inc. Hospice A facility which meets all of the following: (1) primarily provides inpatient hospice care to terminally ill persons; (2) is certified by Medicare as such, or is licensed or accredited as such by the jurisdiction it is in;
Covered providers
2010 Government Employees Health Association, Inc. Benefit Plan
11
Section 3
(3) is supervised by a staff of M.D.'s or D.O.'s, at least one of whom must be on call at all times; (4) provides 24 hour a day nursing services under the direction of an R.N. and has a full time administrator; and (5) provides an ongoing quality assurance program. Skilled Nursing Facility licensed by the state or Medicare certified if the state does not license these facilities. See limitations on page 57. Hospital (1) An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); or (2) A medical institution which is operated pursuant to law, under the supervision of a staff of doctors, and with 24 hour a day nursing service, and which is primarily engaged in providing general inpatient care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which facilities must be provided on its premises or have such arrangements by contract or agreement; or (3) An institution which is operated pursuant to law, under the supervision of a staff of doctors and with 24 hour a day nursing service and which provides services on the premises for the diagnosis, treatment, and care of persons with mental/substance abuse disorders and has for each patient a written treatment plan which must include diagnostic assessment of the patient and a description of the treatment to be rendered and provides for follow-up assessments by or under the direction of the supervising doctor. The term hospital does not include a convalescent home or skilled nursing facility, or any institution or part thereof which: a) is used principally as a convalescent facility, nursing facility, or facility for the aged; b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or c) is operating as a school. What you must do to get covered care Transitional care It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance. Specialty care: If you have a chronic or disabling condition and lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan, or lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than for cause, you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan. If you are in the second or third trimester of pregnancy and you lose access to your PPO specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days. If you are hospitalized when your enrollment begins We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (800) 821-6136. If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.
2010 Government Employees Health Association, Inc. Benefit Plan
12
Section 3
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until: You are discharged, not merely moved to an alternative care center; or The day your benefits from your former plan run out; or The 92nd day after you become a member of this Plan, whichever happens first. These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment. How to get approval for… Your hospital stay Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won't change our decision on medical necessity. In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether they have contacted us. Warning: We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits. For medical and surgical services, you, your representative, your doctor, or your hospital must call InforMed (Medical Management Service - IMMS) before admission. The toll-free number is (800) 242-1025. For admissions to Skilled Nursing Facilities, Long Term Acute Care Facilities, or Rehabilitation Facilities please call OrthoNet to precertify at (877) 304-4419. For all admissions except mental health/substance abuse in the state of Georgia, call Coventry Health Care of Georgia. The toll-free number is (800) 470-2004. For all admissions except mental health/substance abuse in the states of North Carolina and South Carolina, call WellPath. The toll-free number is (800) 708-9355. For all admissions except mental health/ substance abuse in the state of Pennsylvania, call HealthAmerica Pennsylvania. The toll-free number is (800) 755-1135. (For mental health/substance abuse precertification, call InforMed toll-free at (800) 242-1025, see pages 61-62.) If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. Provide the following information: - Enrollee's name and plan identification number; - Patient's name, birth date, and phone number; - Reason for hospitalization, proposed treatment, or surgery; - Name and phone number of admitting doctor; - Name of hospital or facility; and - Number of planned days of confinement. We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital.
How to precertify an admission:
2010 Government Employees Health Association, Inc. Benefit Plan
13
Section 3
Maternity care
You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby. If your hospital stay – including for maternity care – needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days. If no one contacts us, we will decide whether the hospital stay was medically necessary. If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty. If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis. If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis. When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then: For the part of the admission that was medically necessary, we will pay inpatient benefits, but, For the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.
If your hospital stay needs to be extended: What happens when you do not follow the precertification rules
Exceptions:
You do not need precertification in these cases: You are admitted to a hospital outside the United States; You have another group health insurance policy that is the primary payor for the hospital stay; or Medicare Part A is the primary payor for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payor and you do need precertification.
Radiology/Imaging procedures precertification
Radiology precertification is the process by which prior to scheduling specific imaging procedures we evaluate the medical necessity of your proposed procedure to ensure the appropriate procedure is being requested for your condition. In most cases your physician will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your procedure, you should ask your doctor to contact us. The following outpatient radiology services need to be precertified: CT - Computerized Axial Tomography; MRI - Magnetic Resonance Imaging; MRA - Magnetic Resonance Angiography; NC - Nuclear Cardiac Imaging Studies; and PET - Positron Emission Tomography.
2010 Government Employees Health Association, Inc. Benefit Plan
14
Section 3
How to precertify a radiology/imaging procedure:
For outpatient CT, MRI, MRA, NC and PET studies, you, your representative or your doctor must call MedSolutions before scheduling the procedure. The toll free number is (866) 879-8317. For the state of Georgia, call Coventry Health Care of Georgia. The toll-free number is (800) 470-2004. For the states of North Carolina and South Carolina, call WellPath. The toll-free number is (800) 708-9355. For the state of Pennsylvania, call Health America Pennsylvania. The toll-free number is (800) 755-1135. Provide the following information: patient's name, plan identification number, and birth date, requested procedure and clinical support for request, name and telephone number of ordering provider, and name of requested imaging facility. You do not need precertification in these cases: You have another health insurance policy that is the primary payor including Medicare Part A & B or Part B only; The procedure is performed outside the United States; You are an inpatient in a hospital; or The procedure is performed as an emergency.
Exceptions:
Warning: Other services
We will reduce our benefits for these procedures by $100 if no one contacts us for precertification. If the procedure is not medically necessary, we will not pay any benefits. Some services require a referral, precertification, or prior authorization. You need to call us at (800) 821-6136 before receiving treatment for care such as: Physical, occupational and speech therapy (see pages beginning on 41); Growth hormone therapy (GHT) (see page 40); Surgical treatment of morbid obesity (see page 47); Certain prescription drugs (see page 40); Organ and tissue transplant procedures (see pages beginning on 50); Surgical correction of congenital anomalies (see page 47); Inpatient hospital mental health and substance abuse benefits, inpatient care at residential treatment centers and outpatient intensive day treatment (see pages 61-62; Psychological testing (see page 61-62); Injectable hematopoietic drugs (drugs for anemia, low white blood count); Injectable drugs for arthritis, psoriasis or hepatitis; and Surgical treatment of hyperhidrosis (benefits will not be approved unless alternative therapies such as botox injections or topical aluminum chloride and pharmacotherapy have been unsuccessful) (see pages beginning on 47).
2010 Government Employees Health Association, Inc. Benefit Plan
15
Section 3
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for your covered care:
Cost-sharing Deductible Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible and coinsurance) for the covered care you receive. A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for them. Coinsurance amounts do not count toward any deductible. When a covered service or supply is subject to a deductible, only the Plan allowance for the service or supply counts toward the deductible. The calendar year deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment under HDHP. After the deductible amount is satisfied for an individual, covered services are payable for that individual. Under the Self and Family enrollment, all family members' deductibles are considered to be satisfied when the family members' deductibles are combined and reach $3,000 under HDHP. If the billed amount (or the Plan allowance that providers we contract with have agreed to accept as payment in full) is less than the remaining portion of your deductible, you pay the lower amount. Example: If the billed amount is $100, the provider has an agreement with us to accept $80, and you have not paid any amount toward meeting your calendar year deductible, you must pay $80. We will apply $80 to your deductible. We will begin paying benefits once the remaining portion of your calendar year deductible ($1,500 for Self Only and $3,000 for Self and Family) has been satisfied. Note: If you change plans during open season and the effective date of your new plan is after January 1 of the next year, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan. If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option. Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn't begin until you meet your deductible. We will base this percentage on either the billed charge or the Plan allowance, whichever is less. Example: Under the HDHP, you pay 25% of our allowance for non-PPO office visits. If your provider routinely waives your cost If your provider routinely waives (does not require you to pay) your deductibles or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider's fee by the amount waived. For example, if your physician ordinarily charges $100 for a service but routinely waives your 25% coinsurance, the actual charge is $75. We will pay $56.25 (75% of the actual charge of $75). Waivers In some instances, a provider may ask you to sign a "waiver" prior to receiving care. This waiver may state that you accept responsibility for the total charge for any care that is not covered by your health plan. If you sign such a waiver, whether you are responsible for the total charge depends on the contracts that the Plan has with its providers. If you are asked to sign this type of waiver, please be aware that, if benefits are denied for the services, you could be legally liable for the related expenses. If you would like more information about waivers, please contact us at (800) 821-6136, or write to GEHA, P. O. Box 4665, Independence, MO 64051-4665.
2010 Government Employees Health Association, Inc. Benefit Plan
16
Section 4
Differences between our allowance and the bill
Our "Plan allowance" is the amount we use to calculate our payment for covered services. Feefor-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 10. Often, the provider's bill is more than a fee-for-service plan's allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use. PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance. Here is an example about coinsurance: You see a PPO physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, with HDHP, you pay just – 5% of our $100 allowance ($5). Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his/her bill. Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance – plus any difference between our allowance and charges on the bill. Here is an example. You see a non-PPO physician who charges $150 and our allowance is again $100. Because you've met your deductible, you are responsible for your coinsurance, so with HDHP you pay 25% of our $100 allowance ($25). Plus, because there is no agreement between the non-PPO physician and us, the physician can bill you for the $50 difference between our allowance and his/her bill. The following table illustrates the examples of how much you have to pay out-of-pocket, under the HDHP, for services from a PPO physician vs. a non-PPO physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table shows the amount you pay if you have met your calendar year deductible. EXAMPLE Physician's charge Our allowance We pay You owe: Coinsurance +Difference up to charge TOTAL YOU PAY PPO physician $150 We set it at: 100 95% of our allowance: 95 5% of our allowance: 5 No: 0 $5 Non-PPO physician $150 We set it at: 100 75% of our allowance: 75 25% of our allowance: 25 Yes: 50 $75
Your catastrophic protection out-of-pocket maximum for deductibles and coinsurance PPO and Non-PPO
For HDHP covered medical and surgical services with coinsurance, we pay 100% of our allowable amount for the remainder of the calendar year after out-of-pocket expenses for deductibles and coinsurance exceed: $5,000 for Self Only or $10,000 for Self and Family. Out-of-pocket expenses from both PPO and non-PPO providers count toward this limit. If you reach this limit, additional charges up to the Plan allowance will be paid at 100%. Out-of-pocket expenses for this benefit are: The calendar year deductible of $1,500 for Self Only or $3,000 for Self and Family; The 5% coinsurance you pay for PPO charges under medical services and supplies, surgical and anesthesia services and hospital, facility, ambulance services, mental health and substance abuse services; and The 25% coinsurance you pay for non-PPO charges under medical services and supplies, surgical and anesthesia services and hospital, facility and ambulance services, mental health and substance abuse services and pharmacy charges at retail whether in or out-of-network and by mail.
2010 Government Employees Health Association, Inc. Benefit Plan
17
Section 4
The following cannot be counted toward catastrophic protection out-of-pocket expenses and you must continue to pay them even after your expenses exceed the limits described above: Expenses in excess of our allowable amount or maximum benefit limitations such as the amounts in excess of the chiropractic benefit and dental care; Expenses paid by GEHA for preventive care including well child care and immunizations; Expenses in excess of the allowable amount or maximum benefit limitations under the Supplemental Vision Care Plan; The difference between our allowance and the cost of drugs purchased at a non-network pharmacy; The 70% coinsurance for non-preferred sleep aid drugs; and Any amounts you pay because benefits have been reduced for non-compliance with our cost containment requirements (see pages 13-15). Carryover If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan's catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your old plan's catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your old plan will first apply your covered out-of-pocket expenses until the prior year's catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your old plan will pay these covered expenses according to this year's benefits; benefit changes are effective January 1. Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option. If we overpay you When Government facilities bill us We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments. Facilities of the Department of Veteran Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow.
2010 Government Employees Health Association, Inc. Benefit Plan
18
Section 4
When you are age 65 or over and do not have Medicare
Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those payments you would be entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital care and non-physician based care are not covered by this law; regular Plan benefits apply. The following chart has more information about the limits. If you...
are age 65 or over; and do not have Medicare Part A, Part B, or both; and have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)
Then, for your inpatient hospital care,
the law requires us to base our payment on an amount - the "equivalent Medicare amount" - set by Medicare's rules for what
Medicare would pay, not on the actual charge;
you are responsible for your applicable deductibles and coinsurance under this Plan; you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation
of benefits (EOB) form that we send you; and
the law prohibits a hospital from collecting more than the "equivalent Medicare amount".
When inpatient claims are paid according to a Diagnostic Related Group (DRG) limit (for instance, for admissions of certain retirees who do not have Medicare), we will pay 30% of the total covered amount as room and board charges and 70% as other charges and will apply your coinsurance accordingly. And, for your physician care, the law requires us to base our payment and your coinsurance on
an amount set by Medicare and called the "Medicare approved amount," or the actual charge if it is lower than the Medicare approved amount.
If your physician... Participates with Medicare or accepts Medicare assignment for the claim and is a member of our PPO network, Participates with Medicare and is not in our PPO network, Does not participate with Medicare, Then you are responsible for... your deductibles and coinsurance;
your deductibles, coinsurance, and any balance up to the Medicare approved amount; your deductibles, coinsurance, and any balance up to 115% of the Medicare approved amount.
It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount. Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us.
2010 Government Employees Health Association, Inc. Benefit Plan
19
Section 4
When you have the Original Medicare Plan (Part A, Part B, or both)
We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare. We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the statement is submitted to determine our payment for covered services provided to you if Medicare is primary, when Medicare does not pay the VA facility. If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim. Although your physician accepts Medicare assignment, we do not waive your deductibles and coinsurance for covered charges. If your physician does not accept Medicare assignment, then you pay the difference between the "limiting charge" or the physician's charge (whichever is less) and our payment combined with Medicare's payment. It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the "limiting charge." The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to the Medicare carrier that sent you the MSN form. Call us if you need further assistance. Please see Section 9, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare.
