The
Oklahoma State and Education Employees Group Insurance Board
For Plan Year January
1 through December 31, 2009
This
handbook is intended to be an easy-to-use reference to the benefits provided by
the HealthChoice High Option and Basic Plans. It is not intended to be a
complete description of either plan. Please read all the sections of this
handbook carefully for explanations of the eligibility rules and what the Plans
pay, limit, and exclude.
All
Plan provisions, processes, exclusions, and limitations apply to both the High
Option and Basic Plans unless specifically stated otherwise.
Online
information is available through our website at www.sib.ok.gov/ or www.healthchoiceok.com
You
have access to your current plan information via the web. Using the ClaimLink
option from the HealthChoice home page, you can view your eligibility,
benefits, deductible, and claim status, as well as view and print copies of
your Explanations of Benefits. Registration is quick and easy using your name,
date of birth, HealthChoice ID number, ZIP Code, and the last four digits of
your Social Security number. If you have any questions, please contact the
health claims administrator.
You
can easily access the HealthChoice Network Provider Directory through the
HealthChoice website. By clicking on the Provider Listings link on the home
page, you are routed to the Provider Directories page. By clicking on the
Network Medical or Dental Providers link, you can search for a HealthChoice
Network Provider.
It’s
also easy to locate a HealthChoice Network Pharmacy via the website. You must
first click on the Provider Listings link on the home page. You are then routed
to the Provider Directories page. By clicking on the link HealthChoice Network
Pharmacies, you are routed to the pharmacy benefit manager’s website where you
can locate a Network pharmacy.
By
using the online version of the HealthChoice Select Medication List, you can
search for medications by name or by treatment category. The site provides
Preferred or non-Preferred status information and includes a feature that
provides pricing and coverage information for medications. To view the list,
click on View the HealthChoice Select Medication List link and then click
Continue. You are then routed to the pharmacy benefit manager’s website.
The
Frequently Asked Questions link on your website provides an interactive
application that allows you easy access to general Plan information. You have
the ability to search for information by category, topic, or by listing a key
word or phrase.
Plan Identification
Information and Notice
How the HealthChoice Health Plans Work
Required Plan Processes –
Certification
HealthChoice Basic Plan – Outline of
Plan Benefits
HealthChoice High Option Plan – Outline
of Plan Benefits
Covered Services,
Supplies, and Equipment
Preventive Health Care and Immunizations
Prior Authorization Medications
Medications Limited
in Quantity
Plan Exclusions and Limitations
Inaccurate or
Erroneous Information
Corrections to
Benefit Elections
Health Education
Lifestyle Planning
Eligibility and
Effective Dates
Changes to Coverage
After Initial Enrollment
Options for Members
Called to Military Service
Coverage for Other
Eligible Dependents
Loss of Other
Insurance Coverage
Special Rules for
Those Eligible for Medicare
Continuing Coverage After Leaving Employment
COBRA – Consolidated Omnibus Budget
Reconciliation Act
Termination/Reinstatement
of Coverage
Legal Notices and Notifications
Revised
January 2009
HealthChoice
High Option Plan and HealthChoice Basic Plan
Oklahoma
State and Education Employees Group Insurance Board (OSEEGIB)
3545
NW 58th Street, Ste 110
Oklahoma
City, OK 73112
1-405-717-8701
or toll-free 1-800-543-6044
HealthChoice
Member Services and Provider Directory
1-405-717-8780
or toll-free 1-800-752-9475
TDD:
1-405-949-2281 or toll-free 1-866-447-0436
Fax:
1-405-717-8942
Website:
www.sib.ok.gov/ or www.healthchoiceok.com
EDS
Administrative Services, LLC
Correspondence,
Claim Filing, and Claims Review Address
PO Box 24870
Oklahoma City, OK 73124-0870
1-405-416-1800
or toll-free 1-800-782-5218
TDD:
1-405-416-1525 or toll-free 1-800-941-2160
Medco
Toll-free
1-800-903-8113
TDD:
toll-free 1-800-825-1230
Website:
http://www.medco.com
APS
Healthcare
Toll-free
1-800-848-8121
TDD:
toll-free 1-877-267-6367
The
Oklahoma State and Education Employees Group Insurance Board (OSEEGIB) provides
health care benefits to eligible state, education, and local government
employees, former employees, survivors, and their dependents in accordance with
the provisions of Oklahoma Statutes, Title 4, Sections 1301, et seq. The
information provided in this handbook is a summary of the benefits, conditions,
limitations, and exclusions of the HealthChoice High Option and Basic Plans. It
should not be considered an all-inclusive listing.
OSEEGIB
Plan benefits are subject to conditions, limitations, and exclusions. These
conditions, limitations, and exclusions are described and located in Oklahoma
Statutes, OSEEGIB Rules, and Administrative Procedures adopted by the Plan
Administrator. You may obtain a copy of the official OSEEGIB Rules from the
Office of the Oklahoma Secretary of State. A copy of the Administrative
Procedures may be obtained from the Plan Administrator.
PLEASE
READ THIS HANDBOOK CAREFULLY
A
dispute concerning information contained within any OSEEGIB handbook or any
other written materials, including any letters, bulletins, notices, or other
written document, or oral communication, regardless of the source, shall be
resolved by a strict application of OSEEGIB Rules or benefit administration
procedures and guidelines as adopted by the Plan. Erroneous, incorrect,
misleading, or obsolete language contained within any handbook, other written
document, or oral communication, regardless of the source, is of no effect
under any circumstance.
The
benefits of the HealthChoice High Option and Basic Plans are based on
cost-sharing features that include deductibles, copays, and coinsurance. Please
see the Plan Definitions at the back of this
handbook for an explanation of these terms.
The
Plans also have a process called certification which requires providers to have
certain services certified through the HealthChoice Health Care Management
Division or our certification administrator before services are performed.
HealthChoice
allows you to seek care from a HealthChoice Network Provider or a non-Network
provider; however, plan benefits are reduced when you use a non-Network
provider. With a statewide and multi-state network consisting of over 13,000
physicians, hospitals, and other health care professionals and facilities, you
should be able to find a HealthChoice Network Provider that can meet your
health care needs.
Plan
payment is based on set fees known as Allowed Charges. Network Providers have
agreed to accept HealthChoice Allowed Charges for the services and equipment
they provide. By doing this, Network Providers have agreed not to bill you for
amounts greater than the amount allowed by the Plan. Members are responsible
for deductibles, coinsurance amounts, and copays.
On
the other hand, non-Network providers are not contracted with HealthChoice and
are not required to accept the HealthChoice Allowed Charge. This leaves you
responsible for paying the difference between what the provider bills and the
Allowed Charge (also known as balance billing), which can be quite a large
amount of money. Even after reaching your out-of-pocket maximum, you are still
responsible for the difference between the Allowed Charge and the charge billed
by a non-Network provider.
As
an example, let’s say you receive services from a non-Network provider who
charges $100,000; however, the HealthChoice Allowed Charge is $30,000. Under
the High Option Plan, you will be responsible for 50% non-Network coinsurance
until the out-of-pocket maximum is reached, plus the $70,000 difference between
the billed charge and the HealthChoice Allowed Charge. The financial impact
would be even greater under the Basic Plan. The cost of using a non-Network
provider could financially ruin many of our members and demonstrates the
importance of using HealthChoice Network Providers to keep out-of-pocket costs
as low as possible.
HealthChoice
issues one ID card for your health coverage and one ID card for your pharmacy
benefits. The health claims administrator issues the health ID card and the
pharmacy benefit manager issues the pharmacy ID card
To
request additional or replacement health ID cards, contact the health claims
administrator. To request additional or replacement pharmacy ID cards, contact
the pharmacy benefit manager. For contact information, refer to the Plan
Identification Information and Notice section.
Certification
is a review process performed by either the certification administrator or the
HealthChoice Health Care Management Division depending on the type of medical
services to be reviewed.
Certification
is required under some situations, including when you or covered dependents:
Are admitted to a hospital or are advised to
enter a hospital
Require a certain surgical procedure that is
performed in an outpatient facility
Have an observation stay that lasts longer
than 24 hours
Have HealthChoice as the second or third
carrier
Certification
is required three working days prior to scheduled hospital admissions, certain
surgical procedures, and diagnostic imaging performed in an outpatient
facility.
Certification
is required within one working day after an emergency/urgent hospital
admission.
A
ten-percent penalty will be applied to services that are not certified.
The
following surgical procedures require certification through our certification
administrator. A ten-percent penalty will be applied to services that are not
certified. Certification is required three working days prior to the surgical
procedure.
Blepharoplasty – Correction to the eye lid
Rhinoplasty – Reconstruction of the nose
Breast implant removes – Removal of breast
implants
Scar revision – Removal of scar tissue
Breast reduction – Reduction in breast size
Panniculectomy – Reduction in abdomen size
Surgical treatment of varicose veins
The
following diagnostic imaging services require certification through our
certification administrator. A ten-percent penalty will be applied to services
that are not certified. Certification is required three working days prior to
the service. The ten-percent penalty will be applied to all outpatient hospital
facilities, freestanding radiologists, and radiologists who perform the
professional component of the diagnostic imaging service.
Sinus CT/MRI
Head/Brain CT/MRI
Chest CT including spiral CT (RAD)
Spine CT/MRI
Shoulder MRI
PET Scans
To
obtain certification, call the certification administrator at the number listed
in the Plan Identification
Information and Notice section.
The
following services require certification through the HealthChoice Health Care
Management Division:
Non-emergency ground or air ambulance
Hospice
Physical medicine services
Chiropractic care
Durable medical equipment
Oral surgery
Home health care services
Speech therapy
Mental health outpatient services
Botox injections
TMD treatment
This
list is not all-inclusive. Refer to the Covered Services, Supplies, and Equipment section for more
information.
To
request certification previously listed services, your provider must contact
the HealthChoice Health Care Management Division at 1-405-717-8879 or toll-free
-800-543-6044, ext. 8879. TDD users call 1-405-949-2281 or toll-free
1-866-447-0436.
For
authorization processes related to pharmacy benefits, refer to the Pharmacy
Benefits
section.
The
Basic Plan provides first dollar coverage for each covered family member, as
well as catastrophic coverage in the event of a serious medical condition.
The
Plan pays 100% of the first $500 of Allowed Charges for covered medical
services for each covered family member.
You
then pay 100% of the next $500/individual, or $1,000/family, of Allowed Charges
for covered medical services. Only Allowed Charges for covered medical services
apply toward your deductible.
The
Plan then pays 50% and you pay 50% of the next $10,000/individual, or
$20,000/family, of Allowed Charges for covered medical services.
