Benefit Handbook The Harvard Pilgrim HMO For Self Insured Members Massachusetts
This benefit plan is provided to you by your employer on a self-insured basis. Harvard Pilgrim Health Care has arranged for the availability of a network of health care providers and will be performing various administration services, including claims processing, on behalf of the Plan Sponsor. Although some materials may reference you as a member of one of Harvard Pilgrim’s products, Harvard Pilgrim Health Care is not the issuer, insurer or provider of your coverage.
cc 1512/hmo/si/ma 05/06
INTRODUCTION
Welcome to the Harvard Pilgrim HMO (the Plan). Deaf and hard-of-hearing Members who own, or have Thank you for choosing the Plan to help you meet your access to a Teletypewriter (TTY) may communicate health care needs. directly with the Member Services Department by calling HPHC’s TTY machine at 1 800 637 8257. HPHC values With the Plan, your health care is provided or arranged your input and would appreciate hearing from you with through Harvard Pilgrim Health Care’s (HPHC) network any comments or suggestions you may have. of primary care physicians, specialists and other providers. You must choose a Primary Care Physician (PCP) for yourself and each of your family members Harvard Pilgrim Health Care when you enroll in the Plan. Member Services Department 1600 Crown Colony Drive When you enroll, the Plan provides the covered health Quincy, MA 02169 care services described in this Handbook, the Schedule of Benefits brochure and the Prescription Drug 1 888 333 4742 Brochure (if applicable). Such services must be Internet: www.harvardpilgrim.org provided or arranged by your PCP, except in a Medical Emergency or when you are temporarily outside the Non-English speaking Members may also call Harvard Service Area. Pilgrim Health Care's Member Services Department at (The Service Area is the state in which you live.) 1 888 333 4742 to have their questions answered. HPHC offers free language interpretation services in You may call HPHC’s Member Services Department if more than 120 languages. you have any questions. Member Services staff are available to help you with questions about the following: Notice: HPHC uses clinical review criteria to evaluate • Selecting a PCP whether certain services or procedures are Medically Necessary for a Member’s care. Members or their • Your Benefit Handbook practitioners may obtain a copy of any HPHC clinical • Your Plan Benefits review criteria that is applicable to a service or procedure for which coverage is requested. Clinical review criteria • Enrollment may be obtained by calling 1 888 888 4742 ext. 38723.
• Claims
• Provider Information
• Requesting a Provider Directory
• Requesting a Member kit
• Requesting ID cards
• Registering a Concern
2 Non-English speaking Members may also call Harvard Pilgrim Health Care’s Member Services Department at 1 888 333 4742 to have their questions answered. The Plan offers free language interpretation services in more than 120 languages.
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TABLE OF CONTENTS
I. BENEFIT HANDBOOK...... 6
A. ABOUT THE PLAN ...... 6 1. HOW TO USE THIS BENEFIT HANDBOOK...... 6 2. HOW THE PLAN WORKS ...... 7
B. COVERED BENEFITS ...... 12 (See the Schedule of Benefits for a listing of the Covered Benefits selected by your Plan Sponsor and the applicable benefit limitations, Copayments and Deductibles) 1. BASIC REQUIREMENTS FOR COVERAGE...... 12 2. INPATIENT CARE...... 12 3. OUTPATIENT CARE...... 12 4. FAMILY PLANNING SERVICES AND INFERTILITY TREATMENT ...... 14 5. MATERNITY CARE ...... 15 6. MENTAL HEALTH AND DRUG AND ALCOHOL REHABILITATION SERVICES ...... 15 7. DENTAL SERVICES...... 18 8. OTHER SERVICES ...... 18 9. GENERAL EXCLUSIONS ...... 23
C. STUDENT DEPENDENT COVERAGE ...... 25 1. STUDENTS INSIDE THE ENROLLMENT AREA ...... 25 2. STUDENTS OUTSIDE THE ENROLLMENT AREA...... 25
D. REIMBURSEMENT AND CLAIMS PROCEDURES ...... 26 1. CLAIM FILING PROCEDURES...... 26 2. BILLING BY PROVIDERS...... 26 3. REIMBURSEMENT FOR BILLS YOU PAY...... 26 4. LIMITS ON CLAIMS ...... 26
E. APPEALS AND COMPLAINTS ...... 27 1. BEFORE YOU FILE AN APPEAL ...... 27 2. MEMBER APPEAL PROCEDURES ...... 27 3. WHAT YOU MAY DO IF YOUR APPEAL IS DENIED...... 28 4. FORMAL COMPLAINT PROCESS ...... 29
F. ELIGIBILITY ...... 30 1. MEMBER ELIGIBILITY ...... 30 2. EFFECTIVE DATE - NEW AND EXISTING DEPENDENTS...... 30 3. EFFECTIVE DATE - ADOPTIVE DEPENDENTS...... 30 4. EFFECTIVE DATE - OFF-CYCLE ENROLLMENT ...... 30 5. CHANGE IN STATUS ...... 30 6. ADDING A DEPENDENT ...... 30 7. SPECIAL ENROLLMENT RIGHTS...... 31
G. TERMINATION AND TRANSFER TO OTHER COVERAGE...... 32 1. TERMINATION BY THE SUBSCRIBER...... 32 2. TERMINATION FOR LOSS OF ELIGIBILITY...... 32 3. MEMBERSHIP TERMINATION FOR CAUSE ...... 32 4. CONTINUATION OF COVERAGE REQUIRED BY LAW...... 32 5. TRANSFER TO NON-GROUP COVERAGE...... 32
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H. WHEN YOU HAVE OTHER COVERAGE ...... 34 1. BENEFITS IN THE EVENT OF OTHER INSURANCE...... 34 2. PROVIDER PAYMENT WHEN PLAN COVERAGE IS SECONDARY ...... 34 3. WORKER'S COMPENSATION/GOVERNMENT PROGRAMS...... 35 4. SUBROGATION...... 35 5. MEDICAL PAYMENT POLICIES...... 35 6. MEMBER COOPERATION ...... 35 7. THE PLAN’S RIGHTS ...... 35 8. MEMBERS ELIGIBLE FOR MEDICARE...... 35
I. ADMINISTRATION OF BENEFIT HANDBOOK...... 37 1. COVERAGE WHEN MEMBERSHIP BEGINS ...... 37 2. DISAGREEMENT WITH RECOMMENDED TREATMENT ...... 37 3. LIMITATION ON LEGAL ACTIONS ...... 37 4. ACCESS TO INFORMATION ...... 37 5. NOTICE...... 37 6. MODIFICATION OF THIS HANDBOOK...... 38 7. RELATIONSHIP OF HPHC PROVIDERS AND HPHC ...... 38 8. MAJOR DISASTERS...... 38 9. EVALUATION OF NEW TECHNOLOGY...... 38 10. MISSED APPOINTMENTS...... 38 11. UTILIZATION REVIEW PROCEDURES ...... 38 12. QUALITY ASSURANCE PROGRAMS...... 38 13. PROCEDURES USED TO EVALUATE EXPERIMENTAL/INVESTIGATIONAL DRUGS, DEVICES, OR TREATMENTS...... 39 14. PROCESS TO DEVELOP CLINICAL GUIDELINES AND UTILIZATION REVIEW CRITERIA...... 39 15. HIPAA CERTIFICATE OF CREDITABLE COVERAGE...... 39
J. GLOSSARY ...... 40
II. PATIENT RIGHTS...... 44
III. MEMBER RIGHTS & RESPONSIBILITIES ...... 45
IV. CONFIDENTIALITY STATEMENT...... 46
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I. BENEFIT HANDBOOK
A. ABOUT THE PLAN Providers. These are the physicians, hospitals and This section describes how to use your Benefit Handbook. other medical professionals who are either employed by HPHC or under contract to care for Plan Members. You can find HPHC Providers by using 1. HOW TO USE THIS BENEFIT HANDBOOK the HMO Provider Directory. a. About This Benefit Handbook This Benefit Handbook, the Schedule of Benefits and The Provider Directory identifies the Plan’s Primary Prescription Drug Brochure (if your Plan Sponsor Care Physicians (PCPs), specialists, hospitals and offers prescription drug coverage) make up the other providers. It lists providers by state and town, agreement setting forth the terms of the Plan. If you specialty, and languages spoken. You can get a copy have any eligibility questions, we recommend that you see your Plan Sponsor for information. of the Provider Directory by calling the HPHC Member Services Department at 1 888 333 4742. This Handbook describes how your membership The Member Services Department can also answer works. It explains what you must do to obtain questions about HPHC Providers or their qualifications. coverage for services and what you can expect from Harvard Pilgrim Health Care (HPHC) and the Plan. You may also view the Provider Directory on line at This Handbook is also your guide to the most the HPHC Internet site, www.harvardpilgrim.org. important things you need to know. These include: The on-line Provider Directory allows you to search • What is covered for providers by location. The information in the on- line directory may be more current than your paper • What is not covered directory since it is frequently updated by HPHC. • The requirement that you go to your Primary Care The online Provider Directory also provides links to Physician (PCP) for most services several physician profiling sites including one maintained by the Commonwealth of Massachusetts • Any limits or special rules for coverage Board of Registration in Medicine at • Any Copayments and Deductible (if applicable) you www.massmedboard.org. must pay, which are listed in the Schedule of Benefits Although the Provider Directory lists all • Prescription drug benefits will be listed in the Participating Providers, your PCP may refer you Prescription Drug Brochure, if a Covered Benefit only to those Participating Providers with whom he or she is affiliated. Please see Hospitals and b. Words With Special Meaning Specialty Care (Section I.A.2) for information on Some words in this Handbook have special meanings. physician referral networks. The words with special meaning are capitalized and are defined in the Glossary at the end of this Benefit The physicians and other medical professionals in the Handbook. Plan’s provider network participate through contractual arrangements that can be terminated either c. How To Find What You Need To Know by a provider or by HPHC. In addition, a provider The table of contents will help you find what you may leave the Plan’s network because of retirement, need to know. relocation or other reasons. This means that HPHC cannot guarantee that the physician you choose will We also put the most important things first. For continue to participate in the Plan’s network for the example, we list benefits and describe how coverage duration of your Plan membership. If your Primary works. Most limitations on services appear after the Care Physician leaves the network for any reason, the benefit to which they relate on the Schedule of Benefits. Plan will make every effort to notify you at least 30 Any Copayments or Deductible (if applicable) you days in advance, and will help you find a new Plan have to pay is listed in the Schedule of Benefits. physician to meet your health care needs. Please call
the Member Services Department at 1 888 333 4742 d. How To Use Your Provider Directory so that HPHC can help you find a new PCP. In order to be eligible for coverage under the Plan, most services must be received from HPHC
6 e. Your Schedule of Benefits (or Summary of Benefits) If your PCP stops being an HPHC Provider, you will A summary of the benefits selected by your Plan be notified in writing. Whenever possible, HPHC will Sponsor is listed in the Schedule of Benefits. A more notify you at least 30 days before the disenrollment of detailed description of the benefits is in this your PCP and will allow continued coverage of document. In addition, the Schedule of Benefits benefits as described in this Handbook and your contains any limitations and any Copayments and Schedule of Benefits for at least 30 days after the Deductible (if applicable) you must pay. Some health PCP’s disenrollment. This coverage is provided as plans have different Copayment levels based on the long as the PCP has not been disenrolled for quality- type of service you receive. Under such plans, a related reasons or fraud. You will than need to select a lower Copayment applies to some outpatient services, new PCP. As mentioned above, you may select a new including most primary care, obstetrical care, PCP by calling the Member Services Department. gynecological care, mental health care and substance abuse rehabilitation; and a higher Copayment applies b. Your PCP Manages Your Health Care to most outpatient specialty care. Please refer to your Schedule of Benefits for specific information on the 1) Call Your PCP for Care Copayments you are required to pay. When you need care, call your PCP. Except as stated below, all care must be provided or arranged by your PCP. The only exceptions are: 2. HOW THE PLAN WORKS a. Choose a Primary Care Physician (PCP) • Care in a Medical Emergency. When you enroll you must choose a Primary Care • Care when you are temporarily outside the Physician (PCP). You must select a PCP for yourself Service Area (The Service Area is the state in and each covered person in your family. You may which you live.) choose a different PCP for each family member. If you do not choose a PCP when you first enroll, or if • Special services that do not require a Referral. the PCP you select is not available, we will assign a (These services are listed in Section A.2.e.) PCP to you. • For mental health, alcohol and drug rehabilitation A PCP may be a doctor of Internal Medicine, Family services you must call the Behavioral Health Practice, General Practice or Pediatrics. PCPs are listed Access Center at 1 888 777 4742 (see Section in the Provider Directory. You may call Member I.B.6.) Services to confirm that the PCP you select is available. (Detailed information on each of these exceptions If you have not seen your PCP before, we suggest you is provided below.) do the following: Either your PCP or a covering HPHC Provider is • Call your PCP's office as soon as possible and tell available to direct your care 24 hours a day. Talk him or her you are a new Member. to your PCP and find out what arrangements are • Make an appointment to see your new PCP so he available for care after normal business hours. or she can get to know you and begin taking care Some PCPs may have covering physicians after of any medical needs you have. hours and others may have extended office/clinic hours. In the event you are unable to reach your • Ask your previous doctor to send your medical PCP or the covering doctor, you may call HPHC records to your new PCP. for help at 1 888 333 4742 24 hours a day, 7 days a week. Please do not wait until you are sick to call your PCP. You should get to know your doctor as soon as 2) Hospital and Specialty Care possible. Your PCP can take better care of you when he or she is familiar with your health status. Your PCP generally uses one hospital for inpatient care. This is where you will need to go You may change your PCP at any time by calling the for coverage, unless it is Medically Necessary for Member Services Department. Just choose a new PCP you to get care at a different hospital. In some from the Provider Directory. HPHC can make the cases, prior approval by the Plan is required. change effective on the date that you call or on a future date. You must inform the Plan when you change your When you need specialty care, your PCP will refer PCP or care may not be covered. If you change your PCP, you to providers who are affiliated with the any Referrals from your prior PCP become invalid. hospital your PCP uses. These are the providers You will need to get new Referrals from your new PCP. you will need to use for coverage unless it is
7 Medically Necessary for you to get care from a 1) The service was received in a Medical Emergency. provider who is not affiliated with your PCP. (Please see Section A.2.e for information on your This helps your PCP coordinate and maintain the coverage in a Medical Emergency.) quality of your care. Participating Providers with recognized expertise in specialty pediatrics, 2) The service was received while you were (a) including mental health care, are also covered outside of HPHC’s Service Area and meets the when Medically Necessary with a Referral from requirements for the coverage stated in Section your PCP. Your PCP may authorize a standing B.2.f, which is the benefit for temporary travel, or Referral with a specialty care provider when: (b) a dependent student attending school outside 1) the PCP determines that such Referral is the Service Area and meets the requirements as appropriate, 2) the specialty care provider agrees to described in Section C. a treatment plan for the Member and provides the PCP with all necessary clinical and administrative 3) No HPHC Provider has the expertise needed to information on a regular basis, and 3) the services provide the required service. Services by a non- provided are Covered Benefits as described in this HPHC Provider must be authorized in advance by Handbook and your Schedule of Benefits. HPHC, unless one of the exceptions above applies.