2010 Government Employees Health Association, Inc. Benefit Plan
20
Section 4
HDHP Section 5. High Deductible Health Plan Benefits
See page 10 for how our benefits changed this year and pages 98-99 for a benefits summary. Section 5. High Deductible Health Plan Overview.....................................................................................................................23 Section 5. Savings – HSAs and HRAs ........................................................................................................................................26 Section 5. Preventive care ...........................................................................................................................................................32 Preventive care, adult ........................................................................................................................................................32 Preventive care, children ...................................................................................................................................................33 Dental Benefits ..................................................................................................................................................................33 Vision Benefits ..................................................................................................................................................................34 Section 5. Traditional medical coverage subject to the deductible .............................................................................................35 Deductible before Traditional medical coverage begins ...................................................................................................35 Section 5(a). Medical services and supplies provided by physicians and other health care professionals .................................36 Diagnostic and treatment services.....................................................................................................................................36 Lab, X-ray and other diagnostic tests................................................................................................................................37 Preventive care, adult ........................................................................................................................................................37 Preventive care, children ...................................................................................................................................................38 Maternity care ...................................................................................................................................................................38 Family planning ................................................................................................................................................................39 Infertility services .............................................................................................................................................................39 Allergy care .......................................................................................................................................................................40 Treatment therapies ...........................................................................................................................................................40 Physical and occupational therapies .................................................................................................................................41 Speech therapy ..................................................................................................................................................................42 Hearing services (testing, treatment, and supplies)...........................................................................................................42 Vision services (testing, treatment, and supplies) .............................................................................................................43 Foot care ............................................................................................................................................................................43 Orthopedic and prosthetic devices ....................................................................................................................................43 Durable medical equipment (DME) ..................................................................................................................................44 Home health services ........................................................................................................................................................45 Chiropractic .......................................................................................................................................................................45 Alternative treatments .......................................................................................................................................................46 Educational classes and programs.....................................................................................................................................46 Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals .............................47 Surgical procedures ...........................................................................................................................................................47 Reconstructive surgery ......................................................................................................................................................49 Oral and maxillofacial surgery ..........................................................................................................................................49 Organ/tissue transplants ....................................................................................................................................................50 Anesthesia .........................................................................................................................................................................53 Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................54 Inpatient hospital ...............................................................................................................................................................54 Outpatient hospital or ambulatory surgical center ............................................................................................................56 Extended care benefits/Skilled nursing care facility benefits ...........................................................................................57 Hospice care ......................................................................................................................................................................57 Ambulance ........................................................................................................................................................................58 Section 5(d). Emergency services/accidents ...............................................................................................................................59 Accidental injury ...............................................................................................................................................................59
2010 Government Employees Health Association, Inc. Benefit Plan
21
High Deductible Health Plan Section 5
HDHP
Medical emergency ...........................................................................................................................................................59 Ambulance ........................................................................................................................................................................60 Section 5(e). Mental health and substance abuse benefits ..........................................................................................................61 Professional Services ........................................................................................................................................................61 Inpatient hospital and inpatient residential treatment centers ...........................................................................................61 Outpatient hospital ............................................................................................................................................................62 Section 5(f). Prescription drug benefits ......................................................................................................................................64 Covered medications and supplies ....................................................................................................................................68 Section 5(g). Special features......................................................................................................................................................70 Flexible benefits option .....................................................................................................................................................70 Services for deaf and hearing impaired.............................................................................................................................70 High risk pregnancies........................................................................................................................................................70 GEHA NurseLine ..............................................................................................................................................................70 Health Information Library ...............................................................................................................................................70 Health Assessment ............................................................................................................................................................70 Personal Health Record .....................................................................................................................................................70 Section 5(h). Health education resources and account management tools .................................................................................71 Health education resources ...............................................................................................................................................71 Account management tools ...............................................................................................................................................71 Consumer choice information ...........................................................................................................................................71 Care support ......................................................................................................................................................................71 Summary of benefits for the HDHP of the Government Employees Health Association, Inc. 2010 .........................................98
2010 Government Employees Health Association, Inc. Benefit Plan
22
High Deductible Health Plan Section 5
HDHP Section 5. High Deductible Health Plan Overview
This Plan offers a High Deductible Health Plan (HDHP). The HDHP benefit package is described in this section. Make sure that you review the benefits that are available under the benefit product in which you are enrolled. HDHP Section 5, which describes the HDHP benefits, is divided into subsections. Please read Important things you should keep in mind about these benefits at the beginning of each subsection. Also read the General Exclusions in Section 6, they apply to benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP benefits, contact us at (800) 821-6136 or at our Web site at www.geha.com. Our HDHP option provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you build savings for future medical expenses. The Plan gives you greater control over how you use your health care benefits. When you enroll in this HDHP, we establish either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) for you. We automatically pass through a portion of the total health Plan premium to your HSA or credit an equal amount to your HRA based upon your eligibility. Your full annual HRA credit will be available on your effective date of enrollment. To ensure that GEHA pays for the set-up and administrative fees, it is important that you follow the instructions you receive in the mail about how to set up your HSA. With this Plan, preventive care is covered in full if rendered by preferred providers. As you receive other non-preventive medical care, you must meet the Plan's deductible before we pay benefits according to the benefits described on page 36. You can choose to use funds available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-ofpocket, allowing your savings to continue to grow. This HDHP includes five key components: savings; preventive care; traditional medical coverage health care that is subject to the deductible; catastrophic protection for out-of-pocket expenses; and health education resources and account management tools.
Savings Health Savings Accounts (HSA) Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see pages 26-29 for more details). By law, HSAs are available to members who are not enrolled in Medicare, cannot be claimed as a dependent on someone else's tax return, have not received VA medical benefits within the last three months or do not have other health insurance coverage other than another high deductible health plan. In 2010, for each month you are eligible for an HSA premium pass through, we will contribute $60 per month to your HSA for a Self Only enrollment or $120 per month for a Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,050 for an individual and $6,150 for a family. See maximum contribution information on page 27. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment. Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments (not GEHA's pass-through contributions) are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don't deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses. HSA features include: Your HSA is administered by FDIC-insured HSA Bank; Your contributions to the HSA are tax deductible; You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.); Your HSA earns tax-free interest; You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publication 502 for a complete list of eligible expenses);
2010 Government Employees Health Association, Inc. Benefit Plan
23
HDHP Section 5 Overview
HDHP
Your unused HSA funds and interest accumulate from year to year; It's portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire ; and When you need it, funds up to the actual HSA balance are available. Important consideration if you want to participate in a Health Care Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA (such as FSAFEDS offers – see Section 12), this HDHP cannot continue to contribute to your HSA unless it is a limited FSA (LEX HCFSA) specially designed to work with an HSA. You can use a LEX HCFSA only for eligible dental and vision expenses. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish an HRA for you. The exception to this is that FSA coverage is treated as disregarded coverage during the grace period if the balance at the end of the plan year is zero. If you would like more information about a LEX HCFSA and/or would like to enroll in one, please call (888) 999-7893, (TTY (800) 952-0450). You can also read more information at http:// www.opm.gov/hsa/hdhp_index.asp. Health Reimbursement Arrangements (HRA) If you aren't eligible for an HSA, for example you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA. In 2010, we will give you an HRA credit of $720 per year for a Self Only enrollment and $1,440 per year for a Self and Family enrollment. You can use funds in your HRA to help pay your health plan deductible and/or for certain expenses that don't count toward the deductible. HRA features include: For our HDHP option, the HRA is administered by GEHA; Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment; Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP; Unused credits carryover from year to year; HRA credit does not earn interest; HRA credit is forfeited if you leave Federal employment or switch health insurance plans; and An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements. See Who is eligible to enroll in Section 12, under The Federal Flexible Spending Account Program – FSAFEDS. Preventive care The Plan covers preventive care services from preferred providers, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., cancer screenings, cardiac screenings, and mammograms), well-child care, and child and adult immunizations. These services are covered at 100% if you use a network provider and the services are described in Section 5. Preventive care. Preventive care for children is covered at 100%. You do not have to meet the deductible before using these services. This Plan also provides vision care benefits through Avesis, Inc., and provides dental coverage. You do not have to meet the deductible before using these services. The calendar year deductible does not apply to the following services: Supplemental vision care through Avesis Vision Care Plan; and Dental benefits (50% of Plan allowance for diagnostic and preventive services twice per year).
2010 Government Employees Health Association, Inc. Benefit Plan
24
HDHP Section 5 Overview
HDHP
Traditional medical coverage After you have paid the Plan's deductible, we pay benefits under traditional medical coverage described in Section 5. The Plan typically pays 95% for in-network and 75% for out-of-network care. Covered services include: Medical services and supplies provided by physicians and other health care professionals; Surgical and anesthesia services provided by physicians and other health care professionals; Hospital services; other facility or ambulance services; Emergency services/accidents; Mental health and substance abuse; and Prescription drug benefits (covered at 75%). Catastrophic protection for out-of-pocket expenses Your annual maximum for out-of-pocket expenses (deductibles and coinsurance) for covered services is limited to $5,000 per person or $10,000 per family enrollment. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan's allowable amount or benefit maximum). Refer to Section 4, Your catastrophic protection out-ofpocket maximum, and Section 5, Traditional medical coverage subject to the deductible, for more details. Section 5(h) describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.
Health education resources and account management tools
2010 Government Employees Health Association, Inc. Benefit Plan
25
HDHP Section 5 Overview
HDHP Section 5. Savings – HSAs and HRAs
Feature Comparison Health Savings Account (HSA) Health Reimbursement Arrangement (HRA) Provided when you are ineligible for an HSA
GEHA (P.O. Box 168, Independence, MO 64051-0168, toll-free (800) 821-6136, www.geha.com) is the HRA fiduciary for this Plan.
Administrator
The Plan will establish an HSA for you with HSA Bank (P. O. Box 939, Sheboygan, WI 53082-0939, toll-free (866) 471-5964, www.hsabank.com), this HDHP's fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS). Set-up and monthly administrative fees are paid by the HDHP. Eligibility for an HSA is determined on the first day of the month coincident to or following your effective date of enrollment. GEHA will determine eligibility for a passthrough premium contribution if the member is enrolled in the HDHP on the last day of the month. You must: Enroll in this HDHP; Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or longterm care coverage); Not be enrolled in Medicare; Not be claimed as a dependent on someone else's tax return; Not have received VA medical benefits in the last three months; and Complete and return all banking paperwork. If you do not set up your health savings account with HSA Bank within 60 days we will enroll you in the HRA.
Fees Eligibility
None You must enroll in this HDHP. Eligibility is determined on the first day of the month following your effective date of enrollment and will be prorated for length of enrollment. If you enroll in GEHA Health Savings AdvantageSM (HDHP) and do not qualify for an HSA, we will establish an HRA for you. If your eligibility changes mid year, please contact GEHA.
Funding
If you are eligible for HSA contributions, a portion of your monthly health plan premium is deposited to your HSA each month. Premium pass through contributions are based on the effective date of your enrollment in the HDHP. In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc).
The entire amount of your HRA will be available to you upon your enrollment. Eligibility for the annual credit will be determined on the last day of the month following your effective date of enrollment and will be prorated for length of enrollment. Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan).
2010 Government Employees Health Association, Inc. Benefit Plan
26
HDHP Section 5 Savings – HSAs and HRAs
HDHP
Feature Comparison Health Savings Account (HSA) Health Reimbursement Arrangement (HRA) Provided when you are ineligible for an HSA
For 2010, your HRA annual credit is $720 (prorated for mid-year enrollment). Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan). Self and Family enrollment For 2010 a monthly premium pass through of $120 will be made by the HDHP directly into your HSA each month. For 2010, your HRA annual credit is $1,440 (prorated for mid-year enrollment). Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan). The full HRA credit will be available, subject to proration, on the effective date of enrollment. The HRA does not earn interest. Members leaving GEHA mid-year will be expected to return a portion of the annual contribution to GEHA only if they have filed claims against the funds (prorated based on the number of months in the Plan).
Self Only enrollment
For 2010, a monthly premium pass through of $60 will be made by the HDHP directly into your HSA each month.
Contributions/credits
The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,050 for an individual and $6,150 for a family. If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution. You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year. If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA. If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability: You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do
2010 Government Employees Health Association, Inc. Benefit Plan
27
HDHP Section 5 Savings – HSAs and HRAs
HDHP
Feature Comparison Health Savings Account (HSA) Health Reimbursement Arrangement (HRA) Provided when you are ineligible for an HSA
Contributions/credits - cont.
not affect your annual maximum contribution under this HDHP). HSAs earn tax-free interest (does not affect your annual maximum contribution). Catch-up contribution discussed on page 30.
Self Only enrollment Self and Family enrollment Access funds
See page 27 See page 27
You cannot contribute to the HRA. You cannot contribute to the HRA.
You can access your HSA by the following methods: Debit card Withdrawal form Checks Online banking
For qualified medical expenses under your HDHP, you will be automatically reimbursed when claims are submitted through the HDHP. For expenses not covered by the HDHP, such as orthodontia, a reimbursement form will be sent to you upon your request, and available on our website. You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP. Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan. See Availability of funds below for information on when funds are available in the HRA. See IRS Publication 502 for a list of eligible medical expenses. Over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of medical insurance premiums are not reimbursable.
Distributions/withdrawals Medical
You can pay the out-of-pocket expenses for yourself, your spouse or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA. See IRS Publication 502 for a list of eligible medical expenses, including over-the-counter drugs.
Non-medical
If you are under age 65, withdrawal of funds for non-medical expenses will create a 10% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds. When you turn age 65, distributions can be used for any reason without being subject to the 10% penalty, however they will be subject to ordinary income tax.
Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses. Medicare premiums are reimbursable.
2010 Government Employees Health Association, Inc. Benefit Plan
28
HDHP Section 5 Savings – HSAs and HRAs
HDHP
Feature Comparison Health Savings Account (HSA) Health Reimbursement Arrangement (HRA) Provided when you are ineligible for an HSA
The entire amount of your HRA will be available to you upon your enrollment in the HDHP.
Availability of funds
Funds are not available for withdrawal until all the following steps are completed: - Your enrollment in this HDHP is effective (effective date is determined by your agency in accordance with the event permitting the enrollment change); - The HDHP receives record of your enrollment and initially establishes your HSA account with the fiduciary by providing information it must furnish; - You complete the HSA application process either online or via paper forms and the fiduciary sends record of the account to GEHA; and - GEHA contributes funds by the 15th of the month following the month of your effective date.
Account owner Portable
FEHB enrollee You can take this account with you when you change plans, separate or retire. If you do not enroll in another HDHP, you can no longer contribute to your HSA. See pages 23, 24 and 26 for HSA eligibility.
HDHP If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA. If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement subject to timely filing requirements. Unused funds are forfeited. Yes, accumulates without a maximum cap.
Annual rollover
Yes, accumulates without a maximum cap.