The
Plan then pays 100% of all Allowed Charges for covered medical services after
you have reached $5,500/individual, or $11,000/family, in Allowed Charges for
covered medical services. Only Allowed Charges for covered medical services
apply toward your out-of-pocket maximum.
You
have access to a nationwide pharmacy network.
A
Provider Network that helps limit your out-of-pocket costs.
Per
Covered Member $500
Per
Family combined $1,000
Per
Covered Member $5,000
Per
Family combined $10,000
Listed
below are the out-of-pocket maximums. These amounts include deductibles as set
by the Plan:
Health
– Per Covered Member $5,500*
Health
– Per Family combined $11,000*
Pharmacy
– Per Covered Member $2,500
After
meeting the out-of-pocket maximum, the Plan will pay 100% of Allowed Charges.
*You
will still be responsible for the difference between the Allowed Charge and the
billed charge when using a non-Network provider.
Amounts
above the Allowed Charge that are billed by a non-Network provider do not apply
toward the out-of-pocket maximum and are your full responsibility.
The
following charges do not apply to your out-of-pocket maximum and do not qualify
for 100% payment after your out-of-pocket maximum has been met:
Amounts above the HealthChoice Allowed
Charges or maximum benefit limitation
Non-covered services or charges
Amounts above the Allowed Charge billed by a
non-Network provider
Non-Network pharmacy purchases
Non-Preferred medications
Cost differences between generic and
brand-name medications
Non-covered medications
Health
Benefits – No Lifetime Maximum
Pharmacy
Benefits per Covered Member $2,000,000
First
claim: You receive medical services with an Allowed Charge of 200 from a
Network Provider.
Second
Claim: You receive services with an Allowed Charge of $400.
The
claims are paid as follows:
Allowed
charge – first claim $200, second claim $400
First
dollar coverage – first claim $200, second claim $300
Applied
to deductible – first claim $0, second claim $100
Your
responsibility – first claim $0, second claim $100
You
are covering a spouse and three children. All family members have received $500
in medical services earlier in the plan year covered by the Plan at 100%. You
and your spouse both receive $500 in additional services, totaling $1,000 which
is applied to the $1,000 family deductible.
Claim:
Child A receives services with an Allowed Charge of $250.
The
claim is paid as follows:
First
dollar coverage – Allowed Charge $250
Plan
pays at 50% - $125
Your
coinsurance/responsibility - $125
Claim:
You receive medical services from a non-Network provider with a billed charge
of $9,000. The HealthChoice Allowed Charge is $5,000, which means that the
balance of $4,000 is your responsibility because it exceeds the Allowed Charge.
The
claim is paid as follows:
Billed
charge - $9,000
Allowed
charge - $5,000
First
dollar coverage - $500
Applied
to deductible - $500
Plan
pays at 50% - $2,000
Your
coinsurance - $2,000
Billed
charge minus Allowed Charge - $4,000
Your
responsibility - $6,500
The
High Option Plan is a traditional health plan with cost sharing features
consisting of copays, deductibles, and coinsurance. The Plan also provides a
financial safety net for you in the event of a catastrophic medical event.
Office
visits to a HealthChoice Network Provider and certain other services described
elsewhere in this handbook require a $25 copay. Charges for additional services
such as lab work and x-rays apply to your deductible amount first, and then the
Plan pays 80% - 50% for a non-Network provider – of the Allowed Charge for
covered medical services. Copays do not apply to visits to a non-Network
provider.
You
must pay the deductible of $500/individual, or $1,500/family, of Allowed
Charges for covered medical services. Office visits and certain other services
described elsewhere in this handbook are not subject to the deductible.
The
Plan pays 80% of Allowed Charges for covered medical services and you pay 20%
when using a HealthChoice Network Provider. When services are provided by a
non-Network provider, the Plan pays 50% and you pay 50%, plus any amounts above
the Allowed charge. You are also responsible for all non-covered charges
regardless of your provider’s Network participation.
The
Plan pays 100% of Allowed Charges for covered medical services after you have
paid $2,800 - $3,300 non-Network – in Allowed Charges for covered medical
services. Only Allowed Charges for covered medical services apply toward the
out-of-pocket maximum. You will still be responsible for the difference between
the Allowed Charge and the billed charge when using a non-Network provider.
Each
Covered Member - $500
Each
Covered Family - $1,500
Family
deductible can be met with a combination of three or more family members. No
one person can meet more than $500 of the family deductible.
Each
Network Hospital Confinement – No additional deductible
Each
non-Network Hospital Confinement – Additional $300
Each
Emergency Room Visit Network or non-Network facility – Additional $100
Waived
if patient is admitted or if death occurs prior to admission.
Member
pays 20% of Allowed Charges for Network providers and 50% plus any amounts
above Allowed Charges for non-Network providers
Plan
pays 80% of Allowed Charges for Network providers and 50% of Allowed Charges
for non-Network providers
Note:
The deductible must be met before coinsurance is applied.
Health
- $2,800
Pharmacy
- $2,500
Once
you pay $2,800 in Allowed Charges for Network services, the plan will pay 100%
of Allowed Charges for the remainder of the calendar year.
Health
- $3,300*
Pharmacy
- $No out-of-pocket maximum
Once
you pay $3,300 in Allowed Charges for non-Network services, the plan will pay
100% of Allowed Charges for the remainder of the calendar year.
*You
will still be responsible for the difference between the Allowed Charge and the
billed charge when using a non-Network provider.
The
following charges do not apply to the out-of-pocket maximums and do not qualify
for 100% after the out-of-pocket has been met:
Amounts
above the HealthChoice Allowed Charges of maximum benefit limitations
Non-covered
service or charges
Network
copays
Emergency
room deductibles
Non-Network
inpatient deductibles
Non-Network
pharmacy purchases
Non-Preferred
medications
Cost
differences between generic and brand-name medications
Non-covered
medications
Health
Benefits – No Lifetime Maximum
Pharmacy
Benefits Per Covered Member - $2,000,000
First
Claim: You receive medical services with an Allowed Charge of $500 from a
Network Provider.
Second
Claim: You then receive medical services with an Allowed Charge of $800 from a
Network Provider.
The
claims are paid as follows:
Allowed
Charge – first claim $500, second claim $800
Applied
to deductible – first claim $500, second claim $0
Deductible
already paid – first claim $0, second claim $500
Amount
considered for plan benefits – first claim $0, second claim $800
Plan
pays at 80% for Network – first claim $0, second claim $640
Your
coinsurance – first claim $0, second claim $160
Your
responsibility - first claim $500, second claim $160
You
are covering a spouse and two children. Part of the family deductible has been
met with $500 for spouse, $500 for Child A, and $500 for Child B.
Claim:
You receive medical services with an Allowed Charge of $400 from a Network
Provider. The claim is paid as follows:
Allowed
Charge – $400
Deductible
already paid – $1,500
Applied
to deductible – $0
Amount
considered for plan benefits – $400
Plan
pays at 80% for Network – $320
Your
coinsurance – $80
Your
responsibility - $80
First
Claim: You receive services in the emergency room of a Network hospital. These
services have an Allowed Charge of $2,000 and you have not yet met the calendar
year deductible.
Second
Claim: You again receive services in the emergency room of a Network hospital.
The Allowed Charge for these services is $800.
The
claims are paid as follows:
Allowed
Charge for services – first claim $2,000, second claim $800
Emergency
room deductible – first claim $100, second claim $100
Applied
to deductible – first claim $500, second claim $0
Amount
considered for plan benefits – first claim $1,400, second claim $700
Plan
pays at 80% for Network – first claim $1,120, second claim $560
Your
coinsurance – first claim $280, second claim $140
Your
responsibility – first claim $880, second claim $240
You
already paid the $500 calendar year deductible.
Claim:
You have surgery at a non-Network hospital with a billed charge of $9,000. The
HealthChoice Allowed Charge is $5,000, so the balance of $4,000 is your responsibility
because it is above the Allowed Charge.
The
claim is paid as follows:
Billed
charge - $9,000
Allowed
Charge - $5,000
Non-Network
hospital confinement deductible - $300
Amount
considered for plan benefits - $4,700
Plan
pays at 50% for non-Network - $2,350
Your
coinsurance at 50% - $2,300
Billed
charge – Allowed Charge - $4,000
Your
responsibility - $6,650
Benefits
are based on Network or non-Network benefit guidelines. Refer to the Basic Plan guidelines and High Option Plan guidelines for further information.
Covered only as
anesthesia for surgery
Allergy serum is
subject to deductible and coinsurance
Benefits for testing
are limited to one battery of 60 tests every 24 months; excludes testing of the
home environment
Administration of
allergy serum is subject to deductible and coinsurance
Medically necessary
ground or air services
Non-emergency ground
and air ambulance require certification through the HealthChoice Health Care
Management Division
Refer to Certification section
Additional services
such as radiology, laboratory, administering injections, collection of
specimens, manipulative therapy, etc.