Certain specialty services do not require a Referral To find out if a provider is in the network of HPHC from your PCP. Please see “Services That Do Not Providers, you may look in your Provider Directory Require a Referral ” for a list of these specialty or view the directory online at services. If you need mental health care or drug or www.harvardpilgrim.org. alcohol rehabilitation services, you must call the Behavioral Health Access Center at 1 888 777 4742. d. Member Cost Sharing
You are required to share the cost of the Covered If you select a new PCP, all Referrals from your Benefits provided under the Plan. Your Cost Sharing prior PCP become invalid. Your new PCP will may include Deductibles, and Copayments. Your need to assess your condition and provide new Plan may also have an Out-of-Pocket Maximum that Referrals. You must inform the Plan when you change your PCP or care may not be covered. limits the amount of Cost Sharing you may be required to pay. Please refer to your Schedule of Please note that although the Provider Directory Benefits for the specific Cost Sharing amounts that lists all HPHC Providers, your PCP may refer you apply to your Plan. Information about Cost Sharing is only to those HPHC Providers with whom he or described below. she is affiliated. The only exception will be for services that cannot be provided by an affiliated 1) Deductible provider. A Deductible is a specific dollar amount that you pay for Covered Benefits received each calendar year When you are in the Service Area, you must call before benefits subject to the Deductible are payable by your PCP's office before going to a hospital or the Plan. Deductible amounts are incurred on the date specialist, unless you are having a Medical of service. You may have more than one Deductible Emergency. (The Service Area is the state in under your Plan. Your specific Deductible amounts which you live). The only other exception is for are listed in your Schedule of Benefits. the special services that do not require a Referral.
Each Member must pay the individual Deductible c. Using HPHC Network Providers amount for Covered Benefits each calendar year. No Medical Services must be received from HPHC family Member will pay more than the individual Providers to be eligible for coverage by the Plan. Deductible in a calendar year. Mental health and drug and alcohol rehabilitation services must be received from a contracted mental In some instances, a family Deductible applies. The health provider. (Please contact the Behavioral Health family Deductible is met when any combination of Access Center at 1 888 777 4742 to arrange mental Members in a family reach the family Deductible health and drug and alcohol rehabilitation services.) However, there are three specific exceptions to these Amount. Once the family Deductible has been met in requirements. Covered Benefits rendered by a a calendar year, the Deductible is met by all Members provider who is not an HPHC Provider will be for the remainder of the calendar year. covered if one of the following exceptions applies:
8 2) Copayment is the state in which you live.) The Plan covers any A Copayment is a fixed dollar amount that you Medically Necessary services for sickness or injury must pay for certain Covered Benefits. Copayments except the following: are due at the time of service or when billed by the • Care you could have foreseen before leaving the Provider. Copayment amounts specific to your Plan Service Area; are stated in your Schedule of Benefits. • Routine care; 3) Out-of-Pocket Maximums • Childbirth and problems with pregnancy beyond An Out-of-Pocket Maximum is a limit on the the 37th week of pregnancy, or after being told amount of Cost Sharing that you must pay for that you were at risk for early delivery; and Covered Benefits in a calendar year. This excludes any amounts that you pay for prescription drugs. • Follow-up care that can wait until your return to Out-of-Pocket Maximum amounts are listed in the Service Area. your Schedule of Benefits. Your Plan may have If you are hospitalized, you must call both your PCP one or more Out-of-Pocket Maximums. and HPHC within 48 hours, or as soon as you can.
Your PCP will help to arrange for any follow-up care e. Medical Emergency Services you may need. You are always covered for care in a Medical Emergency. A Referral from your PCP is not Please note that HPHC must have your current needed. In a Medical Emergency, you should go address on file in order to correctly process claims to the nearest emergency facility or call 911 or for care outside the Service Area. To change your other local emergency number. Your emergency address, please call HPHC’s Member Services room Copayment and any applicable Deductible are Department. listed on the Schedule of Benefits. g. Services That Do Not Require a Referral A Medical Emergency means a medical condition, While in most cases you will need a Referral from whether physical or mental, manifesting itself by your PCP to get covered care from any other symptoms of sufficient severity, including severe provider, you do not need a Referral for the services pain, that the absence of prompt medical attention listed below. However, you must get these services could reasonably be expected by a prudent layperson from an HPHC Provider. HPHC Providers are listed who possesses an average knowledge of health and in the Provider Directory. We urge you to keep your medicine, to result in placing the health of the PCP informed about such care so that your medical Member or another person in serious jeopardy, serious records are current and up-to-date. Your PCP should impairment to body function, or serious dysfunction be aware of your entire medical situation. of any body organ or part. With respect to a pregnant
woman who is having contractions, Medical (Please note, although these services do not Emergency also means that there is inadequate time to require a Referral, any inpatient care requires effect a safe transfer to another hospital before HPHC approval.) delivery or that transfer may pose a threat to the health or safety of the woman or the unborn child. Family Planning Services:
Examples of Medical Emergencies are: heart attack • Family planning consultation or suspected heart attack, stroke, shock, major blood • Contraceptive monitoring loss, choking, severe head trauma, loss of consciousness, seizures, and convulsions. • Voluntary sterilization including tubal ligation (if a Covered Benefit - please see the Schedule of Please remember that if you are hospitalized, you Benefits) must call your PCP within 48 hours, or as soon as you can. Your PCP will arrange for any follow-up • Voluntary termination of pregnancy (if a Covered care you may need. Benefit - please see the Schedule of Benefits) Maternity Services (The following services do not f. Coverage for Services When You Are Temporarily require a Referral when provided by a participating Outside the Service Area HPHC obstetrician, gynecologist, certified nurse If you are temporarily outside the Service Area and midwife or family practitioner.): you get hurt or sick, don't worry. You do not have to • Consultation for expectant parents call your PCP before getting care. (The Service Area 9 • Prenatal and postpartum care If coverage is provided for the extraction of impacted teeth, the HPHC Provider you can select depends • Prenatal genetic testing (office visits do require a upon where your PCP is located. If your PCP is Referral) located at Harvard Vanguard Medical Associates you must go to the Dental Department for impacted tooth Gynecological Services (The following services extraction at one of the following Harvard Vanguard do not require a Referral when provided by a Medical Associates locations: participating HPHC obstetrician, gynecologist, certified nurse midwife or family practitioner.): Braintree Peabody
• Annual gynecological exam Chelmsford Somerville
• Medically Necessary evaluations for acute or Kenmore emergency gynecological conditions • Follow-up care for obstetrical or gynecological If your PCP is located at any other Health Center, conditions identified during an annual Medical group or Individual Practice, you can gynecological exam or an evaluation for acute or choose any HPHC Provider for the extraction of emergency gynecological conditions impacted teeth. HPHC Providers are listed in your Provider Directory. • Cervical cryosurgery h. Services Provided by a Disenrolled or • Colposcopy with biopsy Non-Participating Provider • Excision of labial lesions 1) Disenrollment of Primary Care Physician (PCP) If your PCP is disenrolled as an HPHC Provider for • Laser cone vaporization of the cervix reasons unrelated to fraud or quality of care, the • Loop electrosurgical excisions of the cervix Plan will use its best efforts to provide you with (LEEP) written notice at least 30 days prior to the date of your PCP’s disenrollment. That notice will also • Treatment of amenorrhea explain the process for selecting a new PCP. You may continue to receive coverage for services • Treatment of condyloma provided by the disenrolled PCP, under the terms of this Handbook and your Schedule of Benefits, for at Dental Services: least 30 days after the disenrollment date. If you • Pediatric preventive dental care for children, if are undergoing an active course of treatment for an covered by your Plan Sponsor. (Please see your illness, injury or condition, the Plan may authorize Schedule of Benefits to determine whether this additional coverage through the acute phase of benefit is covered and the age limit that applies to illness, or for up to 90 days (whichever is shorter). your coverage.) 2) Pregnancy • Extraction of impacted teeth (Please see your If you are a female Member in your second or third Schedule of Benefits to determine whether this trimester of pregnancy and the HPHC Provider you benefit is covered.) are seeing in connection with your pregnancy is • Emergency dental care involuntarily disenrolled, for reasons other than fraud or quality of care, you may continue to receive
coverage for services delivered by the disenrolled Other Services: provider, under the terms of this Handbook and • Routine eye exams (if a Covered Benefit - please your Schedule of Benefits, for the period up to, and see the Schedule of Benefits) including, your first postpartum visit.