2010 Government Employees Health Association, Inc. Benefit Plan
29
HDHP Section 5 Savings – HSAs and HRAs
HDHP If you have an HSA
Contributions All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are either taxdeductible or pre-tax (if made by payroll deduction).You receive tax advantages in any case. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15th of the following year to make HSA contributions for the current year. If you newly enroll in an HDHP during Open Season and your effective date is after January 1st or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability. Contact HSA Bank (P. O. Box 939, Sheboygan, WI 53082-0939, toll free (866) 471-5964, www.hsabank.com) for more details. Catch-up contributions If you are age 55 or older, the IRS permits you to make additional "catch-up" contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury Web site at www.ustreas.gov/offices/public-affairs/hsa/. If you do not have a named beneficiary, if you are married, it becomes your spouse's HSA; otherwise, it becomes part of your taxable estate. You can pay for "qualified medical expenses" as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, over-the-counter drugs, LASIK surgery, and some nursing services. When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare. For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling (800) 829-3676, or visit the IRS Web site at www.irs.gov and click on "Forms and Publications". Note: Although over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances. Non-qualified expenses You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 10% penalty tax on the amount withdrawn. You will receive a periodic statement that shows the "premium pass through", withdrawals, and interest earned on your account. In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA. You can request reimbursement in any amount. Just like a normal bank account, you cannot reimburse yourself for expenses that are greater then the balance in the account.
If you die Qualified expenses
Tracking your HSA balance Minimum reimbursements from your HSA
2010 Government Employees Health Association, Inc. Benefit Plan
30
HDHP Section 5 Savings – HSAs and HRAs
HDHP If you have an HRA
Why an HRA is established If you don't qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you become ineligible to contribute to an HSA. Please review the chart on pages 26-29, which details the differences between an HRA and an HSA. The major differences are: You cannot make contributions to an HRA; Funds are forfeited if you leave the HDHP; An HRA does not earn interest; and HRAs can only pay for qualified medical expenses, such as deductibles and coinsurance expenses, for individuals covered by the HDHP. FEHB law does not permit qualified medical expenses to include 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.
How an HRA differs
2010 Government Employees Health Association, Inc. Benefit Plan
31
HDHP Section 5 Savings – HSAs and HRAs
HDHP Section 5. Preventive care
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental Plan, your
FEHB plan will be First/Primary payor of any Benefit payments and your FEDVIP plan is secondary to your FEHB plan. See Section 9, Coordinating benefits with other coverage.
Benefits in this Section are covered in full if rendered by preferred providers. Preventive services from nonpreferred provider would be applied to your calendar year deductible and payable under Traditional medical coverage benefits. Preventive care for children is covered in full from preferred and non-preferred providers. The calendar year deductible does not apply to benefits in this Section. For other covered services not listed below see Section 5(a).
There is no calendar year deductible for the dental benefits listed below. Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing
works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. If Medicare is your primary payor, GEHA will provide secondary benefits for covered charges. The high deductible health plan deductible and coinsurance is not waived for Medicare members.
The benefits listed below are for the charges billed by a hospital, physician, or other health care professional
for your care.
Benefits Description Preventive care, adult
Professional services such as: Routine physical examinations Routine screenings, limited to: Total blood cholesterol screenings Chlamydial infection Colorectal cancer screening, including - Annual coverage of one fecal occult blood test for members age 40 and older The following screenings at intervals recommended by the American Cancer Society: - Colonoscopy - Double contrast barium enema - Sigmoidoscopy Prostate cancer screening - Annual coverage of one PSA (Prostate Specific Antigen) test for men age 40 and older Routine Pap test - Annual coverage of one Pap smear for women age 18 and older Routine mammogram - Mammograms for diagnostic and/or routine screening PPO: Nothing
You pay You pay
Non-PPO: Covered under Traditional medical coverage subject to deductible
Note: The calendar year deductible does not apply to PPO benefits in this Section.
2010 Government Employees Health Association, Inc.
32
Preventive care, adult - continued on next page HDHP Section 5 Preventive care
HDHP
Benefits Description Preventive care, adult (cont.)
Adult routine immunizations endorsed by the Centers for Disease control and Prevention (CDC) Osteoporosis screening - Bone density tests for osteoporosis screening as recommended by specialty organizations such as the U. S. Preventive Services Task Force or the National Osteoporosis Foundation PPO: Nothing Non-PPO: Covered under Traditional medical coverage subject to deductible
You pay You pay
Not covered:
Professional fees for automated lab tests Separate charges of anesthesiologist for colonoscopy and upper endoscopy procedures, except for high risk patients or patients over 60 years of age
All charges
Preventive care, children
For dependent children under age 22: Childhood immunizations recommended by the American Academy of Pediatrics Well-child care charges for routine examinations, including one routine eye examination per year, immunizations and care Initial examination of a newborn child covered under a family enrollment PPO: Nothing
You pay
Non-PPO: Nothing, except any difference between our Plan allowance and the billed amount
Not covered:
Professional fees for automated lab tests
All charges
Benefits Description Dental Benefits
Diagnostic and preventive services, including examination, prophylaxis (cleaning), X-rays of all types and fluoride treatment
(Scheduled Allowance) We pay
50% up to the Plan allowance for diagnostic and preventive services per year as follows: Two examinations per person, per year Two prophylaxis (cleanings) per person, per year Two fluoride treatments per person, per year $150 in allowed X-ray charges per person, per year (payable at 50%)
You pay
50% up to the Plan allowance and all charges in excess of the Plan allowance for diagnostic and preventive services
Amalgam Restorations Resin - Based Composite Restorations Gold Foil Restorations Inlay/Onlay Restorations Simple Extractions
$21 One surface, $28 Two or more surfaces
All charges in excess of the scheduled amounts listed to the left
$21 Simple extraction
All charges in excess of the scheduled amount listed to the left
2010 Government Employees Health Association, Inc. Benefit Plan
33
HDHP Section 5 Preventive care
HDHP
Supplemental vision care
Avesis Vision Care Plan (800) 672-7552 Using Avesis Incorporated: Avesis Third Party Administrators, Inc. Vision Claims Department P.O. Box 7777, Phoenix, AZ 85011-7777 Avesis will process all claims The following supplemental vision services are covered outside of the HDHP and are not subject to the Plan deductible.
Vision Benefits
GEHA plan
Examination
12 months
Spectacle Lenses
12 months
Frame
24 months
Contact Lenses
12 months
Eye Examination Benefit
Eye Examination
In-Network
Covered in full after a $10 exam copay
Out-of-Network
Reimbursed up to $35
Spectacle Lenses (pair)
Standard Single Vision Standard Bifocal Standard Trifocal Standard Lenticular Progressive
In-Network
Covered in full after a $10 materials copay Covered in full after a $10 materials copay Covered in full after a $10 materials copay Covered in full after a $10 materials copay 20% off U & C, minus $50 allowance after a $10 materials copay Preferred Pricing (20% off retail) Covered in full after a $10 materials copay with a $35 or less wholesale value (approx. retail of $75 to $100)
Out-of-Network
Reimbursed up to $25 Reimbursed up to $40 Reimbursed up to $50 Reimbursed up to $80 Reimbursed up to $40
Lens Options Frame
No reimbursement Reimbursed up to $45
Contact Lenses
(In lieu of frame and spectacle lenses)
$110 allowance after a $10 materials copay Covered in full after a $10 materials copay (excluding lenses covered under the Traditional medical coverage benefits) Reimbursed up to $110 Reimbursed up to $250
Elective Medically necessary
2010 Government Employees Health Association, Inc. Benefit Plan
34
HDHP Section 5 Preventive care
HDHP Section 5. Traditional medical coverage subject to the deductible
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
Preventive care is covered at 100% (see pages 32-33) if rendered by preferred providers and is not subject to
the calendar year deductible. Preventive care from non-preferred providers is covered under Traditional medical coverage subject to the deductible.
The deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment each calendar
year. The Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits under Traditional medical coverage. You must pay your deductible before your Traditional medical coverage may begin.
Under Traditional medical coverage, you are responsible for your coinsurance for covered expenses. You are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After
your coinsurance and deductibles total $5,000 per person or $10,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-ofpocket maximum (such as expenses in excess of the Plan's benefit maximum, or if you use out-of-network providers, amounts in excess of the Plan allowance).
In-network benefits apply only when you use a network provider. When a network provider is not available,
out-of-network benefits apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing
works. Also read Section 9 about coordinating benefits with other coverage.
Benefits Description Deductible before Traditional medical coverage begins
The deductible applies to all benefits in this Section. When you receive covered services, you are responsible for paying the allowable charges until you meet the deductible. After you meet the deductible, we pay the allowable charge (less your coinsurance) until you meet the annual catastrophic out-of-pocket maximum.
You pay After the calendar year deductible… You pay
100% of allowable charges until you meet the deductible of $1,500 for Self Only enrollment or $3,000 for Self and Family enrollment In-network: After you meet the deductible, you pay the indicated coinsurance for covered services. You may choose to pay the coinsurance from your HSA or HRA, or you can pay for them out-of-pocket. If you have an HRA, we will withdraw the amount from your HRA if funds are available. Out-of-network: After you meet the deductible, you pay the indicated coinsurance based on our Plan allowance and any difference between our allowance and the billed amount.
2010 Government Employees Health Association, Inc. Benefit Plan
35
HDHP Section 5 Traditional Medical coverage
HDHP Section 5(a). Medical services and supplies provided by physicians and other health care professionals
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
The deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment each calendar
year. The Self and Family deductible can be satisfied by one or more family members. The calendar year deductible applies to all benefits in this Section.Note: Preventive services from non-preferred providers would be applied to your deductible and payable under Traditional medical coverage benefits. Non-covered charges and charges in excess of the Plan allowable do not count toward the deductible.
After you have satisfied your deductible, coverage begins for Traditional medical services. Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible
medical expenses and prescriptions.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO
provider. When no PPO provider is available, non-PPO benefits apply.
The amounts listed below are for the charges billed by the physician or other health care professional for
your care.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing
works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. If Medicare is your primary payor, GEHA will provide secondary benefits for covered charges. The high deductible health plan deductible and coinsurance are not waived for Medicare members.
When you use a PPO hospital, the professionals who provide services to you in a hospital may not all be
preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if the services are rendered at a PPO hospital, we will pay up to the Plan allowable for services of radiologists, anesthesiologists, emergency room physicians and pathologists who are not preferred providers at the preferred provider rate.
YOU MUST GET PRECERTIFICATION FOR CERTAIN OUTPATIENT IMAGING
PROCEDURES. FAILURE TO DO SO WILL RESULT IN A MINIMUM OF $100 PENALTY. Please refer to precertification information in Section 3 to be sure which procedures require precertification. Penalties are not subject to the catastrophic limit.
Benefits Description Diagnostic and treatment services
Professional services of physicians In physician's office Office medical consultations Second surgical opinions Emergency room physician care (non-accidental injury) During a hospital stay At home In an urgent care center
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
2010 Government Employees Health Association, Inc. Benefit Plan
36
HDHP Section 5(a)
HDHP
Benefits Description Lab, X-ray and other diagnostic tests
Tests, such as: Blood tests Urinalysis Non-routine Pap tests Pathology X-rays Non-routine mammograms CAT Scans/MRI (outpatient requires precertification) Double contrast barium enemas Ultrasound Electrocardiogram and EEG
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount Note: If your PPO provider uses a non-PPO lab or radiologist, we will pay non-PPO benefits for any lab and X-ray charges.
Not covered: Professional fees for automated lab tests
All charges
Preventive care, adult
Professional services such as: Routine physical examinations Routine screenings, limited to: Total blood cholesterol screenings Chlamydial infection Colorectal cancer screening, including - Annual coverage of one fecal occult blood test for members age 40 and older The following screenings at intervals recommended by the American Cancer Society: - Colonoscopy - Double contrast barium enema - Sigmoidoscopy Prostate cancer screening - Annual coverage of one PSA (Prostate Specific Antigen) test for men age 40 and older Routine Pap test - Annual coverage of one Pap smear for women age 18 and older Routine mammogram - Mammograms for diagnostic and/or routine screening Adult routine immunizations endorsed by the Centers for Disease Control and Prevention (CDC) Osteoporosis screening - Bone density tests for osteoporosis screening as recommended by specialty organizations such as the U. S. Preventive Services Task Force or the National Osteoporosis Foundation
You pay
PPO: Nothing (No deductible) Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
2010 Government Employees Health Association, Inc. Benefit Plan
37
Preventive care, adult - continued on next page HDHP Section 5(a)
HDHP
Benefits Description Preventive care, adult (cont.)
Not covered:
Professional fees for automated lab tests
You pay After the calendar year deductible… You pay
All charges
Preventive care, children
For dependent children under age 22: Childhood immunizations recommended by the American Academy of Pediatrics Well- child care charges for routine examinations, including one routine eye examination per year, immunizations and care Initial examination of a newborn child covered under a family enrollment Vision examinations, limited to: Examinations for amblyopia and strabismus
You pay
PPO: Nothing (No deductible) Non-PPO: Nothing (No deductible), except any difference between our Plan allowance and the billed amount
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Professional fees for automated lab tests
All charges
Maternity care
Complete maternity (obstetrical) care, such as: Prenatal care Delivery Postnatal care Physician care such as sonograms Note: Here are some things to keep in mind: You do not need to precertify your normal delivery; see page 14 for other circumstances, such as extended stays for you or your baby. You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary, but you must precertify. We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5(c)) and Surgery benefits (Section 5(b)). We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision. Approved fetal monitors are covered the same as other medical benefits for diagnostic and treatment services.
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Maternity care - continued on next page
2010 Government Employees Health Association, Inc. Benefit Plan
38
HDHP Section 5(a)
HDHP
Benefits Description Maternity care (cont.)
Not covered:
Home uterine monitoring devices, unless preauthorized by our Medical Director Charges 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 rape or incest Charges for services and supplies incurred after termination of coverage
You pay After the calendar year deductible… You pay
All charges
Family planning
A range of voluntary family planning services, limited to: Voluntary sterilizations (see Surgical procedures Section 5(b)) Surgically implanted contraceptives Injectable contraceptive drugs (such as Depo provera) Intrauterine devices (IUDs) Diaphragms Note: We cover oral contraceptives under the prescription drug benefit.
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Reversal of voluntary surgical sterilizations Genetic counseling Preimplantation genetic diagnosis (PGD) Expenses for sperm collection and storage
All charges
Infertility services
Diagnosis and treatment of infertility, except as shown in Not covered Note: Benefits are limited to a maximum of $3,000 per calendar year, per person.