Services referred to
a provider for interpretation
Eligible services for
covered illness or surgery
Includes services
provided by a Certified Registered Nurse Anesthetist (CRNA)
Processing, storage,
and administration of blood and blood products in inpatient and outpatient
settings, including collection and storage of autologous blood
Covered only for
heavy metal poisoning
Limited to 60 visits
per calendar year
Office visit subject
to copay
Visits exceeding 20
per calendar year require certification
Refer to Certification section
Subject to a 15 visit
maximum per calendar year
For High Option
Network benefits, office visit copay applies per visit
Family services
provided in the physician’s office, including surgical procedures for
sterilization, injections, IUDs, and internally time-released implants
Medically necessary
treatment for the repair of injury to sound natural teeth or gums, provided the
accident occurs while the individual is a member of the Plan and the treatment
is performed within 12 months following the date of the accident
Must comply with
applicable certification provisions
Refer to Certification section
Covered under the
pharmacy benefit
Refer to Pharmacy
Benefits
section
Refer to Ancillary
Services in this section
Certification through
the HealthChoice Health Care Management Division is required
Refer to Certification section
Medically necessary
services and supplies for treatment of an emergency illness or injury
Refer to Emergency Care Coverage section
Use of a Network
facility does not guarantee the treating physician or any other provider of services
is a HealthChoice Network Provider
Coverage for the
first pair only after cataract surgery
Covered for diabetics
only
Certification through
the HealthChoice Health Care Management Division is required
Refer to Certification section
Covered for diabetes,
glaucoma, and macular degeneration
Subject to calendar
year limits for routine examinations
For High Option
Network benefits, you pay the office visit copay
Laboratory charges
for a pap test are subject to the deductible and coinsurance
Limited to one
screening and one test per calendar year
This benefit does not
include a comprehensive hearing exam
For High Option
Network benefits, you pay the office visit copay per visit - not subject to the
deductible
Hearing aids are
covered only for participating dependent children up to the age of 18
Hearing aids must be
prescribed, filled, and dispensed by a licensed audiologist
The hearing aid
benefit is limited to every 48 months per impaired ear
Up to 4 additional
ear molds per year for children up to 2 years of age
Certification through
the HealthChoice Health Care Management Division is required
Refer to Certification
section
May be approved for
up to 100 visits per calendar year
Will be monitored by
a HealthChoice nurse case manager
Certification through
the HealthChoice Health Care Management Division is required
Refer to Certification
section
Eligible home health
care prescription medications are covered under the health benefit rather than
the pharmacy benefit
Certain home health
care medications such as Colymycin M, Pulmozyme, Tobramycin, and the Dornase
Alfa Inhaler Solution are covered under the pharmacy benefit rather than the
health benefit; for information, contact the pharmacy benefit manager at the
number listed in the Plan Identification
Information and Notice section
Certification through
the HealthChoice Health Care Management Division is required
Refer to Certification
section
Requires a
physician’s statement of life expectancy of 6 months or less
Certification through
the HealthChoice Health Care Management Division is required
Refer to Certification
section
Refer to Inpatient
Hospital or Outpatient Hospital/Facility Services in this section
Covered in accordance
with the current Centers for Disease Control and Prevention guidelines
Administration
charges are subject to deductible and coinsurance
Some services related
to the diagnosis and treatment of infertility are covered
Prescription drugs
for treatment of infertility
Refer to the Exclusions
section
for services that are not covered
Certification
required
Semi-private room –
unlimited days if medically necessary
Includes intensive
care, coronary care, and all other covered hospital services, such as physician
hospital visits, anesthesia, radiology, or laboratory
High Option Plan members
must pay an additional deductible for each non-Network hospital stay
Includes laboratory
work for physical examinations
Refer to Ancillary
Services in this section
Refer to Preventive
Health Care and Immunizations section
Refer to Physical Therapy/Physical
Medicine in this section
Includes hospital and
delivery with prenatal and postnatal care
Includes one skilled
nurse home health visit if the delivery is at home or in a birthing center; certification
through the HealthChoice Health Care Management Division is required
Includes lab work
associated with prenatal visits
Includes the Mommy
and Me Program. Refer to Mommy and Me in the General
Provisions section.
You must complete a
change form within 30 days following the birth to enroll the baby in the Plan;
a separate calendar year deductible applies to the newborn. Refer to Dependent
Coverage in the Eligibility section.
Inpatient
Certification is
required for inpatient mental health, day treatment, and residential treatment
Inpatient benefits
are limited to 30 days per calendar year*
High Option Plan members
must pay an additional deductible for each non-Network hospital stay
Outpatient
Outpatient benefits
are limited to 26 visits per calendar year*
Outpatient benefits
that exceed 15 visits per calendar year require certification through the
HealthChoice Health Care Management Division
Refer to Certification
section
*Exceptions apply to
diagnoses of schizophrenia, bipolar disorder/manic-depressive illnesses, major
depressive disorder, panic disorder, obsessive-compulsive disorder, and
schizo-affective disorder
Provider must be
licensed by the state in which services are provided
Limited to 60 visits
per calendar year
Visits exceeding 20
per calendar year require certification through the HealthChoice Health Care
Management Division
Refer to Certification
section
Medically necessary
services for evaluation and medical management of an illness or injury,
including preventive care, routine age-limited adult examinations, and well
child care
For High Option
Network benefits, you pay an office visit copay per visit
Refer to Ancillary
Services in this section
Includes the removal
of tumors or cysts
Does not include
removal of wisdom teeth
Certification is
required
For emergency oral
surgery, refer to Emergency Room Treatment in this section
Certification is required
Medically necessary
treatment for the non-experimental transplant of cornea, peripheral stem cell,
bone marrow, skin, liver, heart, lung, pancreas, or kidney
The organ/tissue must
be of human origin
The donor does not
have to be a member of the plan
Procurement and
harvesting are eligible for coverage
Non-member donor
expenses limited to 90 days post transplant
Refer to Certification
section
Wafers and bags are
covered under pharmacy benefits; other ostomy supplies are covered under health
benefits
Includes hospital,
surgery facility, and all other covered outpatient services, including
diagnostic services in conjunction with a surgical procedure or non-emergency
care
Certification is
required for certain surgical procedures performed in an outpatient facility
Refer to Certification
section
Certification through
the HealthChoice Health Care Management Division is required
Refer to Certification
section
Refer to Pharmacy
Benefits section
Limited to 60 visits
per calendar year
Visits exceeding 20
per calendar year require certification through the HealthChoice Health Care
Management Division
For High Option
Network benefits for physical examinations, you pay an office visit copay and
all additional ancillary services and treatments are subject to the deductible
and coinsurance
Refer to Certification
section
Certification through
the HealthChoice Health Care Management Division is required
Covered as durable
medical equipment
Refer to Certification
section
Requires certification
Refer to Certification
section
Services prescribed
by a physician and provided in a licensed skilled nurse facility when medically
necessary
Limited to a maximum
of 100 days per calendar year
Requires
certification
Refer to
Certification section
High Option Plan Only
-
High Option Plan
members must pay an additional deductible for each stay in a non-Network
facility
Covered for restoring
existing speech that has been lost due to disease or injury. Therapy must be
expected to restore the level of speech that the participant had before the
onset of disease or injury.
Not covered for
learning disabilities or birth defects
Limited to 60 visits
per calendar year
Visits exceeding 20
per calendar year require certification through the HealthChoice Health Care
Management Division
Refer to Certification
section
Surgeon, assistant
surgeon, perfusionist, and anesthesiologist, when medically necessary and in
attendance at the surgery
Standby services must
be documented in the patient’s medical record and include time in attendance
Inpatient
Limited to 30 days
per calendar year
Certification is
required for inpatient substance abuse, day treatment, and residential
treatment
High Option Plan members
must pay an additional deductible for each non-Network hospital stay
Outpatient
Outpatient limit is
26 visits per calendar year; however, outpatient benefits which exceed 15
visits per calendar year require certification through the HealthChoice Health
Care Management Division
Refer to Certification
section
Covered if medically
necessary and the provider is in attendance during the surgery
Inpatient or
outpatient facility for covered illness or injury
Certification
required for certain surgeries
Refer to Outpatient
Surgery in this section
Refer to Certification
section
Certification
required through the HealthChoice Health Care Management Division
Refer to Certification
section
Covered for whiplash
only
Prescription
medications used to treat nicotine addiction
Limited to two 90-day
courses of any FDA-approved tobacco cessation product per year
Over-the-counter
medications are not covered
Refer to Organ
Transplants in this section
Refer to Ancillary
Services in this section
Covered for psoriasis
only
Coverage for wigs or
other scalp prostheses for individuals who experience hair loss due to
radiation or chemotherapy treatment resulting from a covered medical condition
Coverage is subject
to annual deductibles and coinsurance
Maximum annual
benefit is $150
Must be obtained from
a licensed cosmetologist or DME provider
An
emergency is defined as a sudden and unexpected symptom that you could
reasonably expect the absence of immediate medical attention would result in
placing the health of you, or others, in serious jeopardy.
In
addition to the $500 deductible and coinsurance required for the High Option
Plan, there is a $100 emergency room deductible per visit for Network and
non-Network facilities. This is waived if you are admitted or death occurs
prior to admission. If emergency treatment cannot be provided and the patient
is referred to another emergency room for treatment, the emergency room
deductible will be waived on the emergency room that could not provide
treatment.
The
$100 emergency room deductible does not apply to the Basic Plan.
Refer
to the Certification section.
Non-Network
Services
You
may have certain benefits for medical emergencies when non-Network emergency
room or inpatient hospital services occur. You must notify a case manager at
the HealthChoice Health Care Management Division at the numbers listed in the Plan Identification Information and Notice
section.
If
an inpatient admission occurs at a non-Network facility as a result of an
emergency, you must notify the certification administrator. Notification must be
within one working day of the admission.
High
Option and Basic Plan
Age
18 through 35 - one every two calendar years, age36 and older - one every
calendar year
High
Option and Basic Plan
Age
50 and older – one routine PSA screening every calendar year
*Maximum
benefit is $65. The deductible and copay are waived for Network services.
Note:
Claims with a non-routine diagnosis are subject to all policy provisions
including deductible and coinsurance.
High
Option and Basic Plan
Age
18 and older – one every calendar year
*If
a routine exam and a gynecological exam are performed separately in the same
year, only one of the exams will be covered.
High
Option Plan
Under
age 40 - $25 copay, one every calendar year; age 40 and older – Plan pays 100%
for Network services**
Basic
Plan
Under
age 40 - One every calendar year, subject to Basic Plan provisions; age 40 and
older – Plan pays 100% for Network services**
*Women
age 39 and under will receive one mammogram per year for a $25 copay when using
a Network provider. Any additional mammograms during the year, or any
mammograms provided by a non-Network provider will be subject to deductible and
coinsurance.
**For
women age 40 and older, the deductible and coinsurance are waived for one mammogram
per year for Network and non-Network services. The maximum benefit for5 a
mammogram performed at a non-Network facility is $115. Any additional
mammograms during the year will be subject to deductible and coinsurance.
The
following routine immunizations are covered according to the current Centers
for Disease Control and Prevention guidelines.
Flu
Hepatitis B for those in high-risk groups
HPV
Pneumonia
Shingles
Tetanus
This
list is not all-inclusive.
Children
up to age 18 for preventive care office visits
Age
zero to 12 months – six every calendar year
Age
one year through two years – four per calendar year
Age
three years through 5 years – two per calendar year
Age
six years through 17 years – one per calendar year
**All
charges are subject to Plan provisions regarding copays, deductibles, and
coinsurance.
Routine
immunizations for healthy infants and children are covered according to the
current Centers for Disease control and Prevention guidelines.
*Immunizations
for adults and children are paid at 100% of Allowed Charges; however, any
charge for administration or office visit is subject to Plan provisions
regarding copays, deductibles, and coinsurance.
The
pharmacy benefits for the HealthChoice High Option and Basic Plans are
identical and include the following features:
Electronic point of sale claim processing
Generic medications are Preferred
medications
If no generic exists, then a Preferred
medication may be the next least expensive choice
If you choose a non-Preferred medication
instead of a Preferred medication, you will be responsible for the difference
in cost, plus the copay
The generic-brand cost difference, the
non-Preferred copay, and medications purchased at non-Network pharmacies will
not apply to your medical deductible or pharmacy out-of-pocket maximum
Pharmacy benefits may cover up to a 34-day
supply or 100 units, whichever is greater. Quantities cannot exceed the FDA
approved ‘usual’ dosing for a 100-day supply. Specific therapeutic categories,
medications, and/or dosage forms may have more restrictive quantity and/or
duration of therapy limitations. Pharmacy benefits are also subject to and
limited by the physician’s orders. Refer to the Medications
Limited in Quantity section.