• Chiropractic care (if a Covered Benefit - please see the Schedule of Benefits) 3) Terminal Illness Please note that only limited coverage is provided for A Member with a Terminal Illness whose HPHC Provider in connection with such illness is dental and chiropractic care, when covered. Please involuntary disenrolled, for reasons other than see the Covered Benefits section and your Schedule fraud or quality of care, may continue to receive of Benefits, before seeking such services. coverage for services delivered by the disenrolled
10 provider, under the terms of this Handbook and the Schedule of Benefits, until the Member’s death.
4) New Membership If you are a new Member, the Plan will provide coverage for services delivered by a physician who is not an HPHC Provider, under the terms of this Handbook and your Schedule of Benefits, for up to 30 days from your effective date of coverage if; • Your employer only offers employees a choice of plans in which the physician is not a participating provider, and
• The physician is providing you with an ongoing course of treatment or is your PCP.
With respect to a Member in her second or third trimester of pregnancy, this provision shall apply to services rendered through the first postpartum visit. With respect to a Member with a Terminal Illness, this provision shall apply to services rendered until death.
Services received from a disenrolled or nonparticipating provider as described in paragraphs 1,2, 3, and 4, above, are only covered when the physician agrees to: • Accept reimbursement from HPHC at the rates applicable prior to notice of disenrollment as payment in full and not to impose Cost Sharing with respect to the Member in an amount that would exceed the Cost Sharing that could have been imposed if the provider had not been disenrolled;
• Adhere to the quality assurance standards of HPHC and to provide the Plan with necessary medical information related to the care provided; and
• Adhere to the Plan’s policies and procedures, including procedures regarding Referrals, obtaining prior authorization and providing Covered Benefits pursuant to a treatment plan, if any, approved by the Plan.
11 B. COVERED BENEFITS It is important for you to note that some of the Specific inpatient care benefits are described below. benefits listed in this section may not be available to a. Acute Hospital Care you under the benefits chosen by your Plan Sponsor. Benefit limitations or variations and your Copayments The Plan covers acute hospital care, including and Deductible (if applicable) will be listed on the emergency admissions, to the extent Medically Schedule of Benefits, and if your Plan Sponsor offers Necessary. There is no limit on the number of days prescription drug benefits, the Prescription Drug covered. Brochure. There are optional benefits that are offered by some Plan Sponsors. These include benefits for vision b. Skilled Nursing Facility Care hardware and adult preventive dental care. If any of The Plan covers care in a health care facility licensed these optional benefits are part of your benefit package, to provide skilled nursing care on an inpatient basis. the benefit will be described in a separate brochure and Such coverage is provided only when you need daily included in your Schedule of Benefits. skilled nursing care or Rehabilitative Services that must be provided in an inpatient setting. The number 1. BASIC REQUIREMENTS FOR COVERAGE of days covered is stated in your Schedule of Benefits. To be covered, all services and supplies must be: c. Rehabilitation Hospital Care • Medically Necessary; The Plan covers care in a facility licensed to provide • Received while an active Member of the Plan; and rehabilitative care on an inpatient basis. The number of days covered is stated in your Schedule of • Provided or arranged through Referral in advance by Benefits. Rehabilitative care includes physical, your PCP. The only exceptions are care needed in a speech and occupational therapies. Medical Emergency, care needed while temporarily outside the Service Area, and the special services that RELATED EXCLUSIONS FOR ALL INPATIENT do not require a Referral listed in Section 1.A.2.e. CARE: Please see specific benefits, and the Schedule of Benefits • Personal items, including telephone and television for any special limits or exclusions from coverage. charges
2. INPATIENT CARE • All charges over the semi-private room rate, except When you need inpatient care, your PCP will make all when a private room is Medically Necessary the necessary arrangements. He or she will coordinate • Rest or Custodial Care any diagnostic or pre-admission work-ups. Your PCP is responsible for getting Plan approval for an admission. • Blood or blood products All you need to do is follow your PCP's instructions. The Plan covers the following inpatient services: • Charges after your hospital discharge • Semi-private room and board • Charges after the date on which your membership • Doctor visits, including consultation with specialists ends
• Medications 3. OUTPATIENT CARE • Lab and x-ray services The Plan covers outpatient care that you receive from your PCP. Outpatient care is also covered at a doctor's • Intensive care office, clinic or hospital, upon Referral from your PCP • Surgery, including related services to an HPHC Provider.
• Anesthesia, including the services of a nurse-anesthetist The only time your care does not need to be provided or • Radiation therapy arranged by your PCP is (1) in a Medical Emergency, (2) when you are temporarily outside the Service Area, • Physical therapy, occupational therapy, and speech or (3) if it is one of the special services that do not therapy require a Referral.
• Private duty nursing
12 a. Preventive Care in the Doctor's Office c. Emergency Room Care The Plan covers preventive care according to your If you are sick or hurt, you must call your PCP before individual medical needs. Your PCP generally going to an emergency room. The only exceptions provides these services. Covered preventive care are in a Medical Emergency or when you are includes: physical examinations; immunizations; temporarily outside the Service Area. Please remember, vision and hearing screening; mammograms; health if you need follow-up care after you are treated in an education; and nutritional counseling. At least six emergency room, you must call your PCP. He or she visits per year are covered for a child from birth to will provide or arrange for the care you need. age one. At least three visits per year are covered for a child from age one to age two. At least one visit per RELATED EXCLUSIONS: year is covered for a child from age two to age six. • Follow-up care, unless provided or arranged by
your PCP Also covered are Medically Necessary diagnostic screening and tests, including, but not limited to, the following: hereditary and metabolic screening at d. Diagnostic Lab and X-Rays birth; newborn hearing screening test; tuberculin The Plan covers outpatient diagnostic laboratory and tests; lead screenings; hematocrit, hemoglobin or x-ray services to diagnose illness, injury, or other appropriate blood tests, and urinalysis; annual pregnancy. Services will be provided at your PCP's cytological screenings; and mammograms, including office or by Referral to an HPHC Provider. a baseline mammogram for women between the ages of thirty-five and forty, and an annual mammogram The Plan also covers human leukocyte antigen testing or for women forty years of age and older. histocompatibility locus antigen testing necessary to establish bone marrow transplant donor suitability 1) Routine Physical Examinations (including testing for A, B, or DR antigens, or any The Plan covers routine physical examinations. combination, consistent with rules, regulations and School, sports, camp, and premarital examinations criteria established by the Department of Public Health). are also covered. e. Physical and Occupational Therapies RELATED EXCLUSIONS: Outpatient physical and occupational therapies are each covered up to the benefit limit described in the • Exams other than those stated above, including Schedule of Benefits. Services are covered only insurance, licensing, and employment exams when needed to improve your ability to perform Activities of Daily Living and when, in the opinion 2) Eye Examinations of your PCP, there is likely to be significant improvement in your condition within that time Eye examinations with an ophthalmologist or period. Your PCP, or an HPHC Provider will order optometrist are covered up to the limit described in therapy for you based on your condition and needs. the Schedule of Benefits. You do not need a Referral. However, services must be provided by an Physical and occupational therapies are covered as HPHC Provider. part of a pulmonary rehabilitation course of treatment to the extent Medically Necessary. These services (Please note this benefit is not covered by all must be approved by HPHC. Plan Sponsors. Please see your Schedule of Benefits) Please note that the outpatient physical and occupational therapies for children under the age of 3 is covered to b. Sick or Injured Care the extent Medically Necessary. The benefit limit stated The Plan covers care when you are sick or injured. in Schedule of Benefits does not apply. Services include, but are not limited to, necessary care and treatment of medically diagnosed Physical, speech and occupational therapies are also congenital defects and birth abnormalities or covered under your inpatient hospital and home premature birth, injections, radiation therapy, health benefits. When such therapies are part of an diagnostic tests and x-rays, dressings, sutures, and approved home care treatment plan they are available casting. If you are sick or injured, call your PCP to on a short-term intermittent basis as described in arrange for the care you need. Section B.9.a. (Home Health Care). Please see that Section for information on in-home coverage.
13 f. Speech-Language and Hearing Services 4. FAMILY PLANNING SERVICES AND The Plan covers diagnosis and treatment of speech, INFERTILITY TREATMENT hearing and language disorders to the extent a. Family Planning Services Medically Necessary by HPHC speech-language Family planning services are covered when provided pathologists and HPHC audiologists. Your PCP by, or with a Referral from, your PCP. (Some of the must refer you for speech-language and hearing services listed below are covered if your Plan services. If you require speech therapy, your PCP or Sponsor has selected such coverage. The Schedule an HPHC Provider will order therapy for you based of Benefits will list these benefits if covered.) When on your condition or needs. covered, the following services can be obtained from
any HPHC Provider without a Referral. RELATED EXCLUSIONS: • Annual gynecological examination • Educational services or testing, except services covered under the benefit for Early Intervention • Family planning consultation Services, below • Pregnancy testing • Services for problems of school performance • Voluntary sterilization, including tubal ligation. • Sensory integrative praxis tests Please note vasectomy requires a PCP Referral (Please see your Schedule of Benefits to determine • Vocational rehabilitation, or vocational evaluations whether this benefit is covered) focused on job adaptability, job placement, or therapy to restore function for a specific occupation • Voluntary termination of pregnancy (Please see your Schedule of Benefits to determine whether g. Early Intervention Services this benefit is covered) The Plan covers early intervention services when • Contraceptive monitoring Medically Necessary. Coverage is provided for Members until three years of age. The Plan provides • Genetic counseling coverage up to the limits described in your Schedule of Benefits. Covered Benefits include: • Injection of birth control medication and the • Screening and assessment of the need for services insertion and removal of birth control implants and devices is covered. However, such medications, • Physical, speech, and occupational therapy implants and devices themselves are only covered if your Plan Sponsor has selected a Prescription • Psychological counseling Drug Rider with birth control coverage.