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Infertility services after voluntary sterilizations Fertility drugs Preimplantation genetic diagnosis (PGD) Assisted reproductive technology (ART) procedures, such as: - artificial insemination - in vitro fertilization - embryo transfer and gamete intrafallopian transfer (GIFT) - intravaginal insemination (IVI) - intracervical insemination (ICI) - intrauterine insemination (IUI) Services and supplies related to ART procedures Cost of donor sperm Cost of donor egg
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
39
HDHP Section 5(a)
HDHP
Benefits Description Allergy care
Testing and treatment, including materials (such as allergy serum) Allergy testing is limited to $500 per person, per calendar year Allergy injections
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Clinical ecology and environmental medicine Provocative food testing and sublingual allergy desensitization
All charges
Treatment therapies
Antibiotic therapy Outpatient cardiac rehabilitation Chemotherapy and radiation therapy Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on pages 50-53. Dialysis – hemodialysis and peritoneal dialysis Intravenous (IV)/Infusion Therapy Growth hormone therapy (GHT) Note: GHT is covered under the prescription drug benefit. We only cover GHT when we preauthorize the treatment. Call (800) 821-6136 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Other services under How to get approval for…in Section 3. Respiratory and inhalation therapies Note: Some medications required for treatment therapies may be available through Medco Pharmacy (mail order) or a Medco participating pharmacy. Medications obtained from these sources are covered under the Prescription Drug Benefits in Section 5(f).
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Chelating therapy except for acute arsenic, gold or lead poisoning Maintenance cardiac rehabilitation Topical hyperbaric oxygen therapy Prolotherapy
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
40
HDHP Section 5(a)
HDHP
Benefits Description Physical and occupational therapies
60 visits per calendar year for the combined services of the following: (One visit is two hours or less of physical or occupational therapy.) - qualified physical therapists and - qualified occupational therapists All physical and occupational therapy visits require preauthorization. Please make an evaluation visit, then contact OrthoNet by phone at (877) 304-4399 or fax to (877) 304-4398 a copy of the evaluation to OrthoNet. Authorizations will be provided in blocks of time and progress reviewed prior to additional authorizations. To precertify physical and occupational therapy in Georgia contact Coventry at (800) 470-2004. In North and South Carolina contact WellPath at (800) 708-9355. In Pennsylvania contact HAPA at (800) 755-1135. Authorizations for physical and occupational therapy are based on medical necessity. In order to make individual-specific authorization decisions, OrthoNet will review the treating provider's evaluation; including diagnosis, duration of member's symptoms (chronic vs. acute), nature or severity of symptoms, timeframes for anticipated recovery or clinical milestones, measurements of joint motion or from standardized tools specific to the condition or affected body part (Simple Shoulder Test, HSS Knee Score, Oswestry, and DASH), and rehab potential. OrthoNet's on-going therapy management is concurrent and based on progress made in therapy. Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury and when a physician: - orders the care - identifies the specific professional skills the patient requires and the medical necessity for skilled services - indicates the length of time the services are needed Note: When you receive medically necessary physical or occupational therapy on an outpatient basis from a qualified professional therapist at a skilled nursing facility, your therapy is covered up to Plan limits.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Exercise programs Long-term rehabilitative therapy Hot and cold packs
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
41
HDHP Section 5(a)
HDHP
Benefits Description Speech therapy
30 visits per calendar year for the services of a qualified speech therapist: (One visit is two hours or less of speech therapy.) Note: We only cover speech therapy when a physician: - orders the care - identifies the specific professional skills the patient requires and the medical necessity for skilled services - indicates the length of time the services are needed All speech therapy visits require preauthorization. Please make an evaluation visit, then contact OrthoNet by phone at (877) 304-4399 or fax to (877) 304-4398 a copy of the evaluation to OrthoNet. Authorizations will be provided in blocks of time and progress reviewed prior to additional authorizations. To precertify speech therapy in Georgia contact Coventry at (800) 470-2004. In North and South Carolina contact WellPath at (800) 708-9355. In Pennsylvania contact HAPA at (800) 755-1135. Authorization for speech therapy is based on medical necessity. In order to make individual-specific authorization decisions, OrthoNet will review the treating provider's evaluation; including diagnosis, duration of member's symptoms, nature or severity of symptoms, timeframes for anticipated recovery or clinical milestones, and rehab potential. OrthoNet's on-going therapy management is concurrent and based on progress made in therapy. Note: When you receive medically necessary speech therapy on an outpatient basis from a qualified speech therapist at a skilled nursing facility, your therapy is covered up to Plan limits.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Computer devices to assist with communications Computer programs of any type, including but not limited to those to assist with speech therapy
All charges
Hearing services (testing, treatment, and supplies)
Diagnostic hearing tests performed by a M.D., D.O. or audiologist
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Hearing aids, testing and examinations for them
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
42
HDHP Section 5(a)
HDHP
Benefits Description Vision services (testing, treatment, and supplies)
First pair of contact lenses or standard ocular implant lenses if required to correct an impairment existing after intraocular surgery or accidental injury 30 outpatient vision therapy visits by an ophthalmologist or optometrist per person, per lifetime
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Computer programs of any type, including but not limited to those to assist with vision therapy Eyeglasses or contact lenses and examinations for them, except for the supplemental vision plan Radial keratotomy and other refractive surgeries Special multifocal ocular implant lenses
All charges
Foot care
Routine foot care only when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Cutting, trimming of toenails or removal of corns, calluses, or similar routine treatment of conditions of the foot, except as stated above
All charges
Orthopedic and prosthetic devices
Artificial limbs and eyes; stump hose Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant following mastectomy Note: See Section 5(b) for coverage of the surgery to insert the device. Note: We will pay only for the cost of the standard item. Coverage for specialty items such as bionics is limited to the cost of the standard item.
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Orthopedic and corrective shoes Arch supports Foot orthotics Heel pads and heel cups Diabetic shoes Bioelectric, computer programmed prosthetic devices
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
43
HDHP Section 5(a)
HDHP
Benefits Description Durable medical equipment (DME)
Durable medical equipment (DME) is equipment and supplies that: Are prescribed by your attending physician (i.e., the physician who is treating your illness or injury) Are medically necessary Are primarily and customarily used only for a medical purpose Are generally useful only to a person with an illness or injury Are designed for prolonged use Serve a specific therapeutic purpose in the treatment of an illness or injury We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include: Oxygen Dialysis equipment Hospital beds Wheelchairs Crutches Walkers Note: Call us at (800) 821-6136 as soon as your physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call. Note: Benefits for durable medical equipment are limited to $25,000 per person, lifetime maximum. Note: We will pay only for the cost of the standard item. Coverage for specialty equipment such as all-terrain wheelchairs is limited to the cost of the standard equipment.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Computer devices to assist with communications Computer programs of any type Air purifiers, air conditioners, heating pads, cold therapy units, whirlpool bathing equipment, sun and heat lamps, exercise devices (even if ordered by a doctor), and other equipment that does not meet the definition of durable medical equipment (page 87) Lifts, such as seat, chair or van lifts Wigs Bone stimulators except for established non-union fractures
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
44
HDHP Section 5(a)
HDHP
Benefits Description Home health services
25 in-home visits per calendar year, not to exceed one visit up to two hours per day when: A registered nurse (R.N.), or licensed practical nurse (L.P.N.) provides the services The attending physician orders the care The physician identifies the specific professional skills required by the patient and the medical necessity for skilled services The physician indicates the length of time the services are needed Note: Covered services are based on our review for medical necessity.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Nursing care requested by, or for the convenience of, the patient or the patient's family Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative Custodial Care Services or supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters by blood, marriage or adoption Inpatient private duty nursing
All charges
Chiropractic
Chiropractic services limited to: 12 visits per calendar year for manipulation of the spine X-rays, used to detect and determine nerve interferences due to spinal subluxations or misalignments $25 per calendar year for chiropractic X-rays Note: No other benefits for the services of a chiropractor are covered under any other provision of this Plan. In medically underserved areas, services of a chiropractor that are listed above are subject to the stated limitations. In medically underserved areas, services of a chiropractor that are within the scope of his/her license and are not listed above are eligible for regular Plan benefits. PPO and Non-PPO
You pay
All charges in excess of $20 per visit All charges in excess of $25 for X-rays of the spine Note: Visits and charges exceeding these amounts are not applied toward the calendar year deductible.
Not covered:
Any treatment not specifically listed as covered Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
45
HDHP Section 5(a)
HDHP
Benefits Description Alternative treatments
Acupuncture: Benefits are limited to 20 procedures per calendar year for medically necessary acupuncture treatments if performed by a Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.)
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
All other alternative treatments, including clinical ecology and environmental medicine Any treatment not specifically listed as covered Naturopathic services
All charges
(Note: Benefits of certain alternative treatment providers may be covered in medically underserved areas; see page 11.)
Educational classes and programs
Coverage is limited to: Smoking Cessation – Up to $100 to aid in smoking cessation, per person, per lifetime, including related expenses such as drugs Diabetes Education – Provided by Certified Diabetes Educators or physician through a program certified by the American Diabetes Association up to $250 per person, per calendar year
You pay
PPO: All charges in excess of $100 Non-PPO: All charges in excess of $100 PPO: All charges in excess of $250 (No deductible) Non-PPO: All charges in excess of $250 (No deductible)
2010 Government Employees Health Association, Inc. Benefit Plan
46
HDHP Section 5(a)
HDHP Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
The deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment each calendar
year. The Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
After you have satisfied your deductible, your Traditional medical coverage begins. Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible
medical expenses and prescriptions.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a
PPO provider. When no PPO provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing
works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. If Medicare is your primary payor, GEHA will provide secondary benefits for covered charges. The high deductible health plan deductible and coinsurance are not waived for Medicare members.
The amounts listed below are for the charges billed by a physician or other health care professional for your
surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).
When you use a PPO hospital, the professionals who provide services to you in a hospital may not all be
preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if the services are rendered at a PPO hospital, we will pay up to the Plan allowable for services of radiologists, anesthesiologists, emergency room physicians and pathologists who are not preferred providers at the preferred provider rate.
YOU MUST GET PRECERTIFICATIONFOR SOME SURGICAL PROCEDURES. Please refer to the
precertification information shown in Section 3 to be sure which services require precertification.
Benefits Description Surgical procedures
A comprehensive range of services, such as: Operative procedures Treatment of fractures, including casting Normal pre- and post-operative care by the surgeon Correction of amblyopia and strabismus Endoscopy procedures Biopsy procedures Removal of tumors and cysts Correction of congenital anomalies - limited to children under the age of 18 unless there is a functional deficit (see Reconstructive surgery) Surgical treatment of obesity (bariatric surgery) is covered only if: - eligible enrollee is 18 or over
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Surgical procedures - continued on next page
2010 Government Employees Health Association, Inc. Benefit Plan 47 HDHP Section 5(b)
HDHP
Benefits Description Surgical procedures (cont.)
A comprehensive range of services, such as - continued - clinical records support a body mass index of 40 or greater (or 35-40 when there is a co-morbid condition such as life-threatening cardiopulmonary problems or severe diabetes mellitus) for a period of six months - documentation of failure to lower the body mass index by a medically supervised program within the last twelve months of diet and exercise of at least six months duration Note: Benefits are payable only for bariatric surgery which meets the above criteria and is performed at centers certified as "well qualified" by the American College of Surgeons or the American Society for Bariatric Surgery. Bariatric surgery must be precertified. Insertion of internal prosthetic devices (see Section 5(a) Orthopedic and prosthetic devices for device coverage information) Voluntary sterilization (e.g., Tubal ligation, Vasectomy) Surgically implanted contraceptives Intrauterine devices (IUDs) Treatment of burns Assistant surgeons are covered up to 20% of our allowance for the surgeon's charge for procedures when it is medically necessary to have an assistant surgeon Note: Post-operative care is considered to be included in the fee charged for a surgical procedure by a doctor. Any additional fees charged by a doctor are not covered unless such charge is for an unrelated condition. When multiple or bilateral surgical procedures performed during the same operative session add time or complexity to patient care, our benefits are: For the primary procedure based on: - Full Plan allowance For the secondary and subsequent procedures based on: - One-half of the Plan allowance Note: Multiple or bilateral surgical procedures performed through the same incision are "incidental" to the primary surgery. That is, the procedure would not add time or complexity to patient care. We do not pay extra for incidental procedures. PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Reversal of voluntary sterilization Services of a standby physician or surgeon Routine treatment of conditions of the foot; see Foot care Surgical treatment of hyperhidrosis unless alternative therapies such as botox injections or topical aluminum chloride and pharmacotherapy have been unsuccessful
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
48
HDHP Section 5(b)
HDHP
Benefits Description Reconstructive surgery
Surgery to correct a functional defect Surgery to correct a condition caused by injury or illness if: - the condition produced a major effect on the member's appearance and - the condition can reasonably be expected to be corrected by such surgery Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm – limited to children under the age of 18 unless there is a functional deficit. Examples of congenital anomalies are: cleft lip; cleft palate; birth marks; and webbed fingers and toes All stages of breast reconstruction surgery following a mastectomy, such as: - surgery to produce a symmetrical appearance of breasts - treatment of any physical complications, such as lymphedemas - breast prostheses; and surgical bras and replacements (see Prosthetic devices for coverage) Note: We pay for internal breast prostheses as hospital benefits if billed by a hospital. If included with the surgeon's bill, surgery benefits will apply. 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.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury if repair is initiated promptly or as soon as the member's medical condition permits Surgeries related to sex transformation or sexual dysfunction Surgeries to correct congenital anomalies for individuals age 18 and older unless there is a functional deficit Charges for photographs to document physical conditions
All charges
Oral and maxillofacial surgery
Oral surgical procedures, limited to: Reduction of fractures of the jaws or facial bones Surgical correction of cleft lip, cleft palate Excision of cysts and incision of abscesses unrelated to tooth structure Extraction of impacted (unerupted or partially erupted) teeth Alveoloplasty, partial or radical removal of the lower jaw with bone graft Excision of tori, tumors, leukoplakia, premalignant and malignant lesions, and biopsy of hard and soft oral tissues Open reduction of dislocations and excision, manipulation, aspiration or injection of temporomandibular joints
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Oral and maxillofacial surgery - continued on next page
2010 Government Employees Health Association, Inc. Benefit Plan 49 HDHP Section 5(b)
HDHP
Benefits Description Oral and maxillofacial surgery (cont.)
Oral surgical procedures, limited to - continued: Removal of foreign body, skin, subcutaneous areolar tissue, reactionproducing foreign bodies in the musculoskeletal system and salivary stones and incision/excision of salivary glands and ducts Repair of traumatic wounds Incision of the sinus and repair of oral fistulas Surgical treatment of trigeminal neuralgia Repair of accidental injury to sound natural teeth such as: expenses for X-rays, drugs, crowns, bridgework, inlays and dentures. Masticating (biting or chewing) incidents are not considered to be accidental injuries. Orthognathic surgery for the following conditions: - severe sleep apnea only after conservative treatment of sleep apnea has failed - cleft palate and Pierre Robin Syndrome - Orthognathic surgery for any other condition is not covered Other oral surgery procedures that do not involve the teeth or their supporting structures
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) Orthodontic treatment Any oral or maxillofacial surgery not specifically listed as covered Orthognathic surgery, except as outlined above for severe sleep apnea, cleft palate and Pierre Robin Syndrome (even if necessary because of TMJ dysfunction or disorder)
All charges
Organ/tissue transplants
Solid organ transplants limited to: Cornea Heart Heart/lung Single, double or lobar lung Kidney Liver Pancreas Intestinal transplants - Small intestine - Small intestine with the liver - Small intestine with multiple organs, such as the liver, stomach, and pancreas
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Organ/tissue transplants - continued on next page
2010 Government Employees Health Association, Inc. Benefit Plan 50 HDHP Section 5(b)
HDHP
Benefits Description Organ/tissue transplants (cont.)