A limited number of medications require
prior authorization for coverage; refer to the Prior Authorization Medications section
Ostomy bags and wafers are covered under
pharmacy benefits and should be purchased at a HealthChoice Network Pharmacy;
other ostomy supplies are covered under health benefits
Diabetic supplies covered under pharmacy
benefits include insulin syringes with needles, testing strips, lancet devices,
and glucometers; quantity limitations apply. For specific details, contact the
pharmacy benefit manager. For contact information, refer to the Plan Identification Information and Notice
section.
Home Health medications such as Colymycin M,
Pulmozyme, Tobramycin, and Dornase Alfa Inhaler Solution are covered under
pharmacy benefits rather than health benefits
The
HealthChoice Pharmacy Program includes a network of pharmacies. In Oklahoma,
there are more than 900 pharmacies that participate in the HealthChoice
pharmacy network. Nationwide, there are nearly 60,000 pharmacies that
participate in the HealthChoice pharmacy network. To locate a HealthChoice
Network Pharmacy, click on the Provider Listing link on our website at www.sib.ok.gov or www.healthchoiceok.com or contact the pharmacy benefits
manager. For contact information, refer to the Plan Identification Information and Notice
section.
Cost
of medication is $100 or less – you pay up to $25, or actual cost if less
Cost
of medication is more than $100 – you pay 25% up to a $50 maximum
Out-of-pocket
maximum - $2,500 per person for Preferred products at Network pharmacies; then
Plan pays 100%
Cost
of medication is $100 or less – you pay up to $50, or actual cost if less
Cost
of medication is more than $100 – you pay 50% up to a $100 maximum
Out-of-pocket
maximum is not applicable to non-Preferred medications
You
pay cost of medication up to $75 maximum plus a dispensing fee
You
pay cost of medication up to $125 maximum, plus a dispensing fee
Note:
If you choose a brand-name medication when a generic is available, you will be
responsible for the difference in cost, plus the copay. The brand-generic cost
difference is not applied to the out-of-pocket maximum and will always be your
responsibility even if your out-of-pocket maximum has been met. The following
charges do not apply to your out-of-pocket maximum and do not qualify for 100% payment
after your out-of-pocket has been met:
Non-Network pharmacy purchases
Non-Preferred medications
Cost differences between generic and
brand-name medications
Non-covered medications
If
your medication is not a generic and does not appear on the HealthChoice Select
Medication List, your options will be to:
Ask your physician for a prescription for a
Preferred medication that you can receive at the Preferred pharmacy copay.
Continue with your current non-Preferred
medication and pay the non-Preferred copay; or obtain a medical necessity
exception if you have specific health problems that require a brand-name
medication that is not a Preferred medication. In order to be considered for
this exception, specific criteria must be met and detailed documentation from
your physician must justify the request for an exception.
The
HealthChoice Select Medication List classifies those medications that are
Preferred by the Plan. This list is subject to change. Contact the pharmacy
benefit manager or visit their website regarding the current status of a
particular medication or to obtain a copy of the HealthChoice Select Medication
List.
Your
share of the cost of most medication is subject to Network copays, medication
cost, non-Network copays, the cost difference between a brand-name and a
generic medication if a brand-name is purchased when a generic is available,
and unit-of-use and quantity limitations.
Certain
specialty medications will be covered only if you order them through Accredo
Health, the pharmacy benefit manager’s specialty pharmacy. Specialty
medications are generally high-cost medications that are typically injected.
Members must pay the applicable copay for each 30-day fill of a specialty
medication.
Accredo
also provides free supplies such as needs and syringes, free shipping, refill
reminder calls, and a personal counseling team of registered nurses and
pharmacists.
Be
aware that if you don’t order your specialty medications through Accredo, you
will be responsible for the full cost of your medications.
For
more information, contact Accredo at the number listed in the Plan Identification Information and Notice
section.
Certain
medications require a Prior Authorization.
Your physician must call the pharmacy
benefit manager to request a Prior Authorization form. This form must be
completed and returned.
Once the fully completed form is received by
the pharmacy benefit manager, a decision will be made within 24 hours.
The pharmacy benefit manager will send
notification of the approval or denial to you and your physician.
If approved, the medication is subject to
the applicable pharmacy copay and will be entered in the pharmacy benefit
manager’s system within 48 hours. If the review is denied, you or your physician
may file an appeal with HealthChoice.
This
list is not all-inclusive and is subject to change. Brand name medications are
listed in all capital letters and generic are in lower case.
ATACAND
(candesartan), ATACAND HCT (candesartan/HCTZ), AVALIDE (irbesartan/HCTZ),
AVAPRO (irbesartan), BENICAR (olmesartan), BENICAR HCT (olmesartan/HCTZ),
COZAAR (losartan), DIOVAN (valsartan), DIOVAN HCT (valsartan/HCTZ), HYZAAR
(losartan/HCTZ), MICARDIS (telmisartan), MICARDIS HCT (telmisartan/HCTZ),
TEVETEN (eprosartan), TEVETEN HCT (eprosartan/HCTZ)
LEXAPRO (escitalopram
oxalate)
RELENZA (zanamivir),
TAMIFLU CAPSULES/SUSPENSIONS (osteltamivir)
IRESSA (gefitinib)
CELEBREX (celecoxib)
ADDERALL, ADDERALL XR
(amphetamine/dextroamphetamine combination); DESOXYN (methamphetamine);
DEXEDRINE, DEXEDRINE SPANSULES, DEXTROSTAT (dextroamphetamine); FOCALIN
(dexmethylphenidate); RITALIN, RITALIN SR, RITALIN LA, METADATE CD, CONCERTA,
METHYLIN ER (methylphenidate); STRATTERA (atomoxetine)
ARANESP
(darbepoetin), PROCRIT/EPOGEN (erythropoietin)
GENOTROPIN
(somatropin), GEREF (somatropin), HUMATROPE
(somatropin), NORDITROPIN (somatropin), NUTROPIN (somatropin), PROTROPIN
(somatropin), SAIZEN (somatropin), SEROSTIM (somatropin), SOMAVERT
(somatropin), ZORBTIVE
Prior Authorization
approved only if you have had radical retropubic prostatectomy surgery,
otherwise these medications are not covered
CAVERJECT, EDEX
INJECTION (alprostadil); CIALIS (tadalafil); LEVITRA (vardenafil); MUSE
(alprostadil); VIAGRA (sildenafil); Yohimbine HCL, both generic and brand-name
ACCOLATE
(zafirlukast), SINGULAIR (montelukast), ZYFLO and ZYFLO CR (zileuton)
LEUKINE
(sargramostim), NEULASTA (pegfilgrastim), NEUMEGA (oprelvekin), NEUPOGEN
(filgrastim), NPLATE
ACTONEL (risedronate
sodium) excludes 30mg; FORTEO INJECTION (teriparatide, RDNA origin injection)
STADOL NASAL SPRAY
(butorphanol)
ACIPHEX
(rabeprazole), PREVACID (lansoprazole); ZEGERID (omeprazole/sodium bicarbonate)
LUNESTA
(eszopielone); ROZEREM (ramelteom)
Prior Authorization
required for age 23 and older
DIFFERIN (adapalene)
all dosage forms, RETIN-A (tretinoin) all dosage forms, TAZORAC (tazarotene)
all dosage forms
Your physician must call the pharmacy
benefit manager to request a Brand-Name Exception Form or to request a
Preferred copay for a non-Preferred medication. Refer to the Plan Identification and Notice section for contact
information.
This review follows the same process as
described in the Pharmacy Prior
Authorization section.
Quantity limits are
based on recommended duration of therapy and/or routine usage for each
medication.
New medications that
become available in the drug categories listed will automatically have quantity
limits per copay. New drug categories may be added throughout the year. If
generic equivalents are available or become available, they will also be
limited in quantity.
Following is a list
of brand-name drugs that have specific quantity limits which are less than the
standard benefit. If generics are available, they will also be limited in
quantity. This list may not be all-inclusive and is subject to change.
ANZEMET, EMEND,
KYTRIL, ZOFRAN
IRESSA
ALORA, CLIMARA,
COMBIPATCH, ESCLIM, ESTRASORB, ESTRADERM, VIVELLE DOT, generic estrogen patches
INTAL, TILADE,
includes other inhaled medications
Cartridges, needles,
syringes, pre-filled syringes, pens, diabetic supplies (over-the-counter)
BECONASE (AQ),
FLONASE, NASACORT (AQ), NASALIDE, NASAREL, NASONEX, RHINOCORT (AQUA), VANCENASE
AMERGE, AXERT, FROVA,
IMITREX, MAXALT, MIGRANAL NS, RELPAX, STADOL NS, TREXIMET, ZOMIG
AVONEX, BETASERON,
COPAXONE, REBIF
RESTASIS
ACTONEL – excludes
30mg, alendronate sodium, BONIVA, FORTEO, FOSAMAX, FOSAMAX D, MIACALCIN NS
ARAVA, ENBREL,
HUMIRA, KINERET, RHEUMATRIX
AMBIEN, AMBIEN CR,
BUTISOL, DALMANE, DORAL, HALCION, LUNESTA, PROSOM, RESTORIL, ROZEREM, SONATA
ANAKIT, EPIPEN,
limited to 2 per calendar year
Inhaler spacers,
limited to 2 per calendar year
ANDRODERM, ANDROGEL,
CATAPRESS TTS, DAYTRANA, EMSAM, fentanyl, LIDODERM, nitroglycerin, ORTHO-EVRA,
OXYTROL, STRIANT, TESTIM GEL, TRANSDERM-SCOPE
There
is no coverage for expenses incurred for or in connection with any of the items
listed in this section. This list is not all-inclusive.
1.
Services supplied by a provider who is a relative by blood or marriage of the
patient or one who normally lives with the patient
2.
Any confinement, medical care, or treatment not recommended by a duly qualified
practitioner
3.
Room humidifiers, air purifiers, pulse oximeters, blood pressure cuffs,
exercise clubs, classes and equipment, swimming pools, Jacuzzi pumps, saunas,
hot tubs, automobiles or adaptive equipment for automobiles, sun lamps,
augmentative communication devices, patient lifts, adaptive bathroom and
self-care equipment, assistive devices, breast pumps, and items not used
exclusively by you or your dependent, or any equipment that exceeds lifetime
maximum benefits, i.e., one walker per lifetime, one air floatation mattress
per lifetime – mattresses not specifically designed for the prevention or
treatment of skin breakdown or healing, or any other bedding purchased for any
other reason
4.