• Nursing care Please see the additional services which do not require a Referral described previously in this Handbook. h. Surgical Day Care *Please note that some Plan Sponsors do not cover Surgical Day Care is a surgery or procedure voluntary sterilization, including tubal ligation, performed in a Surgical Day Care department, and vasectomy, and/or voluntary termination of ambulatory surgery department or outpatient surgery pregnancy, except as Medically Necessary to center that requires operating room, anesthesia and prevent death of the mother. Please refer to your recovery room services. The Plan covers outpatient Schedule of Benefits to see if these are listed as Surgical Day Care, including related services, by an exclusions. HPHC Provider. Your PCP must refer you for these
services. RELATED EXCLUSIONS: i. Second Opinions • Reversal of voluntary sterilization There may be times when you want a second • Birth control implants and devices, unless your opinion. The Plan will cover this as long as you have Plan Sponsor has selected a Prescription Drug a Referral from your PCP. Second opinions will be Rider with birth control coverage covered when given by an HPHC Provider. j. Allergy Treatment b. Infertility Treatment The Plan covers testing, antigens and allergy Infertility is defined as the inability of a presumably treatments. healthy individual to conceive or produce conception
14 during a period of one year. The Plan covers the • Postpartum care following infertility treatments: • Consultation and evaluation • Delivery, including a minimum of 48 hours of inpatient care following a vaginal delivery and a • Laboratory tests minimum of 96 hours of inpatient care following a cesarean section. (Any decision to shorten the • Artificial insemination, including related sperm inpatient stay for the mother and her newborn child procurement and banking will be made by the attending physician and the mother. If early discharge is decided, the mother will • Advanced reproductive technologies, including, be entitled to a minimum of one home visit.) but not limited to, in-vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), zygote • Nursery charges for routine services provided to a intrafallopian transfer (ZIFT), intra-cytoplasmic healthy newborn sperm injection (ICSI), and donor egg procedures, including related egg and inseminated egg procurement, processing and banking RELATED EXCLUSIONS: • Routine maternity (prenatal and postpartum) care Your PCP must refer you for infertility treatment. when you are traveling outside the Service Area For advanced reproductive technologies, your PCP must obtain Plan approval for coverage. • Delivery outside the Service Area after the 37th week (Please note this benefit is not covered by all Plan of pregnancy, or after you have been told that you are Sponsors. Please see your Schedule of Benefits.) at risk for early delivery
Important Notice: HPHC uses clinical guidelines to • Services for a newborn who has not been enrolled as evaluate whether infertility services are Medically a Member, other than nursery charges for routine Necessary. If you are receiving care for infertility, services provided to a healthy newborn HPHC recommends that you review the current • Planned home births guidelines. To obtain a copy, please call 1 888 888 4742 ext. 38723. 6. MENTAL HEALTH AND DRUG AND RELATED EXCLUSIONS: ALCOHOL REHABILITATION SERVICES • Reversal of voluntary sterilization If you need mental health care or drug or alcohol rehabilitation services, you must call the Behavioral • Any infertility treatment related to voluntary Health Access Center at 1 888 777 4742. The phone sterilization or its reversal line is staffed by licensed mental health clinicians. They will assist you in finding appropriate providers and • Infertility treatment for Members who are not arranging the services you require. The Plan covers both medically infertile inpatient and outpatient services as described below. • Any form of surrogacy HPHC requires consent to the disclosure of information
regarding services for mental disorders to the same 5. MATERNITY CARE extent it requires consent for disclosure of information You do not need a Referral for prenatal care. However, for other medical conditions. Any determination of you do need to get this care from a participating HPHC Medical Necessity of mental health services will be obstetrician, gynecologist, certified nurse midwife or made in consultation with a licensed mental health family practitioner. An HPHC Provider must make all professional. arrangements for inpatient care. The Plan covers the following services: PLEASE NOTE: To be covered by the Plan, all mental • Prenatal exams health and drug and alcohol rehabilitation services must be obtained through the Behavioral Health Access • Diagnostic tests Center. The only exceptions apply to: (1) care required • Prenatal genetic testing (office visits do require a in a Medical Emergency, and (2) care when you are Referral) temporarily outside of the Service Area. These exceptions are described in Section A. of this Handbook. • Diet regulation
15 Your benefits for mental health and drug and alcohol be documented by the Member’s PCP or HPHC rehabilitation services depend on the reason the services mental health provider, or when evidenced by are required. Services for three categories of conditions conduct including, but not limited to: are covered to the same extent as medical services for • The inability to attend school physical illnesses. These categories are (1) services for "biologically-based mental disorders," (2) services • The need for hospitalization as a result of the required as a result of rape, and (3) services for children disorder with non-biologically-based mental, behavioral or emotional disorders. (Further information on the three • A pattern of conduct or behavior caused by the categories is provided below.) The mental health and disorder that poses a serious danger to self or drug and alcohol rehabilitation services available under others this Handbook are covered for illnesses within these three Coverage under this subsection shall continue after categories to the extent Medically Necessary, subject to the child’s 19th birthday until either the course of the Copayments and Deductible (if applicable) stated in treatment specified in the child’s treatment plan is the Schedule of Benefits. However, the limits on the completed or coverage under this Benefit Handbook number of visits or hospital days in the Schedule of is terminated, whichever comes first. Benefits do not apply to services within these categories.
a. Services that do not Apply to the Benefit Limits If treatment of a 19 year old, as specified in his or her treatment plan, has not been completed at the Services that are covered to the extent Medically time coverage under this Benefit Handbook is Necessary (without reference to benefit limits in terminated, additional rights to coverage for your Schedule of Benefits) are: mental health treatment may apply. Please call Member Services for further information. 1) Services Required to Treat Biologically-Based Mental Disorders Medically Necessary mental health and drug and The Plan covers services required to treat alcohol rehabilitation services that are not for one biologically-based mental disorders. Biologically- of the three categories listed above are covered based mental disorders are: (1) schizophrenia; (2) subject to both the benefit limits and the schizoaffective disorders; (3) major depressive Copayments and Deductible (if applicable) stated disorder; (4) bipolar disorder; (5) paranoia and in the Schedule of Benefits. other psychotic disorders; (6) obsessive-compulsive (Please note this benefit is not covered by all disorder; (7) panic disorder; (8) delirium and Plan Sponsors. Please see your Schedule of dementia; (9) affective disorders; and (10) any Benefits.) mental disorder designated a biologically-based mental disorder by the Commissioner of the Listed below is a detailed breakdown of your mental Massachusetts Department of Mental Health. health and drug and alcohol rehabilitation coverage: (Please note this benefit is not covered by all Plan Sponsors. Please see your Schedule of Benefits.) b. Inpatient Services - Mental Health Inpatient care is covered up to the limit described in your Schedule of Benefits. That limit does not apply 2) Services Required as a Result of Rape when care is authorized by an HPHC mental health The Plan covers services required to diagnose and clinician for the treatment of a biologically-based treat rape-related mental or emotional disorders mental disorder, rape-related mental or emotional for victims of rape or victims of an assault with disorder, or a non-biologically-based mental, the attempt to commit rape. behavioral or emotional disorder for children, as (Please note this benefit is not covered by all Plan described above. Under those circumstances, Sponsors. Please see your Schedule of Benefits.) inpatient hospitalization is covered to the extent Medically Necessary.
3) Services for Children with Non-Biologically-Based Care in a partial hospitalization program is covered mental, Behavioral or Emotional Disorders up to the limit described in the Schedule of Benefits. The Plan covers services required to diagnose and Partial hospitalization is an intensive outpatient treat non-biologically-based mental, behavioral or program that provides coordinated services in a emotional disorders that substantially interfere therapeutic setting. Each partial hospitalization day with or limit functioning and social interactions counts as one-half of a psychiatric hospital day and is for children through the age of 18. Substantial deducted from the limit described in the Schedule of interference with, or limitation of, function must Benefits available for inpatient services. Partial
16 hospitalization will only be covered if you and your outpatient mental health services are covered to the HPHC Provider agree that this treatment is best for extent Medically Necessary. you. When care is authorized by an HPHC mental health clinician for the treatment of a biologically- Outpatient drug and alcohol rehabilitation services based mental disorder, rape-related mental or are covered up to limit described in the Schedule of emotional disorder, or a non-biologically-based Benefits. That limit does not apply when care is mental, behavioral or emotional disorder for children authorized by an HPHC mental health clinician in as described above, partial hospitalization is covered conjunction with treatment of mental disorders. to the extent Medically Necessary. Under those circumstances, outpatient mental health and drug and alcohol rehabilitation services are (Please note this benefit is not covered by all Plan covered to the extent they are Medically Necessary. Sponsors. Please see your Schedule of Benefits.) (Please note this benefit is not covered by all Plan Sponsors. Please see your Schedule of Benefits.) c. Inpatient Services - Drug and Alcohol Rehabilitation Inpatient rehabilitative care for drug and alcohol RELATED EXCLUSIONS: abuse is covered up to the limit described in the • Schedule of Benefits. That limit does not apply when Educational services or testing, except services care is authorized by an HPHC mental health covered under the benefit for Early Intervention clinician in conjunction with treatment of mental Services disorders. Under those circumstances, inpatient • Services for problems of school performance rehabilitative care is covered to the extent Medically Necessary. • HPHC does not cover mental health services that are (1) provided to Members who are confined or Care in a partial hospitalization program is covered committed to a jail, house of correction, prison, or up to the limit described in the Schedule of Benefits. custodial facility of the Department of Youth Partial hospitalization is an intensive outpatient Services; or (2) provided by the Department of program that provides coordinated services in a Mental Health. therapeutic setting. Each partial hospitalization day counts as one-half of a drug and alcohol abuse • Methadone Maintenance hospital day and is deducted from the limit described in the Schedule of Benefits available for inpatient services. Partial hospitalization will only be covered e. Outpatient Detoxification and if you and your HPHC Provider agree that this Psychopharmacological Services treatment is best for you. When care is authorized by The Plan covers outpatient detoxification and an HPHC mental health clinician in conjunction with psychopharmacological services to the extent they are treatment of mental disorders, partial hospitalization Medically Necessary. The Behavioral Health Access is covered to the extent Medically Necessary. Center will refer you for care, as described previously in this Handbook. Inpatient detoxification is covered as long as it is Medically Necessary. (Please note this benefit is not covered by all Plan Sponsors. Please see your Schedule of Benefits.) (Please note this benefit is not covered by all Plan Sponsors. Please see your Schedule of Benefits.) RELATED EXCLUSION: d. Outpatient Services - Mental Health and Drug and • Methadone Maintenance Alcohol Rehabilitation Services The Plan covers outpatient mental health and drug f. Psychological Testing and Neuropsychological and alcohol rehabilitation services. Coverage is for Assessment evaluation, diagnosis, treatment and crisis The Plan covers psychological testing and intervention. neuropsychological assessment to the extent they are Outpatient mental health services are covered up to Medically Necessary. An HPHC Provider must refer the limit described in the Schedule of Benefits. That you for such testing and obtain HPHC approval for limit does not apply when care is authorized by an coverage. HPHC mental health clinician for the treatment of a (Please note this benefit is not covered by all Plan biologically-based mental disorder, rape-related Sponsors. Please see your Schedule of Benefits.) mental or emotional disorder, or a non-biologically- based behavioral or emotional disorder for children, as described above. Under those circumstances,
17 RELATED EXCLUSIONS: • Teaching plaque control • Educational services or testing, except services covered under the benefit for Early Intervention • X-rays Services (Please note this benefit is not covered by all Plan • Sensory integrative praxis tests Sponsors. Please see your Schedule of Benefits.)
• Services for problems of school performance RELATED EXCLUSIONS: • Fillings If you need mental health care or drug or alcohol rehabilitation services, you must call the Behavioral Health Access Center at 1 888 777 4742. The phone c. Emergency Dental Care line is staffed by licensed mental health clinicians. The Plan covers emergency dental care needed due to They will assist you in determining the type of care an injury to sound, natural teeth. All services, except you need, finding appropriate providers, and for suture removal, must be received within three arranging the services you require. The Behavioral days of injury. Only the following services are Health Access Center will determine the service covered: appropriate to your needs. The Plan covers both inpatient and outpatient services. • Extraction of teeth, needed to avoid infection of teeth damaged in the injury 7. DENTAL SERVICES • Suturing and suture removal The Plan covers only the limited dental services described below. No Referral is required. However, you • Re-implanting and stabilization of dislodged teeth must obtain services from an HPHC Provider. • Re-positioning and stabilization of partly dislodged teeth a. Extraction of Impacted Teeth If your Plan Sponsor has selected coverage for the • Medication received from the provider extraction of bony impacted teeth as part of your benefit package, pre-operative and post-operative RELATED EXCLUSIONS: care, x-rays and anesthesia are covered. You do not need a Referral. However, services must be provided • Fillings by an HPHC Provider. The HPHC Providers you can • Crowns select depend upon where your PCP is located. See Section 1.A.2.e. for details. • Gum care, including gum surgery (Please note this benefit is not covered by all Plan • Braces Sponsors. Please see your Schedule of Benefits.) • Root canals RELATED EXCLUSIONS: • Bridges • Removal of impacted teeth to prepare for or support orthodontic, prosthodontic, or periodontal • Dentures procedures • Bonding b. Preventive Dental Care for Children If your Plan Sponsor has selected coverage for 8. OTHER SERVICES preventive dental care for children as part of your a. Home Health Care benefit package, the following services are covered When you are homebound for medical reasons, the up to the age limit described in your Schedule of Plan covers the home health care services stated Benefits. The Plan covers two preventive dental below on a short-term intermittent basis. To be exams per calendar year. Only the following services eligible, your PCP must find that skilled nursing care are covered: or physical therapy are an essential part of active treatment. There must also be a defined medical goal • Cleaning that your PCP expects you to meet in a reasonable • Fluoride treatment amount of time.