Blood or marrow stem cell transplants limited to the stages of the following diagnoses: (Medical necessity is considered satisfied if the patient meets the staging description.) Allogeneic transplants for - Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia - Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) - Advanced Hodgkin's lymphoma - Advanced non-Hodgkin's lymphoma - Marrow Failure and Related Disorders (i.e., Fanconi's, PNH, pure red cell aplasia) - Chronic myelogenous leukemia - Hemoglobinopathy - Myelodysplasia/Myelodysplastic syndromes - Severe combined immunodeficiency - Severe or very severe aplastic anemia - Amyloidosis - Paroxysmal Nocturnal Hemoglobinuria Autologous transplants for - Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia - Advanced Hodgkin's lymphoma - Advanced non-Hodgkin's lymphoma - Neuroblastoma - Amyloidosis Autologous tandem transplants for - Recurrent germ cell tumors (including testicular cancer) - Multiple myeloma - Denovo myeloma Blood or marrow stem cell transplants for Allogeneic transplants for - Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome) - Advanced neuroblastoma - Infantile malignant osteopetrosis Autologous transplants for - Multiple myeloma - Testicular, mediastinal, retroperitoneal and ovarian germ cell tumors, - Breast cancer - Epithelial ovarian cancer - Waldenstrom's macroglobulinemia
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
2010 Government Employees Health Association, Inc. Benefit Plan
51
Organ/tissue transplants - continued on next page HDHP Section 5(b)
HDHP
Benefits Description Organ/tissue transplants (cont.)
Mini-transplants (nonmyeloblative, reduced intensity conditioning) for covered transplants: Subject to medical necessity Tandem transplants for covered transplants: Subject to medical necessity Note: We cover related medical and hospital expenses of the donor when we cover the recipient. Note: All allowable charges incurred for a surgical transplant, whether incurred by the recipient or donor will be considered expenses of the recipient and will be covered the same as for any other illness or injury subject to the limits stated below. This benefit applies only if the recipient is covered by us and if the donor's expenses are not otherwise covered. Transportation Benefit We will also provide up to $10,000 per covered transplant for transportation (mileage or airfare) to a Plan designated facility and reasonable temporary living expenses (i.e. lodging and meals) for the recipient and one other individual (or in the case of a minor, two other individuals), if the recipient lives more than 100 miles from the designated transplant facility. Transportation benefits are only payable when GEHA is the primary payor. Transportation benefits are payable for follow-up care up to one year following the transplant. The transportation benefit is not available for cornea or kidney transplants. You must contact Customer Service for what are considered reasonable temporary living expenses. Limited Benefits The process for preauthorizing organ transplants is more extensive than the normal precertification process. Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact our Medical Director so we can arrange to review the clinical results of the evaluation and determine if the proposed procedure meets our definition of "medically necessary" and is on the list of covered transplants. Coverage for the transplant must be authorized in advance, in writing by our Medical Director. (Cornea and kidney transplants do not require preauthorization by GEHA's Medical Director.) PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Organ/tissue transplants - continued on next page
2010 Government Employees Health Association, Inc. Benefit Plan
52
HDHP Section 5(b)
HDHP
Benefits Description Organ/tissue transplants (cont.)
We will pay for a second transplant evaluation recommended by a physician qualified to perform the transplant, if: the transplant diagnosis is covered and the physician is not associated or in practice with the physician who recommended and will perform the organ transplant. A third transplant evaluation is covered only if the second evaluation does not confirm the initial evaluation. The transplant must be performed at a Plan-designated organ transplant facility to receive maximum benefits. If benefits are limited to $100,000 per transplant, included in the maximum are all charges for hospital, medical and surgical care incurred while the patient is hospitalized for a covered transplant surgery and subsequent complications related to the transplant. Outpatient expenses for chemotherapy and any process of obtaining stem cells or bone marrow associated with bone marrow transplant (stem cell support) are included in benefits limit of $100,000 per transplant. Tandem bone marrow transplants approved as one treatment protocol are limited to $100,000 when not performed at a Plan designated facility. All treatment within 120 days following the transplant are subject to the $100,000 limit except expenses for aftercare such as outpatient prescription drugs are not a part of the $100,000 limit. Chemotherapy and procedures related to bone marrow transplantation must be performed only at a Plan-designated organ transplant facility to receive maximum benefits. Simultaneous transplants such as kidney/pancreas, heart/lung, heart/liver, are considered as one transplant procedure and are limited to $100,000 when not performed at a Plan-designated organ transplant facility.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount If prior approval is not obtained or a Plandesignated organ transplant facility is not used, our allowance will be limited for hospital and surgery expenses up to a maximum of $100,000 per transplant. If we cannot refer a member in need of a transplant to a designated facility, the $100,000 maximum will not apply.
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Services or supplies for or related to surgical transplant procedures (including administration of high-dose chemotherapy) for artificial or human organ/tissue transplants not listed as specifically covered Donor screening tests and donor search expenses, except those performed for the actual donor Donor search expense for bone marrow transplants Expenses for sperm collection and storage
All charges
Anesthesia
Professional fees for the administration of anesthesia in: Hospital (inpatient) Hospital outpatient department Ambulatory surgical center Office
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Separate charges of anesthesiologist for colonoscopy and upper endoscopy procedures, except for high risk patients or patients over 60 years of age
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
53
HDHP Section 5(b)
HDHP Section 5(c). Services provided by a hospital or other facility, and ambulance services
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
The deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment each calendar
year. The Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
After you have satisfied your deductible, your Traditional medical coverage begins. Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible
medical expenses and prescriptions.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a PPO
provider. When no PPO provider is available, non-PPO benefits apply.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing
works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. If Medicare is your primary payor, GEHA will provide secondary benefits for covered charges. The high deductible health plan deductible and coinsurance are not waived for Medicare members.
The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or
ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) or (b).
When you use a PPO hospital, the professionals who provide services to you in a hospital may not all be
preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if the services are rendered at a PPO hospital, we will pay up to the Plan allowable for services of radiologists, anesthesiologists, emergency room physicians and pathologists who are not preferred providers at the preferred provider rate.
Charges billed by a facility for implantable devices, surgical hardware, etc., are subject to the Plan allowance
which is based on the provider's cost plus a reasonable handling fee. Providers are encouraged to notify us on admission to determine benefits payable.
YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS; FAILURE TO DO SO WILL
RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to be sure which services require precertification. Penalties are not subject to the catastrophic limit.
Benefits Description Inpatient hospital
Room and board, such as: Ward, semiprivate, or intensive care accommodations General nursing care Meals and special diets Note: We only cover a private room if we determine it to be medically necessary. Otherwise, we will pay the hospital's average charge for semiprivate accommodations. The remaining balance is not a covered expense. If the hospital only has private rooms, we will cover the private room rate. Note: When the hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges.
You pay After the calendar year deductible... You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
2010 Government Employees Health Association, Inc. Benefit Plan
54
Inpatient hospital - continued on next page HDHP Section 5(c)
HDHP
Benefits Description Inpatient hospital (cont.)
Other hospital services and supplies, such as: Operating, recovery, and other treatment rooms Prescribed drugs and medicines Diagnostic laboratory tests and X-rays Blood or blood plasma, if not donated or replaced Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services Take-home items Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home Note: We base payment on whether the facility, or a health care professional, bills for the services or supplies. For example, when the hospital bills for its nurse anesthetists' services, we pay Hospital benefits and when the anesthesiologist bills, we pay Surgery benefits. Maternity Care – Inpatient Hospital Room and board, such as: Ward, semiprivate, or intensive care accommodations General nursing care Meals and special diets Note: Here are some things to keep in mind: You do not need to precertify your normal delivery; see page 14 for other circumstances, such as extended stays for you or your baby. You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will cover an extended stay if medically necessary, but you must precertify. Other hospital services and supplies, such as: Delivery room, recovery, and other treatment rooms Prescribed drugs and medicines Diagnostic laboratory tests and X-rays Blood or blood plasma, if not donated or replaced Dressings and sterile tray services Medical supplies and equipment, including oxygen Anesthetics, including nurse anesthetist services Take-home items Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
You pay After the calendar year deductible... You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
Inpatient hospital - continued on next page
2010 Government Employees Health Association, Inc. Benefit Plan 55 HDHP Section 5(c)
HDHP
Benefits Description Inpatient hospital (cont.)
Other hospital services and supplies, such as - continued: We will cover other care of an infant who requires non-routine treatment if we cover the infant under a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
You pay After the calendar year deductible... You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
Not covered:
Any part of a hospital admission that is not medically necessary (see definition), such as when you do not need acute hospital inpatient (overnight) care, but could receive care in some other setting without adversely affecting your condition or the quality of your medical care. Note: In this event, we pay benefits for services and supplies other than room and board and in-hospital physician care at the level they would have been covered if provided in an alternative setting. Custodial care; see definition Non-covered facilities, such as nursing homes, schools Personal comfort items, such as telephone, television, barber services, guest meals and beds Private nursing care
All charges
Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals Blood or blood plasma, if not donated or replaced Pre-surgical testing Dressings, splints, casts, and sterile tray services Medical supplies, including oxygen Anesthetics and anesthesia service Cardiac rehabilitation Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Maintenance cardiac rehabilitation Maternity Care – Outpatient Hospital Delivery room, recovery, and other treatment rooms Prescribed drugs and medicines Diagnostic laboratory tests and X-rays, and pathology services Administration of blood, blood plasma, and other biologicals Blood or blood plasma, if not donated or replaced Pre-surgical testing Dressings and sterile tray services
All charges
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
2010 Government Employees Health Association, Inc.
Outpatient hospital or ambulatory surgical center - continued on next page 56 HDHP Section 5(c)
HDHP
Benefits Description Outpatient hospital or ambulatory surgical center (cont.)
Maternity Care – Outpatient Hospital - continued Medical supplies, including oxygen Anesthetics and anesthesia services
You pay After the calendar year deductible... You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Extended care benefits/Skilled nursing care facility benefits
Inpatient confinement at Skilled Nursing Facilities for the first 14 days following transfer from acute inpatient confinement when skilled care is still required. Benefits limited to $700 per day. No other benefits are payable for inpatient skilled nursing facility charges. Note: If Medicare Part A pays for the first 14 days of Skilled Nursing Facility confinement, no benefits are payable by us.
You pay
Charges in excess of $700 per day All charges after 14 days
Hospice care
Hospice is a coordinated program of maintenance and supportive care for the terminally ill provided by a medically supervised team under the direction of a plan approved independent hospice administration. We pay $4,000 for hospice care on an outpatient basis We pay $250 per day for room and board and care while an inpatient in a hospice up to a maximum of $5,000 These benefits will be paid if the hospice care program begins after a person's primary doctor certifies terminal illness and life expectancy of six months or less and any services or inpatient hospice stay that is part of the program is: Provided while the person is covered by this Plan Ordered by the supervising doctor Charged by the hospice care program Provided within six months from the date the person entered or re-entered (after a period of remission) a hospice care program Remission is the halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred. A readmission within three months of a prior discharge is considered as the same period of care. A new period begins after three months from a prior discharge with maximum benefits available.
You pay
PPO: 5% up to the Plan limits Non-PPO: 25% up to the Plan limits
Not covered:
Charges incurred during a period of remission, charges incurred for treatment of a sickness or injury of a family member that are covered under another plan provision, charges incurred for services rendered by a close relative, bereavement counseling, funeral arrangements, pastoral counseling, financial or legal counseling, homemaker or caretaker services
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
57
HDHP Section 5(c)
HDHP
Benefits Description Ambulance
Local ambulance service (within 100 miles) to the first hospital where treated, from that hospital to the next nearest one if necessary treatment is unavailable or unsuitable at the first hospital, then to either the home (if ambulance transport is medically necessary) or other medical facility (if required for the patient to receive necessary treatment and if ambulance transport is medically necessary). Air ambulance to nearest facility where necessary treatment is available is covered if no emergency ground transportation is available or suitable and the patient's condition warrants immediate evacuation. Air ambulance will not be covered if transport is beyond the nearest available suitable facility, but is requested by patient or physician for continuity of care or other reasons.
You pay After the calendar year deductible... You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Transportation by ambulance is not covered when the patient does not require the assistance of medically trained personnel and can be safely transferred (or transported) by other means
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
58
HDHP Section 5(c)
HDHP Section 5(d). Emergency services/accidents
Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
The deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment each
calendar year. The Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a
PPO provider. When no PPO provider is available, non-PPO benefits apply.
When you use a PPO hospital, the professionals who provide services to you in a hospital may not all be
preferred providers. If they are not, they will be paid by this Plan as non-PPO providers. However, if the services are rendered at a PPO hospital, we will pay up to the Plan allowable for services of radiologists, anesthesiologists, emergency room physicians and pathologists who are not preferred providers at the preferred provider rate.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing
works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. If Medicare is your primary payor, GEHA will provide secondary benefits for covered charges. The high deductible health plan deductible and coinsurance are not waived for Medicare members. What is an accidental injury An accidental injury is a bodily injury sustained solely through violent, external, and accidental means, such as broken bones, animal bites, and poisonings.
Benefits Description Accidental injury
Non-surgical physician services and supplies Related outpatient physician care Surgical care Treatment outside a hospital or in the outpatient/emergency room department of a hospital or urgent care facility Note: Emergency room charges associated directly with an inpatient admission are considered "Other charges" under Inpatient Hospital Benefits (see pages 54-56) and are not part of this benefit, even though an accidental injury may be involved. This provision also applies to dental care required as a result of accidental injury to sound natural teeth. Masticating (chewing) incidents are not considered to be accidental injuries.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and the difference between our allowance and the billed amount
Medical emergency
Outpatient medical or surgical services and supplies billed by a hospital, for emergency room treatment or outpatient medical or surgical services and supplies billed by an urgent care facility. Note: We pay hospital benefits if you are admitted.