Devices which attach to a building – walls, ceilings, floors, etc.
5.
Manipulative and physical therapy for palliative care – treatment for only the
relief of pain; elective care – care designed to relieve recurring subjective
symptoms; or prolonged care – treatment that does not move toward resolution as
documented in the evaluation or re-evaluation goals
6.
Custodial care
7.
Lost, stolen, or damaged medications
8.
Over-the-counter vitamins
9.
Over-the-counter medications
10.
Charges for missed or cancelled appointments, mileage, penalties, finance
charges, separate charges for maintenance, record keeping, or case management
services
11.
Claims submitted later than the last day of the calendar year immediately
following the calendar year in which the service was provided
12.
Convenience items, such as telephones or televisions and personal comfort
items, such as cervical pillows, protective clothing, or shoes
13.
Medical care and supplies for which no charge would be made or no payment would
be requested if the insured individual did not have this coverage
14.
Complications from non-covered or excluded treatments, items, or procedures
15.
Any treatment, device, or medication that is an exclusion of the Plan, whether
or not medical necessity is established
16.
Medical and/or mental health treatment of any kind, including hospital care,
medications, or any medical care or medical equipment which is excessive or
where medical necessity has not been proven
17.
Any medication, device, procedure not FDA approved for general use or sale in
the United States
18.
Illness, injury, or death as a result of committing or attempting to commit an
assault or felony, including participation in a riot or insurrection, as an
aggressor
19
Any treatment or procedure considered experimental or investigational; this
restriction will also apply to any facility, appliance, device, equipment, or
medication
20.
Medical services or treatments not generally accepted as the standard of care by
the medical community
21.
Acupressure
22.
Alopecia
23.
Biofeedback
24.
Contraceptive devices, such as a diaphragm
25.
Dyslexia testing
26.
Electromyography without needle
27.
Food or nutritional supplements
28.
Nutritional analysis
29.
Home dialysis training
30.
Home exercise programs
31.
Home sleep apnea studies
32.
Home uterine monitoring
33.
Kinesiology – movement therapy
34.
Rolf technique – ‘Rolfing’
35.
Surrogate mother expenses
36.
Venipuncture by a physician when also billing for lab charges
37.
Marriage counseling
38.
Expenses incurred prior to the effective date of an individual’s coverage, or
expenses incurred during a period of confinement, which had its inception prior
to the effective date of an individual’s coverage
39.
Any condition covered under an “Extended Benefits” provision of the previous
group health coverage, until the individual has exhausted all extended benefits
available
40.
Hospitalization or other medical treatment furnished to the insured or
dependent after eligibility has terminated
41.
Confinement to a facility unless approved by HealthChoice
42.
Medical and surgical services and supplies in excess of the Allowed Charges
43.
Any claimed expense reimbursed or eligible for reimbursement or indemnification
from any public agency or program, including, but not limited to, any medical
benefits program, state or federal, including military benefits
44.
Bodily injury or illness arising out of or in the course of any employment not
specifically excluded by 85 O.S. §2.1 or 2.6 of the Workers’ Compensation Act
45.
Surgical procedures or treatment performed for cosmetic or elective reasons
unless such procedure is specifically included as a covered charge or is
necessary as a result of an accident; coverage must have been continuous from the
date of the accident to the date of corrective surgery
46.
Breast implants are not covered unless they are necessitated by removal of
diseased tissue
47.
Dental expenses unless incurred as the result of an accidental injury to
natural teeth or gums while coverage is in effect; coverage must have been
continuous from the date of the accident to the date of corrective surgery;
broken or lost artificial teeth, bridges, or dentures are not eligible
48.
Wrongful act or negligence of another when an employee or dependent has
released the responsible party; this exclusion may be waived in individual
cases at the Plan’s option and for good cause
49.
Eye examinations for the fitting of corrective lenses or any charges related to
such examinations; orthoptics, visual training for any diagnosis other than
mild strabismus; or for eyeglasses; except for the first pair used as a
prosthetic replacement after the removal of the natural lens; or for other
corrective lenses, or for radial keratotomy or LASIK
50.
Sex transformation surgeries and treatment for sexual dysfunction including
implants or any nature, reversal of elective sterilization, and in vitro
fertilization or artificial insemination
51.
All treatments for obesity, including but not limited to morbid obesity; all
gastrointestinal tract modifications and all complications and procedures, even
when obesity or morbid obesity has been diagnosed; expenses for weight loss
treatment, advice, or training; outpatient nutritional counseling is covered
only for diabetes
52.
Hearing aids and examinations for fitting or prescription, except for eligible
individuals up to age 18; must be prescribed, filled, and dispensed by a
licensed audiologist
53.
Preoperative or postoperative care generally rendered by the operating surgeon,
unless the surgeon itemizes his charges and the total amount charged is no more
than the total Allowed Charge for the surgery
54.
Behavior modification programs
55.
Some infertility treatment is covered by the Plan. Coverage includes
prescription drugs, but excludes artificial insemination, embryo transplant, in
vitro fertilization, surrogate parenting, ovum transplant, donor semen, gamete
intrafallopian transfer – GIFT, zygote intrafallopian transfer – ZIFT, and
reversal of voluntary sterilization
56.
Impotency medications are only covered by the Plan in the event of radical
retropubic prostatectomy surgery
Your
provider will file your claims for you and payment is automatically made to
your provider.
You
may have to file your claims personally. Claims should be filed as soon as the
services are received or completed. A claim form is not needed. To file a
claim, send a copy of the bill including your name and ID number, the patient’s
name and diagnosis, and codes for procedures performed; this information can be
obtained from the provider. Send your claim to the health claims administrator
at the address listed in the Plan Identification Information and Notice
section.
Non-Network
claims are usually paid to you; however, you may choose to assign benefits to
be paid directly to your provider.
When
a valid assignment of benefits to the provider is submitted with your claim,
payment will be made to the provider. When there is no valid assignment of
benefits, payment will be made to you and you will be responsible for paying your
provider.
Claims
must be received no later than the last day of the calendar year following the
year of the date the claim was incurred. For example, if the date of service
was July 1, 2009, the claim will be accepted through December 31, 2010.
If
you receive medical treatment, services, prescription drugs, or supplies
outside the United States, the following claim procedures must be met.
You must make arrangements to pay for the
services or supplies
You must submit a claim
All claims must be translated into English
and converted to US dollar amounts using the exchange rates applicable for the
dates of service; you must file the original claim along with a translation
The Plan does not pay any costs for
translating claims or medical records
Allowed Charges will be paid at the non-Network
rate of coinsurance; you will be responsible for amounts above the Allowed
Charges
If
you or your enrolled dependents have medical or pharmacy costs that are covered
by another group health plan, HealthChoice benefits will be coordinated so that
the total benefits received are not greater than the charges billed, benefits
allowed, or your responsibility,
Pharmacy
benefits are also subject to COB if you have another group health plan with
pharmacy coverage. If you have other group health coverage that is primary,
your HealthChoice pharmacy claims can still be filed electronically.
If
your pharmacy cannot file electronically, you will need to file a paper claim.
Claims must include a copy of the Explanation of Benefits from your primary
plan or a copy of your pharmacy statement showing the actual cost, your copay,
or out-of-pocket expense.
To
obtain paper pharmacy claim forms, contact the pharmacy benefit manager at the
number listed in the Plan Identification
Information and Notice section. Please complete the patient information at
the top of the form and attach your pharmacy statements. Claims must be mailed
to the address listed on the claim form.
If
you terminate your other group coverage or if it does not include pharmacy
benefits, please send written notice and supporting documentation to the health
claims administrator at the address listed in the Plan Identification and
Notice section.
If
you have questions about Coordination of Benefits, contact the health claims
administrator. If you have questions about how your pharmacy benefits will be
affected by Coordination of Benefits, contact the pharmacy benefit manager at
the number listed in the Plan Identification and Notice section.
When
a VOIC form is needed in relation to the processing of a claim, the health
claims administrator will request one from you. Failure to provide a VOIC when
requested will cause your claims to be delayed or denied for non-compliance.
If
your claim is denied in whole or in part for any reason, you have the right to
have that claim reviewed. Requests for review of your denied health claim, along
with any additional information you wish to provide, must be submitted in
writing to our health claims administrator at the claims review address or call
the health claims administrator.
If
your claim remains denied after a claims review, you may appeal that decision
to the Grievance Panel by contacting
The
Legal Grievance Department
3545
NW 58th St, Ste 110
Oklahoma
City, OK 73112
Or
call 1-405-717-8701, toll-free 1-800-543-6044, TDD 1-405-949-2281, or toll-free
TDD 1-800-447-0436.
The
Grievance Panel is an independent review group as established by statute 74
O.S. Section 1306(6).
All
requests for hearings must be filed within one year of the date you are
notified of the denial of a claim, benefit, or coverage.
You
may submit a request for a Grievance Panel hearing and represent yourself in
these proceedings. If you are unable to submit a request for a Grievance Panel
hearing yourself, only attorneys licensed to practice in Oklahoma are permitted
to submit your hearing request for you, or to represent you through the hearing
process 75 O.S. Section 310(5).
All
claim reviews and final decisions of the Grievance Panel are made as quickly as
possible. After completing the claim review and grievance procedures, an appeal
may be pursued in an Oklahoma District Court.
Subrogation
applies when you are sick or injured as a result of the negligent act or
omission of another person or party. Subrogation means the HealthChoice Plans
have a right to recover any benefit payments made to you or your dependents by
a third party’s insurer, because of an injury or illness caused by the third
party. Third party means another person or organization.
If
you or your covered dependents receive HealthChoice benefits and have a right
to recover damages from a third party, this plan has the right to recover any
benefits paid on your behalf. All payments from a third party, whether by
lawsuit, settlement, or otherwise, must be used to repay HealthChoice.
You
must promptly notify HealthChoice if you make a claim against a third party
regarding any illness or injury for which HealthChoice benefits have been or
will be paid. You or your dependent must provide information requested by
HealthChoice. HealthChoice benefits may be withheld until information is
received.
After
any requested information has been received from you, HealthChoice will process
your covered claims, regardless of whether any third party may eventually be
found liable for the expenses arising from the injury.
For
more information about subrogation, contact OSEEGIB. Do not contact the health claims
administrator regarding subrogation as this will only delay a response.
You
may choose any provider or other practitioner who is licensed or certified
under the laws of the state in which they practice, and who is recognized by
the Plan. Each provider offering health care services and/or supplies is an
independent contractor. The provider retains the provider-patient relationship
with you and is solely responsible to you for medical advice and treatment or
any subsequent liability resulting from that advice or treatment.