18 Care provided on a short-term intermittent basis therapy; medical supplies; appliances; drugs which means care that is provided fewer than eight hours cannot be self-administered; and limited inpatient per day, on a less than daily basis, up to 35 hours per and outpatient respite care. week, for up to 21 consecutive days. If you receive more than one type of skilled service in the home, c. House Calls these time limits apply to all services combined. The Plan covers Medically Necessary house calls
within the Service Area by an HPHC Provider. A When you qualify for home health care services as stated above, the Plan covers the following on a short- Referral from your PCP is required for all specialist term intermittent basis when Medically Necessary: visits.
• Skilled nursing care d. Durable Medical and Prosthetic Equipment • Physical therapy The Plan covers durable medical equipment, including prosthetic devices, when Medically • Occupational therapy Necessary and ordered by an HPHC Provider up to the benefit limit described in the Schedule of • Speech therapy Benefits. The Plan will rent or buy all equipment. The Plan may recover the equipment if your PCP • Medical social services decides you no longer need it or your membership • Nutritional counseling ends. The cost of the repair and maintenance of covered equipment is also covered. • Services of a home health aide Coverage is only available for: Durable medical equipment and supplies are also • The least costly equipment or prosthesis adequate covered to the extent that they are a Medically to allow you to perform Activities of Daily Living; Necessary component of the home health care and services being provided. • One item of each type of equipment that meets the Medically Necessary prenatal and postpartum Member's need. No back-up items or items that homemaker services are covered when a woman is serve a duplicate purpose are covered. For confined to bed rest or her Activities of Daily Living example, the Plan covers a manual or an electric are otherwise restricted on the recommendation of wheelchair, not both. her attending health care provider. Durable medical equipment and prosthetic equipment are covered up to the limit described in the Schedule of Please note that physical and occupational therapies Benefits. The benefit limit does not apply to breast covered under the home health care benefit are not prostheses (including replacements and mastectomy subject to any visit limit. bras) respiratory equipment (including oxygen), glucometers, or durable medical equipment ordered as RELATED EXCLUSIONS: part of an authorized home health care program. Both • Continuous or long-term home health care services the benefit limit and Copayments are based on the cost of equipment to the Plan. • Private duty nursing When you are temporarily outside of the Service b. Hospice Services Area, coverage is provided for equipment available under this Handbook only when the need for it The Plan covers hospice services for terminally ill cannot be foreseen before leaving the Service Area. Members with a limited life-expectancy. Care may be In order to be covered, all equipment must be: provided at home or on an inpatient basis. (Inpatient care is only covered when Medically Necessary to • Able to withstand repeated use control pain and manage acute and severe clinical • Not generally useful in the absence of disease or problems which cannot be managed in a home setting.) injury
Covered Benefits include: physician services; • Suitable for home use nursing care; social services; counseling services; care to relieve pain; home health aide services; • Normally used in the treatment of an illness or occupational, physical, speech, and respiratory injury or for the rehabilitation of an abnormal body part. (This does not apply to prostheses.) 19
• Electronic and myoelectric artificial limbs Covered equipment includes: • Respiratory equipment • Repair or replacement of equipment or devices as a result of loss, negligence, willful damage, or theft • Certain types of braces • Any devices or special equipment needed for • Oxygen and oxygen equipment sports or occupational purposes • Hospital beds • Any home adaptations, including, but not limited to • Wheelchairs home improvements and home adaptation equipment
• Walkers e. Ambulance Transport • Crutches Except in a Medical Emergency, ambulance transport is covered only when arranged by an HPHC Provider. • Canes The Plan covers such ambulance transport to the • Blood glucose monitors, including voice- nearest hospital that can provide the care you need. synthesizers and visual magnifying aids when The Plan also covers transfer from one health care Medically Necessary for their use facility to another when medically necessary.
Covered prostheses include: f. Cosmetic Surgery • Artificial arms and legs, other than electronic and For purposes of this Handbook, cosmetic surgery is myoelectric devices any procedure to change or restore appearance. Your PCP will refer you to an HPHC Provider for such • Artificial eyes surgery. Your PCP must also obtain HPHC approval for coverage. • Breast prostheses, including replacements and mastectomy bras The Plan covers cosmetic surgery only to repair • Ostomy supplies severe disfigurement due to injury or disease or birth defect, including post-mastectomy coverage for: • Wigs, up to the benefit limit described in your Schedule of Benefits 1) Reconstruction of the breast on which the mastectomy was performed; • Therapeutic or molded shoes, and foot orthotics needed to prevent or treat complications of 2) Surgery and reconstruction of the other breast to diabetes, up to the benefit limit described in your produce a symmetrical appearance; and Schedule of Benefits 3) Prostheses and physical complications for all (Please note this benefit is not covered by all Plan stages of mastectomy, including lymphedemas, in Sponsors. Please see your Schedule of Benefits.) a manner determined in consultation with the attending physician and the patient. RELATED EXCLUSIONS: The following items are not covered: g. Kidney Dialysis • Exercise equipment The Plan covers kidney dialysis on an inpatient or outpatient basis, or at home. When Medicare is • Therapeutic or molded shoes, and foot orthotics primary, the Plan will cover services only to the extent (unless specifically covered in your Schedule of payments would exceed what would be payable by Benefits) Medicare. Coverage for dialysis in the home includes non-durable medical supplies, drugs and equipment • Hearing aids (unless specifically covered in your necessary for dialysis. Installation of home equipment Schedule of Benefits) is covered up to $300 in a Member’s lifetime.
• Dentures Dialysis services must be provided by an HPHC Provider. • Wigs (unless specifically covered in your Schedule of Benefits)
20 If you are temporarily outside the Service Area, the • Insulin Plan covers limited dialysis services when approved by the Plan. You must make prior arrangements with • Oral agents for controlling blood sugar your PCP. • Blood test strips h. Human Organ Transplants The Plan covers Medically Necessary human organ • Glucose, ketone and urine test strips transplants, including bone marrow transplants for a • Member with metastasized breast cancer in Diabetic laboratory tests accordance with the criteria of the Massachusetts • Needles, insulin syringes, and insulin pens Department of Public Health. Your PCP will refer you to an HPHC Provider for such care. Your PCP • Lancets must obtain HPHC approval for coverage. • Blood glucose monitors and monitoring strips for If a covered bone marrow transplant service is not home use including voice-synthesizers and visual available from a participating HPHC provider, magnifying aids when Medically Necessary for HPHC will approve coverage for the bone marrow their use transplant services through a non-participating provider. • Insulin pumps and supplies
The Plan covers the following services when the • Therapeutic and molded shoes and inserts for recipient is a Member of the Plan: severe diabetic foot disease when referred by the PCP and prescribed by a podiatrist or other • Care for the recipient qualified doctor and furnished by a podiatrist, orthotist, prosthetist or pedorthist • Donor search costs through established organ donor registries • Outpatient diabetes self-management training and education programs, including medical nutrition • Donor costs that are not covered by the donor's therapy provided by an HPHC diabetes health care health plan provider
If a Member is a donor for a recipient who is not a You must get a prescription from your PCP and Member, the Plan will cover the donor costs for the present it at an HPHC participating pharmacy for Member that is not covered by the recipient's health insulin, oral agents, test strips, needles, standard plan. insulin syringes, insulin pens and lancets. A list of HPHC participating pharmacies is available from the RELATED EXCLUSIONS: Member Services Department. Your PCP will order • Human organ transplants that are Experimental or other equipment through a medical supply vendor. Unproven (Please note this benefit is not covered by all Plan Sponsors. Please see your Schedule of Benefits.) i. Special Formulas and Low Protein Foods The Plan covers the following: k. Cardiac Rehabilitation The Plan covers cardiac rehabilitation. Services must • Special infant formulas approved by the be provided by an HPHC Provider. Coverage Department of Public Health includes only Medically Necessary services for • Formulas for the treatment of malabsorption Members with established coronary artery disease or caused by Crohn's disease, ulcerative colitis, unusual and serious risk factors for such disease. gastroesophogeal reflux, gastrointestinal motility, or chronic intestinal pseudo-obstruction l. Temporomandibular Joint Dysfunction (TMD) Services • Low protein foods for inherited diseases of amino Your coverage for TMD services is limited to medical and organic acids. This coverage is limited to the services only. Your PCP will refer you to an HPHC amount described in the Schedule of Benefits. Provider. The Plan covers only the following services: • Initial consultation j. Diabetes Treatment The Plan covers the following services for persons • X-rays with diabetes to the extent Medically Necessary:
21 p. Chiropractic Care • Physical therapy, subject to the visit limit for outpatient physical therapy If your Plan Sponsor has selected coverage for chiropractic care as part of your benefit package, the • Surgery Plan covers care by a chiropractor up to the amount stated in the Schedule of Benefits for the treatment of RELATED EXCLUSIONS: orthopedic and neuromuscular conditions. The • All services of a dentist, except oral surgery and following services are covered: procedures specifically related to TMJ • Initial diagnostic X-ray
• Care within the scope of standard chiropractic m. Clinical Trials for the Treatment of Cancer practice The Plan covers services for Members enrolled in a
qualified clinical trial of a treatment for any form of You must use a chiropractor who is an HPHC cancer under the terms and conditions provided for Provider. You do not need a Referral from your PCP. under applicable state or federal law. All of the HPHC Providers are listed in the Provider Directory. requirements for coverage under the Plan apply to
coverage under this benefit. The following services (Please note this benefit is not covered by all Plan are covered under this benefit: (1) all services that are Sponsors. Please see your Schedule of Benefits.) Medically Necessary for treatment of your condition,
consistent with the study protocol of the clinical trial, RELATED EXCLUSIONS: and for which coverage is otherwise available under the Plan; and (2) the reasonable cost of an • Care outside the scope of standard chiropractic investigational drug or device that has been approved practice, including but not limited to, surgery, for use in the clinical trial to the extent it is not paid prescription or dispensing of drugs or for by its manufacturer, distributor or provider. medications, internal examinations, obstetrical practice, treatment of infectious disease, or Your PCP must refer you to an HPHC Provider for treatment with crystals. coverage under this benefit. • Diagnostic testing other than initial X-ray If you are participating in a qualified clinical trial, please notify our Care Management Team. You can q. Vision Hardware for Special Conditions do this by calling the Member Services Department If your Plan Sponsor has selected coverage for vision at 1 888 333 4742. The Care Management Team can hardware as part of your benefit package, the Plan provide you with assistance concerning your clinical trial participation. provides limited coverage for contact lenses or eyeglasses for certain eye conditions. Your PCP must n. Drugs that cannot be Self-Administered refer you for these services and obtain HPHC Plan approval for coverage. The coverage provided for the The Plan covers drugs that cannot be self-administered, conditions listed is as follows: including hormone replacement therapy (HRT) when Medically Necessary and administered by your PCP • Post cataract surgery with an intraocular lens or an HPHC Provider. Coverage includes drugs that implant (pseudophakes). Coverage is limited to cannot be self-administered that have been approved $140 per surgery toward the purchase and fitting by the United States Food and Drug Administration, of eyeglass frames and lenses. The replacement of except drugs that the Plan excludes or limits. lenses due to a change in the Member's prescription of .50 diopters or more within 90 days of the
surgery is covered in full. o. Prescription Drug Coverage If your Plan Sponsor has selected coverage for • Post cataract surgery without lens implant prescription drugs as part of your benefit package, (aphakes). One pair of eyeglass lenses or contact please see the Prescription Drug Brochure included lenses is covered in full per year. Coverage of up in your Member Kit. When you have prescription to $50 per year is also provided for the purchase drug coverage, your prescription drug Copayments of eyeglass frames. The replacement of lenses due and Deductible (if applicable) should be listed on to a change in the Member’s prescription of .50 your ID Card. diopters or more is also covered. Replacement of (Please note this benefit is not covered by all Plan lenses due to wear, damage, or loss, is limited to 3 Sponsors. Please see your Prescription Drug per calendar year. Brochure.)