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
2010 Government Employees Health Association, Inc. Benefit Plan
59
HDHP Section 5(d)
HDHP
Benefits Description Ambulance
Local ambulance service (within 100 miles) to the first hospital where treated, from that hospital to the next nearest one if necessary treatment is unavailable or unsuitable at the first hospital, then to either the home (if ambulance transport is medically necessary) or other medical facility (if required for the patient to receive necessary treatment and if ambulance transport is medically necessary). Air ambulance to nearest facility where necessary treatment is available is covered if no emergency ground transportation is available or suitable and the patient's condition warrants immediate evacuation. Air ambulance will not be covered if transport is beyond the nearest available suitable facility, but is requested by patient or physician for continuity of care or other reasons.
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Not covered:
Transportation by ambulance is not covered when the patient does not require the assistance of medically trained personnel and can be safely transferred (or transported) by other means
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
60
HDHP Section 5(d)
HDHP Section 5(e). Mental health and substance abuse benefits
You may choose to get care In-Network or Out-of-Network. You must get our approval for inpatient hospital, inpatient Residential Treatment Centers, and intensive day treatment services. Cost-sharing and limitations for mental health and substance abuse benefits will be no greater than for similar benefits for other illnesses and conditions. Important things you should keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
The deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment each calendar
year. The Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
After you have satisfied your deductible, your Traditional medical coverage begins. Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible
medical expenses and prescriptions.
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. If Medicare is your primary payor, GEHA will provide secondary benefits for covered charges. The high deductible health plan deductible and coinsurance are not waived for Medicare members.
YOU MUST GET PRECERTIFICATION FOR HOSPITAL STAYS, INPATIENT RESIDENTIAL
TREATMENT CENTERS AND INTENSIVE DAY TREATMENT; FAILURE TO DO SO WILL RESULT IN A MINIMUM $500 PENALTY. Please refer to the precertification information shown in Section 3 to be sure which services require precertification. Penalties are not subject to the catastrophic limit.
Benefits Description Professional Services
Individual or group therapy by psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists Medication management Psychological tests (requires precertification) Inpatient professional fees Diagnostic tests Laboratory tests to monitor the effect of drugs prescribed for your condition Electroconvulsive therapy
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance and any difference between our allowance and the billed amount
Inpatient hospital and inpatient residential treatment centers
Room and board, such as: Ward, semiprivate, or intensive care accommodations General nursing care Meals and special diets Note: We only cover a private room if we determine it to be medically necessary. Otherwise, we will pay the hospital's average charge for semi-private accommodations. The remaining balance is not a covered
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
Inpatient hospital and inpatient residential treatment centers - continued on next page
2010 Government Employees Health Association, Inc. Benefit Plan 61 HDHP Section 5(e)
HDHP
Benefits Description Inpatient hospital and inpatient residential treatment centers (cont.)
expense. If the hospital only has private rooms we will cover the private room rate. Note: When the hospital bills a flat rate, we prorate the charges to determine how to pay them, as follows: 30% room and board and 70% other charges. Other hospital services and supplies: Services provided by a hospital
You pay After the calendar year deductible… You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
Outpatient hospital
Services provided by a hospital including partial hospitalization or Intensive Day Treatment Programs
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
Emergency room non-accidental injury
Outpatient services and supplies billed by a hospital for emergency room treatment Note: We pay Hospital benefits if you are admitted.
You pay
PPO: 5% of the Plan allowance Non-PPO: 25% of the Plan allowance
Mental health and substance abuse
Not covered:
Services by pastoral, marital, drug/alcohol and other counselors including therapy for sexual problems Treatment for learning disabilities and mental retardation Telephone therapy Travel time to the member's home to conduct therapy Services rendered or billed by schools, or halfway houses or members of their staffs Marriage counseling Services that are not medically necessary Precertification
You pay
All charges
To be eligible to receive full benefits for mental health and substance abuse, you must follow the authorization process: You must call InforMed at (800) 242-1025 to receive authorization for inpatient care and outpatient intensive day treatment. They will authorize any covered treatment. You should call our Medical Management Department (800) 821-6136 to precertify benefits for psychological testing. Psychological testing claims will be denied if we determine the testing is not medically necessary. If you do not obtain precertification for inpatient care and outpatient intensive day treatment, we will decide whether the stay was medically necessary. If we determine the stay was medically necessary, we will pay the services less the $500 penalty. If we determine that it was not medically necessary, we will only pay for any covered services that are otherwise payable on an outpatient basis. If you remain in the hospital beyond the days we approved and did not get the additional days precertified, we will pay inpatient benefits for the part of the admission that was medically necessary. See Section 3 for details.
2010 Government Employees Health Association, Inc. Benefit Plan
62
HDHP Section 5(e)
HDHP
See these sections of the brochure for more valuable information about these benefits: Section 4, Your costs for covered services, for information about catastrophic protection for these benefits. Section 7, Filing a claim for covered services, for information about submitting out-of-network claims.
2010 Government Employees Health Association, Inc. Benefit Plan
63
HDHP Section 5(e)
HDHP Section 5(f). Prescription drug benefits
Important things you should keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on page 68. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure
and are payable only when we determine they are medically necessary.
The deductible is $1,500 for Self Only enrollment and $3,000 for Self and Family enrollment each calendar
year. The Self and Family deductible can be satisfied by one or more family members. The calendar year deductible applies to all benefits in this Section.
After you have satisfied your deductible, your Traditional medical coverage begins. Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for eligible
medical expenses and eligible prescriptions.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing
works, with special sections for members who are age 65 or over. Also read Section 9 about coordinating benefits with other coverage, including with Medicare. We will not waive the high deductible health plan deductible and coinsurance for Medicare members.
Based on manufacturer's and FDA guidelines, the use of a certain medication may be limited as to its
quantity, total dose, duration of therapy, age, gender or specific diagnosis. Since the prescription does not usually explain the reason the provider prescribed a medication, the requirement of any of these limits and/or prior authorization to confirm the intent of the prescriber may be appropriate.
Some medications must be approved by GEHA and/or Medco before you may purchase them. If you need an extra supply of medications in emergency situations such as if you are called to active military
duty or as a part of the government's continuity of operations, you may receive an extra 30-day supply at retail or if you received a 90-day supply of a specific medication within the last 30 days, arrangements can be made for an additional 60 days to be dispensed through Medco Pharmacy (mail order). Call our office at (800) 821-6136 so that we can work with you to find the most cost effective and efficient manner of meeting your emergency prescription needs.
Each new enrollee will receive a description of our prescription drug program, a combined prescription drug/
plan identification card, and a mail order form, questionnaire, and reply envelope.
As part of our administration of prescription drug benefits, we may disclose information about your
prescription drug utilization, including names of your prescribing physicians, to any treating physician or dispensing pharmacies.
To help increase awareness, GEHA participates in programs to encourage the prescribing of generics and
lower cost alternative preferred brand drugs. These programs may produce savings to you. These programs include generic drug awareness communications or prior approval. In situations where prior approval is required physicians are notified of lower cost preferred brand or generic alternatives. If physician approved, the more cost-effective medication will be dispensed. If the physician does not approve and prefers a nonpreferred drug, a coverage review is initiated at mail service; at a retail pharmacy, to initiate the coverage review, the pharmacist, member, or physician would need to contact Medco. Medical necessity of nonpreferred drug will be reviewed. Unless there are documented clinical reasons why the preferred drug cannot be used you may still obtain the non-preferred drug but you will be responsible for 70% of the cost of the non-preferred drug which will not apply to your annual out-of-pocket maximum. Prescription drug benefits There are important features you should be aware of. These include:
Who can write your prescription: A licensed physician or a licensed dentist must write the prescription (physician assistants and
nurse practitioners can prescribe in select states as state law allows). For Medco Pharmacy (mail order) prescriptions, the physician must be licensed in the United States. In addition, your mailing address must be within the United States or include an APO address. 2010 Government Employees Health Association, Inc. Benefit Plan 64 HDHP Section 5(f)
HDHP
Prescription drug benefits (cont.)
There are important features you should be aware of. These include: (continued) Where you can obtain them: You may fill the prescription at a participating network retail pharmacy, a non-network pharmacy, or through Medco Pharmacy (mail order). You can reduce your out-of-pocket expense if you use a participating network pharmacy or Medco Pharmacy. The difference between our allowance and the cost of the drug at a non-network pharmacy does not apply to the deductible or catastrophic limit.
Covered medication and supplies
You may purchase the following medications and supplies prescribed by a physician from either a pharmacy or by mail: Drugs and medicines (including those administered during a non-covered admission or in a non-covered facility) that by Federal Law of the United States require a physician's prescription for their purchase, except those listed as Not covered; Insulin; Needles and syringes for the administration of covered medications; Contraceptive drugs; and Ostomy supplies (please include the manufacturer's product number to ensure accurate fill of the product). Note: A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written, when a Federally-approved generic drug is available unless substitution is prohibited by state law.
Coordinating with other drug coverage
If you also have drug coverage through another group health insurance plan and we are your secondary insurance, follow these procedures: At participating pharmacies, do not present your GEHA drug card. Purchase your drug using the RX card issued by your primary insurance carrier. Then, mail your pharmacy receipt to GEHA for consideration of possible reimbursement. If your primary insurance does not provide an RX card, then purchase your drug and submit the bill to your primary insurance. When they have made payment, file the claims and the Explanation of Benefit (EOB) with GEHA for consideration of possible reimbursement. In any event, if you use GEHA's prescription drug card when another insurance is primary, you will be responsible for reimbursing us any amount in excess of our secondary benefit. Drugs purchased at non-participating pharmacies should be submitted to our claims office (see page 76) along with the primary insurance EOB. We will accept either the drug receipts or a Medco drug claim form. Submit these claims to GEHA, P.O. Box 4665, Independence, MO 64051-4665, when we are your secondary insurance. If another insurance is primary, you should use their drug benefit. If you elect to use Medco Pharmacy, Medco will bill you directly for 100% of the claim amount. Medco may contact you to secure a form of payment. After you have paid Medco the amount billed, submit the bill to your primary insurance. When your primary insurance makes payment, file the claim and their EOB to us (see page 76). Should Medicare rules change on prescription drug coverage, we reserve the right to require you to use your Medicare coverage as the primary insurance for these drugs. For Medicare Part B insurance coverage: If Medicare Part B is primary, discuss with the retail pharmacy and/or Medco Pharmacy the options to submit Medicare covered medications and supplies to allow Medicare to pay as the primary carrier. Prescriptions typically covered by Medicare Part B include diabetes supplies (test strips, meters), specific medications used to aid tissue acceptance from organ transplants, certain oral medications used to treat cancer, and ostomy supplies. Retail - When using a retail pharmacy for eligible Medicare Part B medication or supplies, present the Medicare ID card. Request the retail pharmacy bill Medicare as primary. Most independent pharmacies and national chains are Medicare providers. To locate a retail pharmacy that is a Medicare Part B participating provider, visit the Medicare website at www.medicare.gov/supplier/home.asp or call Medicare Customer Service at (800) 633-4227. Mail Order - To receive your Medicare Part B-eligible medications and supplies by mail, send your mail-order prescriptions to Medco Pharmacy. Medco will review the prescriptions to determine whether it could be eligible for Medicare Part B coverage. Depending on the type of prescription, it will be forwarded to Liberty Medical or Accredo. You can also contact Liberty Medical directly at (866) 398-7164 to discuss your diabetes supplies.
2010 Government Employees Health Association, Inc. Benefit Plan
65
HDHP Section 5(f)
HDHP
Prescription drug benefits (cont.) Coordinating with other drug coverage (cont.)
For Medicare Part D insurance coverage: GEHA supplements the coverage you get with your Medicare Part D prescription drug plan. Your Medicare drug plan provides your primary prescription drug benefit. GEHA provides your secondary prescription drug benefit. You should have a prescription ID card from your Medicare Part D prescription drug plan and your GEHA ID card. To ensure that you get all the coverage you are entitled to receive, use a pharmacy in the networks for both the GEHA Plan and your Medicare Part D plan, and show both the Medicare Part D ID card and the GEHA ID card when filling a prescription so the pharmacy can coordinate coverage on your behalf.
Medco voluntary formulary
Your prescription drug program includes a voluntary "formulary" feature. The Medco Drug Formulary is a list of selected FDA approved prescription medications reviewed by an independent group of distinguished health care professionals. Prescription drugs are subjected to rigorous clinical analysis from the standpoint of efficacy, safety, side effects, drug-to-drug interactions, dosage and cost-benefit in determining whether they are included on or excluded from the formulary. A formulary is a list of commonly prescribed medications from which your physician may choose to prescribe. The formulary is designed to inform you and your physician about quality medications that, when prescribed in place of other non-formulary medications, can help contain the increasing cost of prescription drug coverage without sacrificing quality. In many therapeutic categories, there are several drugs of similar effectiveness. Many doctors are often unaware of the significant variations in price among these similar drugs and, as a result, their prescribing decisions often do not consider cost. However, when the cost difference is brought to their attention, doctors will frequently prescribe the less costly medications. Your physicians will be contacted to discuss their prescribing decision. No change in the medication prescribed will be made without your physicians' approval. Compliance with this formulary list is voluntary and in general there is no financial penalty for obtaining drugs not on the formulary list. Occasionally there may be exceptions, for additional details refer to page 64, Important things you should keep in mind about these benefits. Any rebates or savings received by the Plan on the cost of drugs purchased under this Plan from drug manufacturers are credited to the health plan and are used to reduce health care costs.
Patient Safety
GEHA has several programs to promote patient safety. Through these programs, we work to ensure safe and appropriate quantities of medication are being dispensed. The result is improved care and safety for our members. Patient safety programs include: Prior approval – Approval must be obtained for certain prescription drugs and supplies before providing benefits for them. Quantity allowances – Specific allowances are in place for certain medications, based on manufacturer and FDA recommended guidelines. Pharmacy utilization – GEHA reserves the right to maximize your quality of care as it relates to the utilization of pharmacies. GEHA will participate in other approved managed care programs, as deemed necessary, to insure patient safety.
How to use Medco network pharmacies (retail)
You may fill your prescription at any participating retail pharmacy. For the names of participating pharmacies, call (800) 551-7675 or visit www.medco.com. To receive maximum savings you must present your card at the time of each purchase, and your enrollment information must be current and correct. In most cases, you simply present the card together with the prescription to the pharmacist. Each purchase is limited to a 30-day supply. Refills cannot be obtained until 75% of the drug has been used. As part of the administration of the prescription drug program, we reserve the right to maximize your quality of care as it relates to the utilization of pharmacies. Some medications may require prior approval by Medco or GEHA.