Although
a provider may recommend or prescribe a service or supply, this does not
necessarily establish coverage by the Plan.
For
information on what types of providers are recognized by the Plan, contact
HealthChoice Provider Relations at 1-405-717-8790 or toll-free 1-800-543-6044.
TDD users call 1-405-949-2281 or toll-free 1-866-447-0436, or check the
Frequently Asked Questions section on the HealthChoice website at www.sib.ok.us
or www.healthchoiceok.com.
Coverage
obtained by means of inaccurate or erroneous information will be cancelled
retroactive to the effective date, and premiums for coverage refunded. The
refunded premiums will be reduced by any claims paid by HealthChoice during
that time.
Anytime
a change is made to your coverage, you will be mailed a Confirmation Statement
(CS). The CS identifies the coverage changes, the effective date of the
changes, and the premium amounts applicable to the changes. The CS is provided
so that you can review changes, and any errors can be identified and corrected
as soon as possible.
You
should review your CS to ensure that the coverage listed is correct. Any
corrections must be submitted to your Insurance/Benefits Coordinator, or for
former employees to OSEEGIB, within 60 days of the election. Corrections
reported after 60 days will be effective the first of the month following
notification.
Despite
your provider’s best efforts, the complexity of arranging for your care and
treatment may result in inaccurate billing. That is why it is important to
check your bill carefully. If certain types of mistakes are made in your bill
and you catch them, you can share in the savings through the Member Audit
Program. You can receive up to 50% of any savings resulting from a billing error
you find up to a maximum reimbursement of $200.
Eligible
errors include charges for services not provided or which are charged
incorrectly. Billing mistakes such as transposed numbers, “addition” mistakes,
and misplaced decimals are not eligible. Only charges for services covered by
the Plan are eligible for the program. Inpatient hospital and ambulatory
surgery center charges are not eligible since payments are not based upon
individually billed items.
If
you find an error has been made on your bill and you wish to participate in the
Member Audit Program, contact the health claims administrator at the number
listed in the Plan Identification
Information and Notice section.
OSEEGIB
shall retain the right to recover any payments made by the Plans in excess of
the maximum allowable expenses, as set forth in the Plans. OSEEGIB shall have
the right to recover such payments, to the extent of excess, from one or more
of the following
Any persons to, or for, or with respect to
whom such payments were made
Any other insurers
Service plans or any other organizations
The
HealthChoice Health Care Management Division has medical case managers
available to assist you with information to maximize your benefits. Case
management assists you in coordinating your care based on individual needs and
provides certification for certain procedures and medical equipment.
Medical
case managers are licensed, certified registered nurses who specialize in
various medical fields. Examples of medical situations when a case manager would
be helpful are
Cancer care
Rehabilitation
HIV/AIDS
Terminal illness
Stroke
Pregnancy and/or pre-term babies
Transplants
Mental health and substance abuse
Specialty durable medical equipment
In or out-of-state emergencies
You
may contact a HealthChoice case manager at 1-405-717-8879 or toll-free 1-800-543-6044,
ext. 8879. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436.
Mommy
and Me is a maternity wellness program that provides access to an experienced
maternity nurse for information and answers to your pregnancy related
questions. The Preconception Program focuses on wellness prior to becoming
pregnant. The Pregnancy Program focuses on having the healthiest pregnancy
possible.
A
risk assessment and information on all aspects of wellness and pregnancy are included
in the program. You may enroll or contact the Mommy and Me nurse by calling toll-free
1-800-475-9926. TDD users call 1-405-949-2281 or toll-free 1-866-447-0436. You
may also enroll via our website at www.sib.ok.gov or www.healthchoiceok.com.
The
HELP staff offers a wide variety of wellness opportunities for you if you
choose to become and stay well. Wellness opportunities include
A walking club in which HELP will send you
various incentive items at each 100 miles logged
Fitness facility discounts
HealthVoice newsletters containing health
tips and activities
Online health and wellness information
For
further information on wellness programs, call the HELP line at 1-405-717-8991
or toll-free 1-800-318-2365. TDD users call 1-405-949-2281 or toll-free
1-866-447-0436.
For
Current Employees and Their Dependents
You
are eligible to participate in the HealthChoice plans if you are
A current Education employee eligible to
participate in the Oklahoma Teachers’ Retirement System and working a minimum
of four hours per day or 20 hours per week.
A current State of Oklahoma or Local
Government employee regularly scheduled to work at least 1,000 hours a year and
not classified as a temporary or seasonal employee.
Coverage
for new employees becomes effective the first day of the month following your
entry-on-duty date or the date you become eligible with your employer. If you
wish to make changes to the coverage you initially elected, you have a 30-day
window following the date you became eligible to make benefit changes. These
changes are effective the first day of the month following the date the change
is made.
You
must be enrolled in one of the health plans in order for your dependents to be
enrolled. If dependent coverage is selected, all of your eligible dependents
must be covered unless they are covered under another group health plan, or are
eligible for Indian or military health benefits.
If
you are enrolled in one of the health plans and have a new dependent as a
result of marriage, birth, adoption, or placement for adoption, you may enroll
your dependents provided you request the enrollment within 30 days following
the marriage, birth, adoption, or placement for adoption. All other enrollments
must be made during the annual Option Period and some limitations will apply.
Eligible
dependents include
Your spouse (including common-law*)
Your unmarried children up to age 25
provided you are primarily responsible for their support
Your dependent, regardless of age, who is
incapable of self-support, and who has a disability that was diagnosed before
the age of 25, subject to medical review and approval
Your stepchildren, provided you are
primarily responsible for their support, or regardless of residence if your
spouse has been court ordered to provide coverage and your spouse is also being
covered
Other dependent children - in the absence of
a federal income tax return listing the children as dependents, you will be
required to provide and have approved a Declaration of Dependency form
For
additional information, refer to Coverage for Other
Eligible Dependents.
*Common-law
marriages are recognized by the Plan. A new employee can add a common-law
spouse at the same time the employee enrolls. A current employee can request
coverage on a common-law spouse during the annual Option Period, or in the
event the common-law spouse loses other group coverage. To enroll a common-law
spouse, the employee and spouse must sign and submit an Enrollment/Change Form.
Newborns
will be covered the first 48 hours following a vaginal birth or the first 96
hours following a cesarean section without enrollment. To continue coverage on your
newborn, you must add him/her within 30 days of the birth. If you are a current
employee and do not enroll your newborn during this 30-day time period, you
will not be able to do so until the next annual Option Period. If you are a
former employee and do not enroll your newborn during this 30-day time period,
you will not be able to do so in the future. Your newborn’s Social Security
number is not required at the time of initial enrollment, but must be provided once
it is received from the Social Security Administration. If enrolled, insurance
premiums must be paid for the full month of your child’s birth.
Eligible
dependents can be excluded from coverage if they have group health coverage or
are eligible for Indian or military health benefits.
You
may also elect to exclude your spouse from coverage. You and your spouse must both
sign the Spouse Exclusion section of your Enrollment/Change Form.
A
dependent who is no longer eligible may apply for continuation of coverage
under COBRA for a maximum of 36 months. Refer to the Continuing Coverage After Termination of Employment
section
for more information.
Note
– If your spouse is also a primary member of a HealthChoice plan through his/her
employer, dependent children may be covered under either parent’s health plan,
provided the parent is also enrolled in the health plan. Dependent children
cannot be covered under both parents’ plans.
If
you previously declined enrollment in either of the health plans because you
had other group health insurance coverage, Indian or military health benefits,
you may enroll
Within 30 days after the date your other
group coverage ends
During the annual Option Period
Certain
qualifying events may allow a midyear benefit change; however, an
Enrollment/Change Form must be completed within 30 days of the qualifying
event. Examples of midyear qualifying events include
A change in your legal marital status, such
as marriage, divorce, or death of spouse
A change in the number of your dependents,
such as the birth of a child
A change in employment status that affects
your eligibility or that of your spouse or dependent
An event that causes your dependent to meet,
or fail to meet eligibility requirements
Commencement or termination of adoption
procedures
Any judgments, decrees, or orders (employer
may allow changes only to health and dental)
Medicare eligibility for you or a dependent
Medicaid eligibility for you or a dependent,
limited to two changes per plan year; once out and once back in or vice versa
Changes in the coverage of your spouse or
dependent under another employer’s plan
Eligibility for leave under the Family
Medical Leave Act (FMLA)
You
may only make changes to coverage within 30 days of a qualifying event or
during the annual Option Period.
All
changes to coverage must be in compliance with the rules of your employer’s
Section 125 Plan, or if no 125 Plan is offered, in compliance with allowed
midyear coverage changes as defined by Title 26, Section 125, of the Internal
Revenue Codes, as amended, and pertinent regulations. Current employees must
contact their Insurance/Benefits Coordinator for an Enrollment/Change Form to
make changes in coverage.
You
may only make eligible changes within 30 days of a qualifying event. Dependents
or new benefit plans other than vision, cannot be added during the annual
Option Period.
Former
employees and surviving dependents must submit requests for changes to coverage
in writing to
Oklahoma
State and Education Employees Group Insurance Board
3545
NW 58th, Ste 110
Oklahoma
City, OK 73112
Verbal
requests for changes in coverage will not be accepted.
Note
– Oklahoma law prohibits dropping your spouse/dependents in anticipation of a
divorce or legal separation. If you are in the process of separation or
divorce, it is important that you contact your legal counsel for advice before
making any changes to your benefits coverage.
Under
the Uniform Services Employment and Re-employment Rights Act of 1994 (USERRA),
coverage can be continued for up to 24 months. USERRA provides certain rights
and protections for all employees called to serve our nation. All branches of
the military including the Army, Navy, Marines, Air Force, Coast Guard, all
Military Reserve units, and all National Guard units come under USERRA.
In
addition to health care provided by the military, you have the following four
choices regarding your current coverage
1.
Retain all coverage. Your current employer is responsible for collecting and
forwarding all premiums to OSEEGIB.
2.
Discontinue member coverage but retain dependent coverage. This is the COBRA
option and dependents will be billed directly at 102% of premiums, the COBRA
rate, for health, dental and/or vision coverage. Under COBRA rules, life and
disability insurance cannot be retained.
3.
Discontinue all coverage except life insurance. You will be billed directly.
4.
Discontinue all member and dependent coverage.
Regardless
of whether you receive written or verbal military orders, the OSEEGIB staff,
and/or your Insurance/Benefits Coordinators will assist you in making any
benefits arrangements.
There
is no penalty for renewing coverage upon discharge from active duty if coverage
is elected within 30 days of the return to the same employment.