22 • Keratoconus. One pair of contact lenses is covered • Transportation other than by ambulance. in full per year if there is a medical need. The replacement of lenses, due to a change in the • Services for which you are legally entitled to Member’s condition, is limited to 3 per affected treatment at government expense. This includes eye per calendar year. disabilities related to military service.
• Post retinal detachment surgery that occurred • Costs for services by a Workers' Compensation third while a Plan Member, or for one year after party liability, other insurance coverage, or an surgery. For a Member who wore eyeglasses or employer under state or federal law. contact lenses prior to retinal detachment surgery, the Plan covers the full cost of one lens per • Hair removal or restoration, including, but not limited affected eye up to one year after the date of to, electrolysis, laser treatment, transplantation or surgery. For Members who have not previously drug therapy. worn eyeglasses or contact lenses, the Plan covers • the full cost of a pair of eyeglass lenses and up to Routine foot care, biofeedback, pain management $50 toward the purchase of the frame, or the full programs, massage therapy, including myotherapy cost of a pair of contact lenses. and sports medicine clinics. (Please note this benefit is not covered by all Plan • Any treatment with crystals. Sponsors. Please see your Schedule of Benefits.) • Blood and blood products.
The following are optional benefit Riders which your • Educational services (including problems of school Plan Sponsor may select as part of your benefit package. performance) or testing for developmental, If any of these optional benefits are part of your benefit educational, or behavioral problems except services package, please see the separate brochures included with covered under the benefit for Early Intervention. your Schedule of Benefits. • Sensory integrative praxis tests. r. Vision Hardware Rider • Physical examinations and testing for insurance, s. Preventive Dental Rider for Adults licensing or employment purposes.
t. Prescription Drug Rider • Vocational rehabilitation, or vocational evaluations on job adaptability, job placement, or therapy to restore function for a specific occupation. 9. GENERAL EXCLUSIONS The Plan does not cover the following: • Charges after the date on which your membership • Services your PCP or an HPHC Provider has not ends. provided, arranged or approved except: (1) in a • All charges over the semi-private room rate, except Medical Emergency, (2) when you are outside of the when a private room is Medically Necessary. Service Area; or (3) the special services that do not require a Referral, listed in section A.2.e. • Charges after your hospital discharge.
• Services for cosmetic purposes, except as described • Follow-up care to an emergency room visit, unless in this Handbook and the Schedule of Benefits. provided or arranged by your PCP.
• Commercial diet plans, weight loss programs, and any • Rest or Custodial Care. services in connection with such plans or programs. • Personal comfort or convenience items (including • Gender reassignment surgery and all related drugs telephone and television charges); lancets; exercise and procedures. equipment; electronic and myoelectronic artificial arms and legs; foot orthotics (unless specifically • Drugs, devices, treatments or procedures that are covered in your Schedule of Benefits); wigs (unless Experimental or Unproven. specifically covered in your Schedule of Benefits); • Refractive eye surgery, including but not limited to and derotation knee braces; and repair or replacement lasik surgery and orthokeratology and lens of durable medical equipment or prosthetic devices as implantation, for correction of myopia, hyperopia and a result of loss, negligence, willful damage, or theft. astigmatism.
23 • Non-durable medical supplies, unless used in the • Any home adaptations, including but not limited to course of diagnosis or treatment in a medical facility home improvements and home adaptation equipment or in the course of authorized home health care; Long-term care
• Reversal of voluntary sterilization (including any • Private duty nursing, unless received as part of services for infertility related to voluntary sterilization inpatient care services or its reversal) and any form of surrogacy. • Methadone maintenance • Infertility treatment for Members who are not medically infertile. • Birth control injections, implants and devices, unless your Plan Sponsor has provided coverage for • Routine maternity (prenatal and postpartum) care Prescription Drugs. when you are traveling outside the Service Area. HPHC does not cover mental health services that are (1) • Delivery outside the Service Area after the 37th week provided to Members who are confined or committed to of pregnancy, or after you have been told that you are a jail, house of correction, prison, or custodial facility of at risk for early delivery. the Department of Youth Services; or (2) provided by • Planned home births the Department of Mental Health.
• Services for a newborn who has not been enrolled as Any services not specified in this Handbook and a Member, other than nursery charges for routine Schedule of Benefits. services provided to a healthy newborn. The Plan does not cover the following services unless • Removal of impacted teeth to prepare for or support specifically provided in your Schedule of Benefits: orthodonic, prosthodontic or periodontal procedures. • Therapeutic or molded shoes, and foot orthotics, • Dental fillings; crowns; gum care, including gum unless a benefit for such services is listed in the surgery; braces; root canals; bridges; and dentures. Schedule of Benefits. • Devices or special equipment needed for sports or • Dental services, except the specific dental services occupational purposes. listed in the Schedule of Benefits. Restorative, periodontal, orthodontic, endodontic, prosthodontic, • Care outside the scope of standard chiropractic and dental services for temporomandibular joint practice, including but not limited to, surgery, dysfunction (TMD) are not covered. prescription or dispensing of drugs or medications, internal examinations, obstetrical practice, or • Eyeglasses, contact lenses and fittings, except as treatment of infectious. Diagnostic testing for listed in this Handbook and the Schedule of Benefits. chiropractic care other than an initial x-ray. • Chiropractic services, including osteopathic • Services for which no charge would be made in the manipulation, unless a benefit for such services is absence of insurance. listed on the Schedule of Benefits.
• Charges for any products or services, including, but • Acupuncture, aromatherapy, and alternative not limited to, professional fees, medical equipment, medicine, unless a benefit for such services is listed drugs, and hospital or other facility charges, that are on the Schedule of Benefits. related to any care that is not a Covered Benefit • under this Handbook. Hearing aids or dentures unless a benefit for such services is listed on the Schedule of Benefits. • Services for non-Members and services after membership termination.
• Services or supplies given to you by: (1) anyone related to you by blood, marriage or adoption, or (2) anyone who ordinarily lives with you.
• Charges for missed appointments.
• Services that are not Medically Necessary.
24 C. STUDENT DEPENDENT COVERAGE b. Benefits for Out-of-Area Student Coverage When your Dependent child goes to school away from For student Dependents who attend school outside home, he or she may continue to receive Plan benefits. the Enrollment Area, the Plan covers the following The Plan coverage works one of two ways for student services when Medically Necessary and related to a Dependents, depending on where they go to school. specific illness or condition.
1. STUDENTS INSIDE THE ENROLLMENT AREA Any Cost Sharing amounts will be applied as listed in the Schedule of Benefits. If your Dependent child goes to school inside the
Enrollment Area, then he or she can choose an HPHC PCP near school. This PCP manages your child's care 1) Outpatient Services just as your PCP does for you. The Plan covers all outpatient services listed in this Handbook and the Schedule of Benefits, The Enrollment Area is where Members, except for a other than mental health care (which is described Dependent child going to school, must live to be eligible below) except the following: for enrollment. The Enrollment Area includes all the • Routine examinations and preventive care, places where HPHC Providers are available to care for including immunizations; you. You may obtain a list of the cities and towns along with a map of the current Enrollment Area from HPHC’s • Preventive dental care and the extraction of Member Services. HPHC may revise the Enrollment Area impacted teeth, if Covered Benefits; from time to time. • Home health care, including maternity home 2. STUDENTS OUTSIDE THE ENROLLMENT AREA care programs and house calls; If your Dependent child goes to school outside the • Maintenance or replacement of prosthetic Enrollment Area, the Plan provides special coverage. devices or durable medical equipment; This is because there are no nearby HPHC PCP's who can manage your child's care while he or she is going to school. • Cosmetic surgery;
This special coverage allows benefits for care that could • Elective Procedures that can be delayed until the have been foreseen before your child left the Enrollment Member returns to the Service Area without Area. It also provides different benefits for outpatient permanent damage to the Member’s health; and mental health services. All the rules and limits on • Second opinions. coverage listed in the Benefit Handbook apply to these benefits, except that your Dependent child does not need to get care through his or her PCP. 2) Inpatient Services The Plan covers inpatient services listed in this PLEASE NOTE: YOUR DEPENDENT CHILD IS Handbook, except for Elective Procedures. ENTITLED TO ALL THE BENEFITS IN THIS Elective Procedures are services that can be HANDBOOK WHEN HE OR SHE RETURNS TO delayed until your child's return to the Enrollment THE ENROLLMENT AREA AND RECEIVES Area without permanent damage to his or her CARE FROM HPHC PROVIDERS. health. You must call your PCP and HPHC within 48 hours of hospitalization. The telephone a. Eligibility for Out-of-Area Student Coverage numbers are on your ID card. Coverage for students living outside the Enrollment Area is available only to a Dependent who is: 3) Mental Health and Drug and Alcohol Abuse Services • An unmarried child of a Subscriber or The outpatient mental health care and the drug and Subscriber's spouse who meets the definition of alcohol rehabilitation services listed in this Dependent according to the agreement between Handbook are each covered up to a maximum of 8 HPHC and your Plan Sponsor. visits per calendar year to the extent such benefits have not been provided by HPHC Providers within • Enrolled on a full-time basis at an accredited the Enrollment Area. All visits covered outside of educational institution located outside the the Enrollment Area will be counted against your Enrollment Area; and child's benefit under your Schedule of Benefits. • Registered in advance with HPHC as a student Visits not used while outside the Enrollment Area attending school outside the Enrollment Area. during the calendar year may be used within the Enrollment Area in accordance with this Handbook HPHC or the Plan Sponsor may require reasonable and your Schedule of Benefits. evidence that a Member meets the above requirements.
25 D. REIMBURSEMENT AND CLAIMS PROCEDURES The information in this section applies when you receive Here is the information we need to process your claim: services from a non-HPHC Provider. Generally, this 1) The Member's full name and address; would happen only when you get care: • In a Medical Emergency; or 2) The Member's date of birth;
• When you are temporarily outside the Service Area. 3) The Member's Plan ID number (on the front of the patient's Plan ID card); In most cases, you should not receive bills from an HPHC Provider. 4) The name and address of the person or institution providing the services for which the claim is made 1. CLAIM FILING PROCEDURES and their tax identification number; In order to be paid by HPHC, all claims must be filed in 5) The date the service was rendered; writing or electronically. (Providers should contact HPHC for instructions concerning electronic filing.) 6) The CPT code (or a brief description of the illness or Claims must be submitted to the following addresses: injury) for which payment is sought;
Claims for Pharmacy Services 7) The Member’s diagnosis; MedImpact 8) The amount of the Provider’s charge; and DMR Department 10680 Treena Street, 5th Floor 9) For pharmacy items, a drug receipt stating: the San Diego, CA 92131 Member’s name and Plan ID number, the name of the drug or medical supply, the drug National Drug Claims for Mental Health and Drug and Alcohol Code (NDC) number, the quantity, the number of Rehabilitation Services: day’s supply, the date the prescription was filled, the HPHC - Behavioral Health Access Center prescribing physician’s name, the pharmacy name C/O PacifiCare and address, and the amount paid. P.O. Box 31053 Laguna Hills, CA 92654-1053 Reimbursement for prescription drugs will only be made if prescription drug coverage is selected by All Other Claims: your Plan Sponsor. Information on prescription HPHC Claims drug coverage may be found in your Prescription P.O. Box 699183 Drug Brochure. Quincy, MA 02269-9183 Members can contact the MedImpact help desk at 2. BILLING BY PROVIDERS 1 800 788 2949 for assistance with pharmacy claims. If you get a bill for a Covered Benefit you may ask the provider to: Please note that more information for some claims may be required. If you have any questions about claims, 1) Bill the Plan on a standard health care claim form please call the HPHC Member Services Department. (such as the CMS 1500 or the UB-82/92 form); and 2) Send it to HPHC at the address listed on the back of 4. LIMITS ON CLAIMS your Plan ID card. To be eligible for payment, HPHC must receive claims within one year of the date care was received.