2010 Government Employees Health Association, Inc. Benefit Plan
66
HDHP Section 5(f)
HDHP
Prescription drug benefits (cont.) How to use Medco Pharmacy (mail order)
Through this service, you may receive up to a 90-day supply of maintenance medications for drugs which require a prescription, ostomy supplies, diabetic supplies and insulin, syringes and needles for covered injectable medications, and oral contraceptives. Some medications may not be available in a 90-day supply from Medco even though the prescription is for 90 days. Even though insulin, syringes, diabetic supplies and ostomy supplies do not require a physician's prescription, to obtain through Medco Pharmacy you should obtain a prescription (including the product number for ostomy and insulin pump supplies) from your physician for a 90-day supply. Some medications may require approval by Medco or GEHA. Not all drugs are available through Medco Pharmacy. In order to use Medco Pharmacy, your prescriptions must be written by a physician licensed in the United States. In addition, your mailing address must be within the United States or include an APO address. Each enrollee will receive a kit that includes a brochure describing the Medco Pharmacy service, an order form, a questionnaire, and a return envelope. To order new prescriptions, ask your doctor to prescribe needed medication for up to a 90-day supply, plus refills, if appropriate. Complete the Health, Allergy, & Medication Questionnaire the first time you order through this service. Complete the information on the Ordering Medication Form; enclose your prescription and the correct deductible and coinsurance. Mail to: Medco P.O. Box 30493 Tampa, FL 33630-3493 Fax: Or you can ask your physician to fax your prescriptions to Medco. To do this, provide your doctor with your ID number (located on your ID card) and ask him or her to call (888) 327-9791 for instructions on how to use Medco's fax service. You should receive your medication within 14 days from the date you mail your prescription. You will also receive reorder instructions. If you have any questions or need an emergency consultation with a registered pharmacist, you may call Medco tollfree at (800) 551-7675 available 24 hours a day, 7 days a week except Thanksgiving and Christmas. Forms necessary for refills will be provided each time you receive a supply of medication from the service. Electronic transmission: Or you can ask your physician to transmit your prescriptions electronically to Medco. Refilling your medication: to be sure you never run short of your prescription medication, you should re-order on or after the refill date indicated on the refill slip or when you have approximately 14 days of medication left. To order by phone: Call Member Services at (800) 551-7675. Have your refill slip with the prescription information ready. To order by mail: To order online: Simply mail your refill slip and deductible and coinsurance in the return envelope. Go to http://www.geha.com/prescriptions/OnlinePharmacy..html then click on the link to Medco, or go to www.medco.com.
2010 Government Employees Health Association, Inc. Benefit Plan
67
HDHP Section 5(f)
HDHP
Benefits Description Covered medications and supplies
Medco Network Pharmacy (retail) All coinsurance is for up to a 30-day supply. A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written (DAW), when a Federally-approved generic drug is available. Note: Under the HDHP coinsurance for prescription drugs goes toward a $5,000 individual and $10,000 family annual combined prescription and medical out-of-pocket limit, except for the 70% coinsurance for non-preferred sleep aid drugs. Non-Network Retail If a participating pharmacy is not available where you reside or you do not use your identification card, you must submit your claim to: Medco P.O. Box 14711 Lexington, KY 40512 Your claim will be calculated on the 25% coinsurance and the appropriate deductible. Reimbursement will be based on GEHA's costs had you used a participating pharmacy. You must submit original drug receipts. All coinsurance is for up to a 30-day supply. Note: When a claim is submitted for direct reimbursement of a compound medication, the pricing is based on the contractual discounted Average Wholesale Price (AWP) cost for the ingredient with the highest cost and the total quantity of ingredients. The professional fee and applicable sales tax are also included in the pricing. Note: Under the HDHP coinsurance for prescription drugs goes toward a $5,000 individual and $10,000 family annual combined prescription and medical out-of-pocket limit, except for the 70% coinsurance for non-preferred sleep aid drugs. Medco Pharmacy (mail order) All coinsurance is for up to a 90-day supply. A generic equivalent will be dispensed unless you or your physician specifies that the prescription be dispensed as written (DAW), when a Federally-approved generic drug is available. Note: Under the HDHP coinsurance for prescription drugs goes toward a $5,000 individual and $10,000 family annual combined prescription and medical out-of-pocket limit, except for the 70% coinsurance for non-preferred sleep aid drugs. 25% of Plan allowance 25% of network price and any difference between our allowance and the cost of the drug
You pay After the calendar year deductible… You pay
25% of Plan allowance
2010 Government Employees Health Association, Inc. Benefit Plan
68
HDHP Section 5(f)
HDHP
Benefits Description Non-covered medications and supplies
The following medications and supplies are not covered under the GEHA health plan:
Drugs and supplies for cosmetic purposes Vitamins, nutrients and food supplements even if a physician prescribes or administers them including enteral formula available without a prescription Nonprescription medicines Drugs to aid in smoking cessation except those limited to the $100 lifetime maximum as part of the smoking cessation benefit (see page 46). You may not obtain smoking cessation drugs with your Medco prescription card or through Medco Pharmacy (mail order). You must purchase these drugs and file the claim with us. Medical supplies such as dressings and antiseptics Drugs which are investigational Drugs prescribed for weight loss Drugs to treat infertility Drugs to treat impotency
You pay After the calendar year deductible… You pay
All charges
2010 Government Employees Health Association, Inc. Benefit Plan
69
HDHP Section 5(f)
HDHP Section 5(g). Special features
Special features
Flexible benefits option
Description
Under the flexible benefits option, we determine the most effective way to provide services. We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms. Until you sign and return the agreement, regular contract benefits will continue. Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process. By approving an alternative benefit, we cannot guarantee you will get it in the future. The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits. If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular benefits will resume if we do not approve your request. Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.
Services for deaf and hearing impaired High risk pregnancies
TDD service is available at (800) 821-4833 for members who are hearing impaired. To participate in our enhanced maternity program, call (800) 821-6136 at any time as soon as you think you or your covered dependent may be pregnant. Early participation in the program guarantees you ongoing communication with a registered nurse throughout the pregnancy. Complimentary educational materials include the book "From Here to Maternity". Have a health question or concern Registered nurses provide answers to your health questions 24 hours a day, 7 days a week. Call toll-free (888) 257-4342 for health information and counseling. This program is voluntary and confidential. When you call the GEHA NurseLine number, you can choose to listen to recorded messages on more than 1,000 health topics. GEHA members will receive a pamphlet with instructions for using this service. Our new online Health Assessment can help you evaluate your health and monitor your risk for certain conditions. This program is voluntary and confidential. To access this tool, register for Member Web Services at www.geha.com and click on Health Toolbox. Our new Personal Health Record helps you track health conditions, allergies, medications and more. This program is voluntary and confidential. To access this tool, register for Member Web Services at www.geha.com and click on Health Toolbox.
GEHA NurseLine
Health Information Library Health Assessment
Personal Health Record
2010 Government Employees Health Association, Inc. Benefit Plan
70
HDHP Section 5(g)
HDHP Section 5(h). Health education resources and account management tools
Special features
Health education resources
Description
Visit our website at www.geha.com for the Health e-Report Newsletter. Visit our Wellness Center tab on our website at www.geha.com/wellness_center for information on: General health topics; Links to health care news; Cancer and other specific diseases; Drugs/medication interactions; Kids health; Patient safety information; and Several helpful website links.
Account management tools
For each HSA, HRA and HDHP account holder, we maintain a complete claims payment history online through www.geha.com. Your balance will also be shown on your explanation of benefits (EOB) form. You will receive an EOB after every claim. If you have an HSA, - You will receive a monthly statement from the HSA Bank outlining your account balance and activity for the month - You may also access your account on-line at www.hsabank.com If you have an HRA, - Your HRA balance will be available on-line through www.geha.com - Your balance will also be shown on your explanation of benefits (EOB form) If you have an HDHP, - Complete claims payment history is available online through www.geha.com - You will also receive an explanation of benefits (EOB) after every claim
Consumer choice information
If you have GEHA's Health Savings AdvantageSM HDHP, you may choose any provider. However, you will receive discounts when you see a network provider. Directories are available online at www.geha.com. Pricing information for prescription drugs is available at www.medco.com. Link to online pharmacy through Medco at www.medco.com. Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.geha.com.
Care support
GEHA has a strong patient safety program. Pharmacy initiatives help ensure that members have fewer health complications related to prescription drugs. Disease management programs help our members with specific health conditions such as heart disease and diabetes. Medical case managers assist patients with high risk pregnancies, durable medical equipment, transplants and other special needs. Patient safety information is available on-line at http://www.geha.com/wellness_center/patient_safety.html
2010 Government Employees Health Association, Inc. Benefit Plan
71
HDHP Section 5(h)
Non-FEHB benefits available to Plan members
The benefits in this section are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information contact the Plan at (800) 821-6136 or visit their website at www.geha.com.
Non-Covered Prescription Drugs (800) 417-1893 Certain prescription drugs not covered by GEHA's Prescription Drug Program are available to GEHA health plan members at a discount. If your physician writes a prescription for a non-covered drug to treat impotency or hair loss, you may purchase it through the Medco Pharmacy, paying 100% of the discounted amount. To order, complete the form called Ordering Medications from the Medco Pharmacy. Mail this form along with your prescription and check or credit card number to: Medco P.O. Box 30493 Tampa, FL 33630-3493 If paying by a check, please call first to obtain the cost of the medication. Full payment must be included with your order.
Online Shopping www.medco.com GEHA health plan members have access to special features offered on the Medco Web site, www.medco.com. On this Web site, you can refill mail order prescriptions and manage your mail order account. A new feature is online shopping for thousands of consumer health products available from the Medco Health Store. Items available include non-prescription medications and other healthrelated products that complement prescription drug care.
CONNECTION Hearing (888) HEARING (432-7464) www.HEARPO.com Free to all GEHA health plan members, CONNECTION Hearing offers a discount hearing program through HearPO. Use of this program can help maximize your hearing aid benefit dollars. Plan highlights include:
Substantial discounts on all levels of digital hearing aids through the largest national network of hearing care professionals; Three-year repair warranties covering repairs and one time loss and damage coverage; Choice of an extensive product line from several leading hearing aid manufacturers; First-year clinical visits at no additional cost to the patient; No limit on how often participants, their dependents or participants' extended family members can use the program; and Highest customer satisfaction ratings in the hearing aid industry.
Simply call (888) HEARING (432-7464) to learn more about the hearing program.
CONNECTION Fitness (800) 294-1500 www.globalfit.com/geha GEHA health plan members can take advantage of special discounts available through our CONNECTION Fitness program by GlobalFit. This new program offers discounts on gym memberships at more than 10,000 health clubs nationwide, discounts on workout equipment and videos, discounts on the NutriSystem weight management program, and discounts on 12-week health coaching programs. Call GlobalFit or visit the GlobalFit website for more information.
2010 Government Employees Health Association, Inc. Benefit Plan
72
Non-FEHB benefits available to Plan members Section 5
CONNECTION Dental (800) 296-0776 www.geha.com Free to all GEHA health plan members, CONNECTION Dental can reduce your costs for dental care. CONNECTION Dental is a network of more then 39,000 individual providers at approximately 66,000 provider locations. Participating providers have agreed to limit their charges to reduced fees for GEHA health plan members. As a GEHA health plan member, you can take advantage of this program in addition to receiving basic dental benefits provided under the GEHA health plan. Just show your CONNECTION ID card before you receive services. To find a participating CONNECTION Dental provider in your area, call (800) 296-0776 or visit www. geha.com and click on Provider Search. Please confirm provider participation prior to your visit.
CONNECTION Dental Plus (800)793-9335 www.geha.com Available for an additional premium, CONNECTION Dental Plus is a supplemental dental plan that pays benefits for a wide variety of procedures, from cleanings and X-rays to crowns, dentures and orthodontia for children. This optional dental insurance is provided directly by GEHA. Certain waiting periods and limitations apply. Enrollment is open to all current and former federal employees, retirees and annuitants, including those who are not members of the GEHA health plan. Parents can cover their unmarried dependent children up to their 25th birthday in this Plan. When you also join the GEHA health plan, you pay a lower premium for CONNECTION Dental Plus. Covered Services Calendar Year Deductible Per Person $0 Provider Participation We pay
Class A Specified Diagnostic and Preventative
In-Network Out-of-Network
100% 80%
Class B Other Diagnostic, Preventative, Restorative & Specified Oral Surgery Class C Endodontics, Periodontics, Prosthodontics & Crowns, Inlays, Onlays Class D Orthodontics-Comprehensive Case (ages 6-17)
$50
In-Network Out-of-Network
80% 70%
$100
In-Network Out-of-Network
50% 40%
$0
In-Network Out-of-Network
$50 per month $25 per month
This is a partial summary of the terms, conditions and limitations of CONNECTION Dental Plus. To get an enrollment packet or more information on coverage and rates, please call CONNECTION Dental Plus at (800) 793-9335 or visit www.geha.com.
Benefits described in this section are not part of the FEHB contract or premium, and you cannot file a FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. The GEHA PPO coinsurance does not apply. GEHA does not guarantee that providers are available in all areas or that prices at a participating provider are lower than prices that may be available from a non-participating provider.
2010 Government Employees Health Association, Inc. Benefit Plan
73
Non-FEHB benefits available to Plan members Section 5
Section 6. General exclusions – things we don't cover
The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. We do not cover the following:
Services, drugs, or supplies you receive while you are not enrolled in this Plan; Services, drugs, or supplies that are not medically necessary; Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice; Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants); 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; sexual dysfunction or sexual inadequacy; Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; Services or supplies for which no charge would be made if the covered individual had no health insurance coverage; Services, drugs, or supplies you receive without charge while in active military service; Services or supplies furnished by immediate relatives or household members, such as spouse, parents, children, brothers or sisters
by blood, marriage or adoption;
Services or supplies furnished or billed by a noncovered facility, except that medically necessary prescription drugs and physical,
occupational and speech therapy rendered by a qualified professional therapist on an outpatient basis are covered subject to Plan limits;
Services or supplies for cosmetic purposes; Surgery to correct congenital anomalies for individuals age 18 and older unless there is a functional deficit; Services or supplies not specifically listed as covered; Services or supplies not reasonably necessary for the diagnosis or treatment of an illness or injury, except for routine physical
examinations and immunizations;
Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives
(does not require the enrollee to pay) a deductible or coinsurance, we will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived;
Charges which the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not
covered by Medicare Parts A and/or B (see page 19), doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare (limiting charge) (see page 20), Never event policies (see page 88), or State premium taxes however applied;
Charges in excess of the "Plan allowance" as defined on pages 89-90; Biofeedback, educational, recreational or milieu therapy, either in or out of a hospital; Inpatient private duty nursing; Stand-by physicians and surgeons; Clinical ecology and environmental medicine; Chelation therapy except for acute arsenic, gold, or lead poisoning; Treatment for impotency, even if there is an organic cause for impotency. (Exclusion applies to medical/surgical treatment as well
as prescription drugs);
Treatment other than surgery of temporomandibular joint dysfunction and disorders (TMJ);
2010 Government Employees Health Association, Inc. Benefit Plan 74 Section 6
 Computer devices to assist with communications; Surgical treatment of hyperhidrosis unless alternative therapies such as botox injections or topical aluminum chloride and
pharmacotherapy have been unsuccessful;
Computer programs of any type, including but not limited to those to assist with vision therapy or speech therapy; Weight loss programs; Home test kits including but not limited to HIV and drug home test kits; Telephone consultations; or Genetic testing and counseling.