If
you are a member of a Military Reserve unit or the National Guard and
anticipate being called to active service, notify your Insurance/Benefits
Coordinator at work.
You
may also obtain coverage for certain other dependents if they are legally adopted,
you have legal guardianship, or the dependents meet other specific
requirements. You must
Request coverage within the time frame
specified in each category listed below
Provide the necessary documentation
Meet all eligibility requirements
Pay all premiums
Cover all eligible dependents
An
adopted dependent is eligible for coverage the first day of the month in which
you obtain physical custody of the child. You must submit an Enrollment/Change
Form to HealthChoice, including a copy of your adoption papers. In the absence
of adoption papers or other court records, someone involved in the adoption
process, such as your attorney or a representative of the adoption agency, must
provide proof of the date you actually received custody of the child pending
the final adoption hearing.
You
must request coverage within 30 days of the date of the initial placement for
adoption, otherwise
Current employees cannot add coverage until
the next annual Option Period
Former employees are not allowed to add
coverage at any future date
Guardianship
follows the same guidelines as an adoption, except that coverage will not begin
until the first day of the month following the date the child was placed in
your custody.
In
the absence of a court order indicating adoption, guardianship, or divorce, you
may request coverage for other eligible dependents by submitting an
Enrollment/Change Form with a copy of the portion of your most recent income
tax return that lists the children as dependents for income tax deduction
purposes.
Coverage
for other eligible dependents begins on the first day of the month following
the date you obtained physical custody and never applies retroactively.
In
the absence of a federal income tax return listing the children as dependents,
you will be required to provide a Declaration of Dependency Form as specified
by the Plan. Coverage, when approved, begins on the first day of the month
following approval and never applies retroactively.
You
must request coverage within 30 days of the date of initial placement,
otherwise
Current employees cannot add coverage until
the next annual Option Period
Former employees are not allowed to add
coverage at any future date
Note
– The Plan retains the right to verify the dependent status of the children, to
request copies of that portion of your most recent income tax return that lists
the children as dependents, and to discontinue coverage for any dependents that
are found to be ineligible.
You
may not have enrolled in a HealthChoice Plan because you were covered under
another group health plan. If you later lose coverage under another group
health plan, you may enroll in one of the HealthChoice Plans within 30 days
following the date of the loss of your other coverage. You may elect to have
HealthChoice coverage begin on the first day of the month in which you actually
lost the other group coverage, subject to payment of the full premium for that
month. Otherwise, coverage shall become effective under this Plan on the first
day of the month following the election.
Participating
former employees may add a spouse within 30 days of their spouse’s loss of
other group health insurance. Proof of loss will be required. Loss of
individual health coverage is not a qualifying event and does not allow
enrollment under this Plan.
Loss
of another type of group coverage, such as dental coverage, does not grant the
right to enroll in a health plan. Also, loss of group health coverage does not
grant the right to enroll in other types of HealthChoice plans, such as dental
or life.
Each
month, you must pay the full premium for the coverage you have selected.
Failure to pay premiums on a timely basis will result in your coverage
terminating at the end of the month in which the last premium was received.
If
you are on approved leave without pay through your employer, you may continue
coverage for up to 24 months from the first day you begin leave without pay
status. You must make timely premium payments in full each month to your
Insurance/Benefits Coordinator.
If
your coverage terminates for failure to pay premiums on a timely basis, you may
re-enroll as a new employee upon returning to work.
If
you take leave under the Family Medical Leave Act (FMLA), please make premium
payment arrangements with your employer before taking leave.
If
you or your covered dependents become eligible for Medicare, either as a result
of age or because of disability, your employer’s group plan will remain primary
and Medicare will be your secondary coverage. Upon termination of employment,
your Medicare coverage will become the primary insurance carrier.
Unless
you are a state employee, you may accept or reject coverage under your
employer’s group health plan. If you reject this Plan, Medicare will be the
primary payer for Medicare-covered health services. If you reject your
employer’s group health plan, your employer cannot provide you with a plan that
pays supplemental benefits for Medicare-covered services, nor subsidize such
coverage.
If
you are a former employee and you or your covered dependent are under age 65
and eligible for Medicare, you must notify OSEEGIB and provide your Medicare ID
number (HICN) as it appears on your Medicare card. Medicare supplement coverage
will become effective the date you become eligible for Medicare, or the first
day of the month following notification to OSEEGIB, whichever is later. Late
notice will not allow for a refund of excess premiums paid.
For
further information regarding Medicare enrollment, call the Social Security
Administration toll-free at 1-800-772-1213 or TTY 1-800-325-0778. You may also
access information regarding Medicare enrollment at www.medicare.gov or call Medicare toll-free
at 1-800-633-4227 or TTY 1-866-226-1819.
All
of the HealthChoice pharmacy plans provide “Creditable Coverage.” This means
the coverage offered through HealthChoice is at least as good as the standard
Medicare prescription drug coverage.
If
you or your spouse leaves the active employment that allows you to participate
in HealthChoice coverage, you will have the option to continue coverage through
the HealthChoice Medicare Supplement Plans, which include either Medicare Part
D or creditable coverage prescription drug benefits.
If
you leave employment, you and/or your covered dependents may be able to keep
coverage under the Plan through one of the following options:
Vesting or retirement rights through one of
the public employee retirement systems established by the State of Oklahoma
Years of service with state, education, or
local government employers; more information on Years of Service follows
Receiving benefits through the HealthChoice
Disability Plan administered by OSEEGIB
Survivors’ Rights for your covered
dependents in the event of your death
COBRA – Consolidated Omnibus Budget
Reconciliation Act
Each
month, premiums must be paid in full. Failure to pay premiums on a timely basis
will result in termination of coverage at the end of the month in which the
last premium was received.
You
may keep coverage after leaving employment if you make an election within 30
days following your termination date, and you meet one of the following
conditions:
You are eligible to participate in the
Oklahoma Public Employees Retirement System and have eight or more years of
service with a participating employer, but do not have a vesting right
You are eligible to participate in the
Oklahoma Teachers’ Retirement System and have had ten or more years of service
with a participating employer
You are an employee of an education employer
that participates in the Plan, but does not participate in the Oklahoma
Teachers’ Retirement System and have ten or more years of service
You are an employee of a local government
employer that participates in the Plan but does not participate in the Oklahoma
Public Employees Retirement System and have eight or more years of service
If
you were a career tech employee or a common school employee who terminated
active employment on or after May 1, 1993, you may continue coverage through
the Plan as long as the school system from which you retired or vested
continues to participate in the Plan. If your school system terminates coverage
under the Plan, you must follow your school system to its new insurance
carrier.
If
you were an employee of an education entity other than a common school; e.g.,
higher education, charter school, etc., you may continue coverage through the
Plan as long as the education employer from which you retired or vested
continues to participate in the Plan. There is no grandfathered date for this
type of entity, so if your employer terminates coverage with the Plan, you must
follow your former employer to its new insurance carrier regardless of the date
you terminated active employment.
If
you were a local government employee who terminated active employment on or
after January 1, 2002, you may continue coverage through the Plan as long as
the employer from which you retired or vested continues to participate in the
Plan. Otherwise, if your local government employer terminates coverage with the
Plan, you must follow your former employer to its new insurance carrier.
Note:
You cannot reinstate coverage that you discontinue or allow to lapse unless you
return to work as an employee of a participating employer and maintain that
coverage for three years. Some reinstatement exceptions may apply if you are a
state employee who terminated employment as a result of a Reduction in Force –
RIF.
For
any group that joins the Plan after the grandfathered dates specified
previously, all members, including current and former employees, must follow
the group to the new insurance carrier.
You
may keep health coverage in effect as an employee if you are receiving benefits
through the HealthChoice Disability Plan. You may continue coverage as long as
you are covered under the HealthChoice Disability Plan and pay premiums in a
timely manner. You must maintain continuous coverage. If you discontinue
coverage, or allow coverage to lapse, it cannot be reinstated unless you return
to work as an employee of a participating employer.
Your
surviving spouse and dependents have 60 days following your death to notify
OSEEGIB that they wish to continue coverage. Coverage will be effective the
first day of the month following your death.
Your
surviving spouse is eligible to continue insurance coverage as long as premiums
are paid.
Surviving
dependent children are eligible for coverage until age 25 or the child marries.
Disabled
dependent children will be eligible to continue survivors’ coverage as long as
they continue to meet the HealthChoice definition of a disabled dependent.
Note:
COBRA continuation of coverage is available for dependent children who lose
eligibility.
If
your or your dependents coverage is terminated for any of the reasons that
follow, each covered member has the right to elect temporary continuation of
coverage through COBRA.
You
are eligible for limited continuation of coverage, up to 18 months, if you lose
coverage due to:
A reduction in your hours of employment
Termination of your employment for reasons
other than gross misconduct
Your
covered spouse is eligible for limited continuation of coverage if coverage is
lost for reasons such as:
Your death – also refer to Survivors’
Rights
Termination of your employment for reasons
other than gross misconduct
A reduction in your hours of employment
resulting in loss of coverage
A divorce or legal separation*
Your
covered dependent children are eligible for limited continuation of coverage if
coverage is lost for reasons such as:
Your death – also refer to Survivors’ Rights
Termination of your employment for reasons
other than gross misconduct
A reduction in your hours of employment
resulting in loss of coverage
A divorce or legal separation of the
parents*
Your dependent no longer meets the
requirements for dependent status
If
you are a participating current employee, it is your responsibility to notify
your employer within 30 days of a divorce, legal separation, or your child’s
loss of dependent status under this Plan.
If
you are a former employee, you must notify OSEEGIB in writing within 30 days of
a divorce, legal separation, or your child’s loss of dependent status under
this Plan.
You
or your eligible dependents must elect continuation of coverage within 60 days
after the later of the following events occurs:
The date the qualifying event would cause
you or your dependent to lose coverage
The date your employer notifies you or your
dependents of continuation of coverage rights
If
the qualifying event is related to termination of employment or reduced hours,
the coverage may be continued for a maximum period of 18 months. If the
qualifying event is for any other eligible reason, the coverage may be
continued for a maximum period of 36 months. However, continuation of coverage
will terminate immediately for you and/or all covered dependents under the
following circumstances:
The Plan ceases to provide coverage
The required premiums are not paid in a
timely manner
You and/or your dependents become covered
under another group health plan or qualify for Medicare
If
you have additional questions regarding COBRA, contact your Insurance/Benefits
coordinator or OSEEGIB.
*Oklahoma
law prohibits dropping your spouse/dependents in anticipation of a divorce or
legal separation. If you are in the process of a legal separation or divorce,
it is important you contact your legal counsel for advice before making changes
to your benefits coverage.