3. REIMBURSEMENT FOR BILLS YOU PAY The Plan limits the amount paid for services that are not If you pay a provider who is not an HPHC Provider for rendered by HPHC Providers. The most that will be paid a Covered Benefit, we will reimburse you. Just send for such services is the Usual, Customary and Reasonable receipts from the provider which show proof of Charge. You may have to pay the balance if the claim is payment. Costs of non-Covered Benefits are not for more than the Usual, Customary and Reasonable reimbursable. Charge.
26 E. APPEALS AND COMPLAINTS For all appeals, except mental health and drug and This section explains HPHC’s procedures for processing alcohol rehabilitation services appeals, please send appeals and complaints and the options available to you your request to the following address: if an appeal is denied. HPHC Member Appeals Member Services Department 1. BEFORE YOU FILE AN APPEAL Harvard Pilgrim Health Care, Inc. 1600 Crown Colony Drive Claim denials may result from a misunderstanding with Quincy, MA 02169. a provider or a claim processing error. Since these problems can be easy to resolve, we recommend that Telephone: (888) 333 4742 Members contact an HPHC Member Service FAX: (617) 509 3085 Representative prior to filing an appeal. (A Member Service Representative can be reached toll free at (888) If your appeal involves a mental health and drug and 333 4742 or at (800) 637 8257 for TTY service.) The alcohol rehabilitation service, please send it to the Member Service Representative will investigate the following address: claim and either resolve the problem or explain why the HPHC Member Appeals claim is being denied. If you are dissatisfied with the C/O PacifiCare response of the Member Service Representative, you P.O. Box 850346 may file an appeal using the procedures outlined below. Braintree, MA 02185
2. MEMBER APPEAL PROCEDURES Telephone: (888) 777 4742 If you are dissatisfied with a decision on HPHC’s FAX: (800) 383 2194 coverage of services you may appeal to HPHC. Appeals may also be filed by a Member’s representative or a No appeal shall be deemed received until actual provider acting on a Member’s behalf. HPHC has receipt by HPHC at the appropriate address or established the following steps to ensure that Members telephone number listed above. receive a timely and fair review of internal appeals. When we receive your appeal, we will assign an Appeal Coordinator to manage your appeal HPHC staff is available to assist you with the filing of throughout the appeal process. We will send you a an appeal. If you wish such assistance, please call letter identifying your Appeal Coordinator. That (888) 333 4742. letter will include detailed information on the appeal process. Your Appeal Coordinator is a. Initiating Your Appeal available to answer any questions you may have To initiate your appeal, you or your representative about your appeal. Please feel free to contact your should write or FAX a letter to us about the Appeal Coordinator if you have any questions or coverage you are requesting and why you feel it concerns about the appeal process. should be granted. (If your appeal qualifies as an expedited appeal, you may contact us by telephone. b. Appeal Process See Section E.2.c. for the expedited review The Appeal Coordinator will investigate your appeal procedure.) Please be as specific as possible in and determine if additional information is required. your appeal request. We need all the important Such information may include medical records, details in order to make a fair decision, including statements from your doctors, and bills and receipts for pertinent medical records and itemized bills. We services you have received. You may also provide must get this information within one hundred and HPHC with any written comments, documents, eighty (180) days of the denial of coverage. records or other information related to your claim.
If you have a representative, including a medical HPHC divides appeals into two types, “Pre-Service provider, submit an appeal on your behalf, the Appeals” and “Post-Service Appeals,” as follows: appeal must include a statement, signed by you, • A “Pre-Service Appeal” requests coverage of a authorizing the representative to act on your behalf. health care service that the Member has not yet In the case of an expedited appeal, such received. authorization must be provided within 48 hours • after submission of the appeal. A “Post-Service Appeal” requests coverage of a health care service that the Member has already
received.
27 HPHC will review Pre-Service Appeals and send a You, your representative or a provider acting on your written decision within 30 days of the date the appeal behalf may request an expedited appeal by telephone was received by HPHC. HPHC will review Post- or fax. (Please see “Initiating Your Appeal,” above, Service Appeals and send a written decision within for the telephone and fax numbers.) HPHC will 60 days of the date the appeal was received by investigate and respond to your request within 72 HPHC. These time limits may be extended by mutual hours. We will notify you of the decision on your agreement between you and HPHC. appeal by telephone and send you a written decision within two business days thereafter. After we receive all the information needed to make a decision, your Appeal Coordinator will inform you, in If you request an expedited appeal of a decision to writing, whether your appeal is approved or denied. discharge you from a hospital, we will continue to HPHC’s decision of your appeal will include: (1) a pay for your hospitalization until we notify you of summary of the facts and issues in the appeal; (2) a our decision. summary of the documentation relied upon; (3) the specific reasons for the decision, including the clinical To enable us to conduct such a quick review of the rational, if any; and (4) the identification of any expedited appeal, we must limit the expedited appeal medical or vocational expert consulted in reviewing process to the circumstances listed above. Your help your appeal. This decision is HPHC’s final decision in promptly providing all necessary information is under the appeal process. If HPHC’s decision is not essential for us to provide you with this quick review. fully in your favor, the decision will also include a If we do not have sufficient information necessary to description of other options for further review of your appeal. These are also described in Section 3, below. decide your appeal, HPHC will notify you that additional information is required within 24 hours If your appeal involves a decision on a medical issue, after receipt of your appeal. the Appeal Coordinator will obtain the opinion of a qualified physician or other appropriate medical 3. WHAT YOU MAY DO specialist. The health care professional conducting the IF YOUR APPEAL IS DENIED review must not have either participated in any prior If you disagree with the decision of your appeal, you may decision concerning the appeal or be the subordinate of (1) have your appeal decision reconsidered, (2) seek such person. Upon request, your Appeal Coordinator alternative dispute resolution through the U.S. Department will provide you with a copy, free of charge, of any of Labor or (3) seek legal action under Section 502(a) of written clinical criteria used to decide your appeal and the Employee Retirement Income Security Act (ERISA). the identity of the physician (or other medical specialist) You may take any one of these actions in any order. For consulted concerning the decision. example, you are not required to request reconsideration before seeking alternative dispute resolution or legal action. You have the right to receive, free of charge, all Below is a summary of these options. documents, records or other information relevant to the initial denial and your appeal. a. Reconsideration of an Appeal Decision c. Expedited Review Procedure: Many Plan Sponsors offer reconsideration following an appeal decision. Please see your Plan Document HPHC will provide you with an expedited review if Face Sheet, enclosed with this Benefit Handbook, to your appeal involves services which: determine what rights, if any, you have to (1) If delayed, could seriously jeopardize your life or reconsideration of your appeal. health or ability to regain maximum function, b. Alternative Dispute Resolution (2) In the opinion of a physician with knowledge of your medical condition, would result in severe You and your Plan may have other voluntary pain that cannot be adequately managed without alternative dispute resolution options, such as the care or treatment, or mediation. One way to find out what may be available is to contact your local U.S. Department of Labor (3) Involves the continuation of inpatient services Office and your state insurance regulatory agency. following emergency care. c. Legal Action If your appeal involves services that meet one of You may also be able to bring legal action under these criteria, please inform us and we will provide Section 502(a) of the Employee Retirement Income you with an expedited review. Security Act (ERISA).
28 4. FORMAL COMPLAINT PROCESS If you have any concerns about your care under the Plan or about HPHC’s service, HPHC wants to know about it. HPHC is here to help. Please call or write to:
HPHC Member Services Department Harvard Pilgrim Health Care 1600 Crown Colony Drive Quincy, MA 02169
Attn: Member Concerns 1 888 333 4742
We will respond to you as quickly as we can. Most concerns can be investigated and responded to within thirty (30) days.
29 F. ELIGIBILITY This section describes requirements concerning 3. EFFECTIVE DATE - ADOPTIVE DEPENDENTS eligibility under the Plan. It is important to understand An adoptive child who has been living with you, and that eligibility of Dependents and effective dates of for whom you have been receiving foster care payments, coverage are determined by the Plan Sponsor. Please see may be covered from the date the petition to adopt is your Plan Sponsor or the Plan Administrator listed on filed. An adoptive child who has not been living with you the Face Sheet included with this Handbook for may be covered from the date of placement in your home descriptions of eligibility for Dependents and effective for purposes of adoption by a licensed adoption agency. dates of coverage. 4. EFFECTIVE DATE - OFF-CYCLE ENROLLMENT 1. MEMBER ELIGIBILITY Under the Health Insurance Portability and a. Residence Requirement Accountability Act, individuals may enroll in the Plan at To be eligible for coverage under this Plan, you must any time if: 1) the employee’s spouse or eligible live, and maintain a permanent residence, within the Dependent has lost other insurance; 2) the employee Enrollment Area at least nine months of a year. This marries; 3) if the Plan Sponsor’s contributions toward does not apply to a Dependent child who is: the dependent's coverage are terminated; 4) the employee has a newborn or adopts a child. The • Enrolled as a full-time student attending an employee must make a written request for enrollment accredited educational institution, or within thirty (30) days of one of these qualifying events. • Enrolled as a Dependent child under a Qualified For reasons 1, 2 and 3, the effective date must be no Medical Support Order. Dependents who enroll later than the first day of the first month after HPHC under a Qualified Medical Support Order whose receives the enrollment request. For reason 4, the permanent residence is outside the Enrollment effective date must be the date of birth in the case of a Area will be subject to the limitations described in newborn Dependent, or in the case of an adoptive this Handbook in Section I.1.c. Dependent, the effective date must be the date of adoption or placement for adoption.
If you have any questions about these requirements, 5. CHANGE IN STATUS you may call the Member Services Department at 1 888 333 4742. They can give you a current list of It is your responsibility to inform your Plan Sponsor and the cities and towns in the Enrollment Area. HPHC of all changes that affect Member eligibility. These changes include: address changes; marriage of a b. Subscriber Eligibility Dependent; death of a Member; and when a Dependent To be a Subscriber under this Plan, you must: is no longer enrolled in an accredited educational institution on a full-time basis. Please note that HPHC • Be an employee of the Plan Sponsor, in must have your current address on file in order to accordance with employee eligibility guidelines correctly process claims for care outside the Service Area. agreed to by the Plan Sponsor and HPHC; and • Be enrolled through a Plan Sponsor that is up-to- 6. ADDING A DEPENDENT date in the payment of the applicable payments It is important to understand that eligibility of for coverage. Dependents and effective dates of coverage are determined by the Plan Sponsor. Dependents of eligible
employees who meet eligibility guidelines will be c. Dependent Eligibility enrolled in the Plan using HPHC enrollment forms or in Please see your Plan Sponsor or benefits administrator a manner otherwise agreed to in writing by HPHC and for a description of Dependent eligibility as agreed the Plan Sponsor. HPHC must receive proper notice upon by your Plan Sponsor and HPHC. from the Plan Sponsor of any Member enrollment in, or termination from, the Plan no more than 60 days after 2. EFFECTIVE DATE - such change is to be effective unless otherwise required NEW AND EXISTING DEPENDENTS by law. Please see your Plan Sponsor or the Plan Please see your Plan Sponsor’s benefit administrator for Administrator listed on the Face Sheet included with information on enrollment and effective dates of this Handbook for information on Dependent eligibility coverage. and effective dates of coverage.