2010 Government Employees Health Association, Inc. Benefit Plan
75
Section 6
Section 7. Filing a claim for covered services
How to claim benefits To obtain claim forms, claims filing advice or answers about our benefits, contact us at (800) 821-6136, or at our Web site at www.geha.com. In most cases, providers and facilities file claims for you. Your physician must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. Mail to: GEHA P.O. Box 4665 Independence, MO 64051-4665 For claims questions and assistance, call us at (800) 821-6136. When you must file a claim -- such as for services you received overseas or when another group health plan is primary -- submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show: Name of patient and relationship to enrollee; Plan identification number of the enrollee; Name and address of person or firm providing the service or supply; Dates that services or supplies were furnished; Diagnosis; Type of each service or supply; and The charge for each service or supply. Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills. In addition: You must send a copy of the explanation of benefits (EOB) form you received from any primary payor (such as the Medicare Summary Notice (MSN)) with your claim. Bills for home nursing care must show that the nurse is a registered or licensed practical nurse and should include nursing notes. Claims for rental or purchase of durable medical equipment; private duty nursing; and physical, occupational, and speech therapy require a written statement from the physician specifying the medical necessity for the service or supply and the length of time needed. Claims for prescription drugs and supplies that are not purchased through the prescription drug program must include receipts that show the prescription number, name of drug or supply, prescribing physician's name, date, and charge. A copy of the physician's script must be included with prescription drugs purchased outside the United States. To control administrative costs, we will not issue benefit checks that do not exceed $1. Records Keep a record of the medical expenses of all covered family members as deductibles and maximum allowances apply. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances they will serve as evidence of your claim. We will not provide duplicate or year-end statements. Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31, of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. Once we pay benefits, there is a three-year limitation on the re-issuance of uncashed checks.
Deadline for filing your claim
2010 Government Employees Health Association, Inc. Benefit Plan
76
Section 7
Overseas claims
For covered services you receive in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States, send itemized bills that include an English translation. A copy of the physician's script must be included with prescription drugs purchased outside the United States. Charges should be converted to U.S. dollars using the exchange rate applicable at the time the expense was incurred. If possible, include a receipt showing the exchange rate on the date the claimed services were performed. Covered providers outside the United States will be paid at the PPO level of benefits. All overseas claims, including prescription drug reimbursement, should be submitted to: GEHA, Foreign Claims Department, P. O. Box 4665, Independence, MO 64051-4665. Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if you do not respond.
When we need more information
2010 Government Employees Health Association, Inc. Benefit Plan
77
Section 7
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your claim or request for services, drugs, or supplies – including a request for preauthorization/prior approval required by Section 3. Disagreements between you and the HDHP fiduciary regarding the administration of an HSA or HRA are not subject to the disputed claims process.
Step
Description
Ask us in writing to reconsider our initial decision. You must: a) Write to us within 6 months from the date of our decision; and b) Send your request to us at: GEHA, P.O. Box 4665, Independence, MO 64051-4665; 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.
1
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. If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within: 90 days after the date of our letter upholding our initial decision; or 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or 120 days after we asked for additional information. Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group 2, 1900 E Street, NW, Washington, DC 20415-3620.
4
2010 Government Employees Health Association, Inc. Benefit Plan
78
Section 8
Step
The disputed claims process- continued Send OPM the following information:
Description
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure; Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms; Copies of all letters you sent to us about the claim; Copies of all letters we sent to you about the claim; and Your daytime phone number and the best time to call. Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim. Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.
5
OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals. If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended. OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record. You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.
Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and a) We haven't responded yet to your initial request for care or preauthorization/prior approval, then call us at (800) 821-6136 and we will expedite our review; or b) We denied your initial request for care or preauthorization/prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment
too, or
You may call OPM's Health Insurance Group 2 at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time.
2010 Government Employees Health Association, Inc. Benefit Plan
79
Section 8
Section 9. Coordinating benefits with other coverage
When you have other health coverage or auto insurance You must tell us if you or a covered family member has coverage under any other health plan or has 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 payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' guidelines. When we are the primary payor, we will pay benefits described in this brochure. When we are the secondary payor, 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. There is no change in benefit limits or maximums when we are the secondary payor. If your primary payor requires preauthorization or requires you use designated facilities or provider for benefits to be approved, it is your responsibility to comply with these requirements. In addition you must file the claim to your primary payor within the required time period. If you fail to comply with any of these requirements and benefits are denied by the primary payor, we will pay secondary benefits based on an estimate of what the primary carrier would have paid if you followed their requirements. Please see Section 4, Your costs for covered services, for more information about how we pay claims. What is Medicare Medicare is a health insurance program for: People 65 years of age or older; Some people with disabilities under 65 years of age; and People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant). Medicare has four parts: Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (If you were a Federal employee at any time both before and during January 1983, you will receive credit for your Federal employment before January 1983.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact (800) MEDICARE (800-633-4227), (TTY (877) 486-2048) for more information. Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check. Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get your Medicare benefits. We do not offer a Medicare Advantage plan. Please review the information on coordinating benefits with Medicare Advantage plans beginning on page 82. Part D (Medicare prescription drug coverage). There is a monthly premium for Part D coverage. If you have limited savings and a low income, you may be eligible for Medicare's Low-Income Benefits. For people with limited income and resources, extra help in paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA). For more information about this extra help, visit SSA online at www.socialsecurity.gov, or call them at (800) 772-1213, (TTY (800) 325-0778). Before enrolling in Medicare Part D, please review the important
2010 Government Employees Health Association, Inc. Benefit Plan
80
Section 9
disclosure notice from us about the FEHB prescription drug coverage and Mediicare. The notice is on the first inside page of this brochure. The notice will give you guidance on enrolling in Medicare Part D. Should I enroll in Medicare The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits three months before you turn age 65. It's easy. Just call the Social Security Administration tollfree number (800) 772-1213, (TTY (800) 325-0778) to set up an appointment to apply. If you do not apply for one or more Parts of Medicare, you can still be covered under the FEHB Program. If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don't have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down. Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage. If you are eligible for Medicare, you may have choices in how you get your health care. Medicare Advantage is the term used to describe the various private health plan choices available to Medicare beneficiaries. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare Advantage plan. (Please refer to page 19 for information about how we provide benefits when you are age 65 or older and do not have Medicare.) The Original Medicare Plan (Part A or Part B) The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan. When we are the primary payor, we process the claim first. When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at (800) 821-6136 or see our Web site at www.geha.com. We do NOT waive deductibles or coinsurance for Medicare members enrolled in the High Deductible Health Plan. Tell us about your Medicare coverage You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare. A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare's payment. You may be responsible for paying the difference between the billed amount and the amount we paid.
Private contract with your physician
2010 Government Employees Health Association, Inc. Benefit Plan
81
Section 9
 Medicare Advantage (Part C)
If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at (800) MEDICARE (800-633-4227), (TTY (877) 486-2048) or at www.medicare.gov. If you enroll in a Medicare Advantage plan, the following options are available to you: This Plan and another plan's Medicare Advantage plan: You may enroll in another plan's Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan's network and/or service area, but we will not waive any of our coinsurance or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in Medicare Advantage plan so we can correctly coordinate benefits with Medicare. Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage 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 Advantage plan's service area.
Medicare prescription drug coverage (Part D)
When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan.
2010 Government Employees Health Association, Inc. Benefit Plan
82
Section 9
Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates whether Medicare or this Plan should be the primary payor 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. (Having coverage under more than two health plans may change the order of benefits determined on this chart.)
Primary Payor Chart
A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the individual with Medicare is... Medicare This Plan
1) Have FEHB coverage on your own as an active employee 2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant 3) Have FEHB through your spouse who is an active employee 4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above 5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and... You have FEHB coverage on your own or through your spouse who is also an active employee You have FEHB coverage through your spouse who is an annuitant 6) 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) and you are not covered under FEHB through your spouse under #3 above 7) Are enrolled in Part B only, regardless of your employment status 8) Are a Federal employee receiving Workers' Compensation disability benefits for six months or more B. When you or a covered family member... 1) Have Medicare solely based on end stage renal disease (ESRD) and... It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period) It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD 2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and... This Plan was the primary payor before eligibility due to ESRD (for 30 month coordination period) Medicare was the primary payor before eligibility due to ESRD 3) Have Temporary Continuation of Coverage (TCC) and... Medicare based on age and disability Medicare based on ESRD (for the 30 month coordination period) Medicare based on ESRD (after the 30 month coordination period) C. When either you or a covered family member are eligible for Medicare solely due to disability and you... 1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee 2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant D. When you are covered under the FEHB Spouse Equity provision as a former spouse *Workers' Compensation is primary for claims related to your condition under Workers' Compensation. 2010 Government Employees Health Association, Inc. Benefit Plan 83 Section 9
for Part B services *
for other services
TRICARE and CHAMPVA
TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs. Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.
Workers' Compensation
We do not cover services that: You need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar Federal or State agency determines they must provide; or OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws. Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.
Medicaid
When you have this Plan and Medicaid, we pay first. Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these State programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the State program.
When other Government agencies are responsible for your care When others are responsible for injuries
We do not cover services and supplies when a local, State, or Federal government agency directly or indirectly pays for them.
If GEHA pays benefits for an illness or injury for which you or your dependent are later compensated or reimbursed from another source, you must refund GEHA from any recovery you or your dependent obtain. All GEHA benefit payments in these circumstances are conditional, and remain subject to our contractual benefit limitations, exclusions, and maximums. By accepting these conditional benefits, you agree to the following: The covered person or his/her legal representative must contact GEHA's Subrogation Unit at (800) 821-4742, Ext. 5503 or 5735 as soon after the incident as possible and provide all requested information, including prompt disclosure of the terms of all settlements, judgments, or reimbursements. The covered person must sign any releases GEHA requires to obtain information about his/her claim from other sources. Include all benefits paid by GEHA in any claim for compensation you or your dependent assert against any tortfeasor, insurer, or other party for the injury or illness, and assign all proceeds recovered from any party, including your own and/or other insurance, to GEHA for up to the amount of the benefits paid.
2010 Government Employees Health Association, Inc. Benefit Plan
84
Section 9
 When benefits are payable under the Plan in relation to the illness or injury, GEHA may, at its option: Subrogate, that is, take over the covered person's right to receive payments from other parties. The covered person or his/her legal representative will transfer to GEHA any rights he or she may have to take legal action arising from the illness or injury to recover any sums paid on behalf of the covered person; or Enforce its right to seek reimbursement, that is recover from the covered person, or his/her legal representative, any benefits paid from any payment the covered person is entitled to receive from other parties. You must cooperate in doing what is reasonably necessary to assist us, and you must not take any action that may prejudice our rights to recover reimbursement. Reimburse GEHA on a first priority basis, in full up to the amount of benefits paid, out of any settlements, judgments, and/or recoveries that you obtain from any source, no matter how characterized, i.e., as "pain and suffering." GEHA enforces this right of reimbursement by asserting a lien against any and all recoveries received, including first party Medpay, Personal Injury Protection, No-Fault coverage, Third-Party, and Uninsured and Underinsured coverage. GEHA's lien consists of the total benefits paid to diagnose or treat the illness or injury. GEHA's lien applies first, regardless of the "make whole" and "common fund" doctrines. No reduction of GEHA's lien can occur without our written consent, including reduction for attorney fees and costs. Sign a Reimbursement Agreement if asked by GEHA to do so. However, a Reimbursement Agreement is not necessary to enforce our lien. We may delay processing of your claims until we receive a signed Reimbursement Agreement or Assignment of the proceeds of a claim. GEHA's lien extends to all related expenses incurred prior to the settlement or judgment date, even if those expenses were not submitted to GEHA for payment at the time you reimbursed GEHA. The lien remains the member's obligation until it is satisfied in full. Failure to refund GEHA or cooperate with our reimbursement efforts may result in an overpayment that can be collected from you or any dependent. When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.com, you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost. If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial: Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan. Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care. This Plan does not cover these costs. Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials, this Plan does not cover these costs.
Clinical trials
2010 Government Employees Health Association, Inc. Benefit Plan
85
Section 9
Section 10. Definitions of terms we use in this brochure
Accidental injury An injury caused by an external force or element such as a blow or fall that requires immediate medical attention. Also included are animal bites, poisonings, and dental care required to repair injuries to sound natural teeth as a result of an accidental injury, not from biting or chewing. The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of discharge are counted as the same day. An authorization by an enrollee or spouse for the Plan to issue payment of benefits directly to the provider. The Plan reserves the right to pay the member directly for all covered services. 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. There is one deductible for the entire Plan year for covered services - medical, prescription, inpatient, outpatient, mental health and chiropractic care - you must incur for almost all covered services and supplies before we start paying benefits. For those covered services with coinsurance, we pay 100% of our allowable amount for the remainder of the calendar year after your out-of-pocket-expenses for deductibles and coinsurance exceed $5000 for self only coverage or $10,000 for family coverage. Cost categories: Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays and scans, and hospitalizations related to treating the patient's condition whether the patient is in a clinical trial or is receiving standard therapy; Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care; or Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. Coinsurance Congenital anomaly Coinsurance is the percentage of our allowance that you must pay for your care. You may also be responsible for additional amounts. (see pages 16-18) A condition existing at or from birth which is a significant deviation from the common form or norm. For purposes of this Plan, congenital anomalies include cleft lips, cleft palates, birthmarks, webbed fingers or toes and other conditions that the Plan may determine to be congenital anomalies. Surgical correction of congenital anomalies is limited to children under the age of 18 unless there is a functional deficit. In no event will the term congenital anomaly include conditions relating to teeth or intra-oral structures supporting the teeth. Any procedure or any portion of a procedure performed primarily to improve physical appearance and/or treat a mental condition through change in bodily form. Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible and coinsurance) for the covered care you receive. Services we provide benefits for, as described in this brochure. Treatment or services, regardless of who recommends them or where they are provided, that could be rendered safely and reasonably by a person not medically skilled, or that are designed mainly to help the patient with daily living activities. These activities include but are not limited to: personal care such as help in: walking; getting in and out of bed; bathing; eating by spoon, tube or gastrostomy; exercise; dressing; homemaking, such as preparing meals or special diets;
Admission
Assignment Calendar year Calendar year deductible
Catastrophic limit
Clin