If
you elect to continue coverage under COBRA, an extension of the maximum period
of coverage may be available if a qualified beneficiary is disabled or a second
qualifying event occurs. You must notify OSEEGIB of a disability or second
qualifying event in order to extend the coverage continuation period. Failure
to provide timely notice of a disability or second qualifying event may affect
your right to extend the coverage continuation period.
Your
coverage, as well as any dependent coverage, ends on the last day of the month
if one or more of the following events takes place:
You terminate employment with a
participating employer and choose not to continue coverage through vesting,
non-vest, retirement, disability, or COBRA
You do not pay the required premiums
The Plan is terminated
Your death occurs
In
addition, a dependent’s coverage will end on the last day of the month he/she
ceases to be an eligible dependent. Upon review by OSEEGIB, if you or your
dependent is found to be ineligible, coverage will be terminated effective on
the first day of the month of discovery. OSEEGIB reserves the right to recover
any claims paid on behalf of an ineligible member.
If
you are currently employed by a participating employer and discontinue coverage
on yourself, or your dependents, you cannot apply for reinstatement of coverage
for at least 12 months. To reinstate discontinued coverage, you must enroll
within 30 days of:
The expiration of the 12 month waiting
period; if coverage is not reinstated within 30 days of the end of the waiting
period, you cannot enroll in coverage until the next annual Option Period
The loss of other group health coverage or
other qualifying event
To
reinstate coverage, proof of the loss of other group coverage or other
qualifying event must be submitted.
Reinstated
coverage must be maintained for three years to allow you to carry it into
retirement.
If
you are a former state employee who:
Had a vested or retirement based on the
provisions of any of the state public retirement systems,
Was separated from state service as a result
of a reduction in force anytime after July 1, 1997,
And was offered severance benefits pursuant
to the State Government Reduction in Force and Severance Benefits Act
You
may reinstate health insurance coverage at any time within two years following
the date of the reduction in force from the state. Reinstated coverage must be
maintained for three years to allow you to carry it into retirement.
For
further information, contact HealthChoice Member Services at the numbers in the
Plan Identification Information and Notice
section.
This notice describes how medical information about you may be used and
disclosed and how you can get access to this information. Please review it
carefully.
OSEEGIB is a State of
Oklahoma governmental agency created and governed by Oklahoma law for the
purpose of administering health, life, disability, and dental
This notice describes
and gives you examples of the permitted ways your health information may be
used and disclosed.
OSEEGIB uses and
discloses your protected health information for your treatment, payment for
services, and OSEEGIB business operations in the administration of health
plans. The health claims you submit, or health claims submitted by providers
for your treatment, contain protected health information and are processed for
payment and data collection by claims administrators according to Oklahoma law
and contractual terms of confidentiality with OSEEGIB. Your health information
is used and disclosed by OSEEGIB employees and other entities under contract
with OSEEGIB according to the ‘minimum necessary’ standard. OSEEGIB or its
claims administrators may use and disclose health information, to determine
medical necessity for pre-certification of hospital and medical
You have the right
to: a) inspect and copy your health information, (generally EOBs) with the
exception of psychotherapy notes and/or information that requires a court
order; b) amend and restrict the health information that OSEEGIB discloses
about you; however, OSEEGIB is not required to agree to a requested restriction;
c) request your communications remain confidential with OSEEGIB; d) receive a
copy of this Notice; e) file a complaint if you believe OSEEGIB has improperly
used or disclosed your information; f) request a listing of disclosures, except
for treatment, payment, business operations, and per your authorization after
April 14, 2003; and g) receive a paper copy of this Notice upon request if you
have received this Notice electronically.
OSEEGIB reserves the
right to change the terms of this Privacy Notice and will provide all
interested persons a revised notice either by U.S. Postal Service delivered to
the individual’s mailing address on file with OSEEGIB or electronic
communication by posting the revised Privacy Notice on the OSEEGIB website at www.healthchoiceok.com and www.sib.ok.gov
If you believe your
privacy rights have been violated, call or send a written complaint to the
OSEEGIB HIPAA Information Officer at 3545 NW 58th, Suite 110, Oklahoma City,
Oklahoma, 73112, 1-405-717-8701, toll-free 1-800-543-6044, TDD 1-405-949-2281,
or toll-free TDD 1-866-447-0436; the Secretary of the U.S. Department of Health
and Human Services (HHS) at the Office of Civil Rights, 1301 Young Street, Ste
1169, Dallas, Texas, 75202, 1-214-767-4056, or submit an electronic complaint
according to directions located on the HHS Office of Civil Rights website.
Complaints to HHS must be filed within 180 days after the date on which you
became aware, or should have been aware, of the violation. No retaliation is
allowed against the individual filing a complaint.
Revised Notice
effective August 5, 2005
When health insurance terminates, a Certificate of coverage will be sent
to your last known address. OSEEGIB will mail certificates for education and
local government employees, former members, surviving dependents, and COBRA
participants. The Employees Benefits Council (EBC) will mail Certificates of
Coverage to state employees. A Certificate of Coverage may be required, as
proof of previous group health coverage, by your next health plan for a waiver
of preexisting condition limitations.
Under the Oklahoma Breast Cancer Patient Protection Act, group health
plans, insurers, and HMOs that provide medical and surgical benefits in
connection with a mastectomy must provide benefits for certain reconstructive
surgeries effective for the first plan year beginning on or after January 1,
1998. In the case of a participant or beneficiary who is receiving benefits
under a plan in connection with a mastectomy and who elects breast
reconstruction, federal law requires coverage in a manner determined in
consultation with the attending physician and the patient for:
Reconstruction of the breast on
which the mastectomy was performed
Surgery and reconstruction on
the other breast to produce a symmetrical appearance
Prostheses and treatment of
physical complications at all stages of the mastectomy, including lymphedemas
This coverage is subject to a plan’s annual deductibles and coinsurance
provision. These provisions are generally described in the plan’s benefit
handbook.
HealthChoice provides coverage for side effects that are commonly
associated with radical retropubic prostatectomy surgery, including but not
limited to impotence and incontinence, and for other prostate related
conditions.
*If you have questions about the HealthChoice coverage of mastectomies
and reconstructive surgery or prostate related conditions, contact EDS
Administrative Services at the numbers listed in the Plan Identification
Information and Notice section.
HealthChoice provides a benefit for wigs or other scalp prostheses for
individuals who are experiencing hair loss due to radiation or chemotherapy treatment
resulting from a covered medical condition. Coverage is subject to annual
deductibles and coinsurance, not to exceed $150 annually. The wig or scalp
prosthesis must be obtained from a licensed cosmetologist or DME provider.
Bodily
injury sustained as the direct result of an accident, independent of any other
cause, which occurs while insurance coverage is in force.
The
set dollar amount allowed under the Plans for a covered service or supply.
A
review process performed by either the certification administrator or the
HealthChoice Health Care Management Division depending on the type of medical
services to be reviewed.
The
percentage of Allowed Charges that will be paid by you and by HealthChoice once
your deductible is satisfied.
A
cost sharing arrangement in which you pay a set dollar amount for specific
services.
A
procedure that primarily serves to improve appearance.
The
initial amount of out-of-pocket expense you pay on Allowed Charges before a
benefit is paid by the Plan.
The
amount of out-of-pocket expense you pay on Allowed Charges after the Plan has
paid $500 in Allowed Charges for covered medical services.
Your legal spouse (including common-law).
Your unmarried children up to age 25
provided you are primarily responsible for their support
Your dependent, regardless of age, who is
incapable of self-support, and who has a disability that was diagnosed before
the age of 25, subject to medical review and approval
Your stepchildren, provided you are
primarily responsible for their support, and regardless of residence if your
spouse has been ordered by the court to provide coverage and your spouse is
also being covered.
Other dependent children; in the absence of
a federal income tax return listing the children as dependents, you will be
required to provide and have approved a Declaration of Dependency form
An
employee of a participating employer who receives compensation for services
rendered and is listed on that employer’s payroll. This includes persons
elected by popular vote (i.e., board members for education and elected
officials of state and local government, state employees, rural water district
board members, county election board secretaries, and any employee otherwise
eligible who is on approved leave without pay, not to exceed 24 months).
Education employees must be eligible to
participate in the Oklahoma Teachers’ Retirement System and work a minimum of four
hours per day or 20 hours per week.
Local government employees, including rural
water districts, must be employed in a position requiring a minimum of 1,000
hours work per year.
An
employee who is participating in any of the Plans authorized by or through the
State and Education Employees Group Insurance Act who retired or vested their
rights with a state funded retirement plan, or has the required years of
service with a participating employer.
A
list of Preferred medications designed to maximize health outcomes and reduce
costs.
Any
eligible employee and/or eligible dependents who waived coverage or failed to
enroll within 30 days of the initial enrollment offering, or any participating
member or dependent who voluntarily terminates coverage and re-enrolls.
Certain
medications have a maximum quantity limitation due to approved therapy
guidelines. They have specific quantity limits per copay which are less than
the standard benefit. Quantity limits are based on recommended duration of
therapy and/or routine usage for each medication.
Direct
care and treatment within the standards of good medical practice within the
community that is appropriate and necessary for the symptoms, diagnosis, and
treatment of the condition. Services or supplies must be the most appropriate
supply or level of service which can safely be provided. For hospital stays,
inpatient acute care is necessary due to the intensity of services you are
receiving or the severity of your condition; also, when safe and adequate care
cannot be received as an outpatient or in a less intense medical setting.
Services or supplies cannot be primarily for the convenience of you, the
caregiver, or provider. The fact that services or supplies are medically
necessary does not, in itself, assure that the services or supplies are covered
by the Plan.
A
provider who has entered into a contract with OSEEGIB to accept the Plan’s
Allowed Charges for services and/or supplies provided to Plan participants.
Any
service, procedure, or supply excluded from coverage and not paid for by the
Plan.
The
annual time period established by OSEEGIB in which changes may be made to
coverage.
The
Oklahoma State and Education Employees Group Insurance Board.
The
amounts for which you are responsible based on the use of Network or
non-Network services, including deductible and coinsurance. You will still be
responsible for all amounts above the Allowed Charges when using non-Network
providers.
Any
municipality, county, education employer, or other state agency whose employees
or members are eligible to participate in any plan authorized by or through the
State and Education Employers Group Insurance Act.
The
HealthChoice health insurance plans offered through OSEEGIB as described in
this handbook.
Prior
authorization review is used to provide clinically driven, medically relevant
criteria that must be met before a drug can be approved for coverage. Ideal
products for this type of review are medications that may have limited
therapeutic uses and drugs requiring extensive monitoring for side effects.