30 7. SPECIAL ENROLLMENT RIGHTS If an employee declines enrollment for the employee and his or her Dependents (including his or her spouse) because of other health insurance coverage, the employee may be able to enroll in this Plan in the future along with his or her Dependents, provided that enrollment is requested within 30 days after other coverage ends. In addition, if the employee has a new Dependent as a result of marriage, birth, adoption or placement for adoption, the employee may be able to enroll along with his or her Dependents, provided that enrollment is requested within 30 days after the marriage, birth, adoption or placement for adoption.
31 G. TERMINATION AND TRANSFER TO OTHER COVERAGE 4. CONTINUATION OF COVERAGE 1. TERMINATION BY THE SUBSCRIBER REQUIRED BY LAW You may end your membership under this Plan with a. Federal Law your Plan Sponsor's approval. HPHC must receive a If you lose Plan Sponsor eligibility and the Plan completed Enrollment/Change form from the Plan Sponsor has twenty (20) or more employees, you Sponsor within sixty (60) days of the date you want your may be eligible for continuation of group coverage membership to end. under the Federal law known as the Consolidated Omnibus Budget Reconciliation Act (COBRA). 2. TERMINATION FOR LOSS OF ELIGIBILITY You should contact your Plan Sponsor for more The Member’s coverage may end under this Plan for information if health coverage ends due to: failing to meet any of the specified eligibility 1) Separation from employment; requirements. You will be notified if coverage ends for loss of eligibility. HPHC or the Plan Sponsor will 2) Reduction of work hours; or inform you in writing. 3) Loss of dependency status. You may be eligible for continued enrollment under federal law, if your membership is terminated. See Continuation of coverage may not be extended "Continuation of Coverage Required by Law" in this beyond the applicable time allowed under federal Section for more information. law. The size of your Plan Sponsor will determine whether you select your continuation of coverage PLEASE NOTE THAT HPHC MAY NOT HAVE rights under state or federal law. CURRENT INFORMATION CONCERNING MEMBERSHIP STATUS. PLAN SPONSORS MAY 5. TRANSFER TO NON-GROUP COVERAGE NOTIFY HPHC OF ENROLLMENT CHANGES RETROACTIVELY. AS A RESULT, THE HPHC has non-group health plans for people who are no INFORMATION HPHC HAS MAY NOT BE longer eligible for coverage through your Plan Sponsor. CURRENT. ONLY YOUR PLAN SPONSOR CAN To be eligible for non-group coverage you must: CONFIRM MEMBERSHIP STATUS. a. Send HPHC notice that you are applying to convert 3. MEMBERSHIP TERMINATION FOR CAUSE within sixty three (63) days of the last day of Plan Sponsor coverage; A Member's coverage may end for any of the following
causes: b. Maintain residence within the Enrollment Area; • Providing false or misleading information on an application for membership; c. Be eligible for non-group enrollment under the state and federal laws that apply in the state where you • The failure to pay Copayments; live; • Committing or attempting to commit fraud to obtain benefits for which the Member is not eligible under d. Not have been terminated from membership in the this Handbook; Plan for cause, as listed in this Handbook; and
• Obtaining or attempting to obtain benefits under this e. Pay the non-group premium for the period starting Handbook for a person who is not a Member; or with the date Plan Sponsor coverage ends.
• The commission of acts of physical or verbal abuse The non-group premium must be received by HPHC by a Member which pose a threat to providers or within sixty (60) days of the due date. other Members and which are unrelated to the
Member's physical or mental condition. Non-Group coverage is only available to residents of Notice of termination of membership for providing false states in which HPHC, or one of its affiliated health information shall be effective immediately upon notice plans, offer non-group health maintenance organization to a Member. Notice of termination of membership for coverage at the time coverage is sought. (At the time of the other causes will be effective fifteen (15) days after this writing, HPHC and its affiliates offer non-group notice. Administrative fees paid for periods after the plans to cover Members in New Hampshire, effective date of termination will be refunded. Massachusetts, and Maine).
32
The applicant may enroll only in a plan offered in his or her state of residence. Benefits vary by state and are different than those offered under this Handbook.
Please call HPHC Member Services for current information on the availability and benefits of non- group plans offered by HPHC, or an HPHC affiliate, in the state where you live.
33 H. WHEN YOU HAVE OTHER COVERAGE b. A Dependent Child Whose Parents Are Not This section explains how benefits under this Benefit Separated or Divorced Handbook will be coordinated with other insurance The order of benefits is determined as follows: benefits available to pay for health services that a Member 1) The benefits of the plan of the parent whose has received. Benefits are coordinated among insurance birthday falls earlier in a year are determined carriers to prevent duplicate recovery for the same before those of the plan of the parent whose service. Nothing in this section should be interpreted to birthday falls later in that year; but, provide coverage for any service or supply that is not expressly covered under this Handbook. 2) If both parents have the same birthday, the benefits of the plan that covered the parent longer are 1. BENEFITS IN THE EVENT OF determined before those of the plan that covered OTHER INSURANCE the other parent for a shorter period of time; Benefits under this Handbook and the Schedule of 3) However, if the other plan does not have the rule Benefits will be coordinated to the extent permitted by described in (1) above, but instead has a rule law with other plans covering health benefits, including: based upon the gender of the parent, and if, as a motor vehicle insurance, medical payment policies, result, the plans do not agree on the order of home owners insurance, governmental benefits benefits, the rule in this Plan (the "birthday rule") (including Medicare), and all Health Benefit Plans. The will determine the order of benefits. term "Health Benefit Plan" means all HMO and other prepaid health plans, Medical or Hospital Service c. Dependent Child/Separated or Divorced Parents Corporation plans, commercial health insurance and Unless a court order, of which the Plan has self-insured health plans. There is no coordination of knowledge, specifies one of the parents as benefits with Medicaid plans or with hospital indemnity responsible for the health care benefits of the child, benefits amounting to less than $100 per day. the order of benefits is determined as follows: 1) First the plan of the parent with custody of the child; Coordination of benefits will be based upon the Usual, Customary and Reasonable Charges for any service that 2) Then, the plan of the spouse of the parent with is covered at least in part by any of the plans involved. If custody of the child; benefits are provided in the form of services, or if a 3) Finally, the plan of the spouse of the non-custodial provider of services is paid under a capitation parent arrangement, the reasonable value of such services will
be used as the basis for coordination. No duplication in d. Active/Inactive Employee coverage of services shall occur among plans. The benefits of the plan that covers the person as an When you are covered by two or more Health Benefit active employee are determined before those of the plan that covers the person as a laid-off or retired Plans, one plan will be "primary" and the other plan (or employee. plans) will be "secondary." The benefits of the primary plan are determined before those of secondary plan(s) e. Longer/Shorter Length of Coverage and without considering the benefits of secondary If none of the above rules determines the order of plan(s). The benefits of secondary plan(s) are benefits, the benefits of the plan that covered the determined after those of the primary plan and may be employee, Member or Subscriber longer are reduced because of the primary plan's benefits. determined before those of the plan that covered that person for the shorter time. In the case of Health Benefit Plans that contain provisions for the coordination of benefits, the following If you are covered by a Health Benefit Plan that does rules shall decide which Health Benefit Plans are not have provisions governing the coordination of primary or secondary: benefits between plans, that plan will be the primary plan. a. Dependent/Non-Dependent The benefits of the plan that covers the patient as an 2. PROVIDER PAYMENT WHEN PLAN employee, Member or Subscriber are determined COVERAGE IS SECONDARY before those of the plan that covers the person as a When your Plan coverage is secondary to your coverage dependent. under another Health Benefit Plan, payment to a provider of services may be suspended until the provider 34 has properly submitted a claim to the primary plan and To enforce its subrogation rights under this Handbook, the claim has been paid, in whole or in part, or denied the Plan will have the right to take legal action, with or by the primary plan. The Plan may recover any without your consent, against any party to secure payments made for services in excess of the Plan’s recovery of the value of services provided or paid for by liability as the secondary plan, either before or after the Plan for which such party is, or may be, liable. payment by the primary plan.
Nothing in this Handbook shall be construed to limit the 3. WORKER'S COMPENSATION/GOVERNMENT Plan’s right to utilize any remedy provided by law to PROGRAMS enforce its rights to subrogation under this Handbook. If HPHC has information indicating that services provided to you are covered under Worker's 5. MEDICAL PAYMENT POLICIES Compensation, employer's liability or other program of If you are entitled to benefits under the medical payment similar purpose, or by a federal, state or other government benefit of a motor vehicle, motorcycle, boat, agency, payment may be suspended for such services homeowners, hotel, restaurant, or other insurance until a determination is made whether payment will be policy, such coverage shall become primary to the made by such program. If payment is made for services coverage under this Handbook for services rendered in for an illness or injury covered under Worker's connection with a covered loss under that policy. The Compensation, employer's liability or other program of benefits under this Handbook shall not duplicate any similar purpose, or by a federal, state or other government benefits to which you are entitled under any medical agency, the Plan will be entitled to recovery of its payment policy or benefit. All sums payable for services expenses from the provider of services or the party or provided under this Handbook to Members that are parties legally obligated to pay for such services. covered under any medical payment policy or benefit
are payable to the Plan. 4. SUBROGATION Subrogation is a means by which health plans recover 6. MEMBER COOPERATION expenses of services where a third party is legally You agree to cooperate with the Plan in exercising its responsible for your injury or illness. rights of subrogation and coordination of benefits under this Handbook and Schedule of Benefits. Such If another person or entity is, or may be, liable to pay for cooperation will include, but not be limited to, a) the services related to your illness or injury which have been provision of all information and documents requested by paid for or provided by the Plan, the Plan will be the Plan, b) the execution of any instruments deemed subrogated and succeed to all rights of the Member to necessary by the Plan to protect its rights, c) the prompt recover against such person or entity 100% of the value of assignment to the Plan of any monies received for the services paid for or provided by the Plan. The Plan services provided or paid for by the Plan, and d) the will have the right to seek such recovery from, among prompt notification to the Plan of any instances that may others, the person or entity that caused the injury or give rise to the Plan’s rights. You further agree to do illness, his/her liability carrier or your own auto insurance nothing to prejudice or interfere with the Plan’s rights to carrier, in cases of uninsured or underinsured motorist subrogation or coordination of benefits. coverage. The Plan will also be entitled to recover from a Member 100% of the value of services provided or paid If you fail to perform the obligations stated in this for by the Plan when you have been, or could be, Subsection you shall be rendered liable to the Plan for reimbursed for the cost of care by another party. any expenses the Plan may incur, including reasonable attorneys fees, in enforcing its rights under this Handbook. The Plan’s right to recover 100% of the value of services paid for or provided by the Plan is not subject 7. THE PLAN’S RIGHTS to reduction for a pro rata share of any attorney’s fees Nothing in this Handbook shall be construed to limit the incurred by the Member in seeking recovery from other Plan’s right to utilize any remedy provided by law to persons or organizations. The Plan’s right to 100% enforce its rights to subrogation or coordination of recovery shall apply even if a recovery the Member benefits under this Plan. receives for the illness or injury is designated or
described as being for injuries other than health care expenses. The subrogation and recovery provisions in 8. MEMBERS ELIGIBLE FOR MEDICARE this section apply whether or not the Member recovering When you receive Covered Benefits that are eligible for money is a minor. coverage by Medicare as the primary payer, the claim
35 must be submitted to Medicare before payment by HPHC. The Plan will be liable for any amount eligible for coverage that is not paid by Medicare. You shall take such action as is required to assure payment by Medicare.
If you are eligible for Medicare by reason of End Stage Renal Disease, the Plan will be the primary payor for Covered Benefits during the "coordination period" specified by federal regulations at 42 CFR Section 411.62. Thereafter, Medicare will be the primary payor. When Medicare is primary (or would be primary you were timely enrolled) the Plan will pay for services only to the extent payments would exceed what would be payable by Medicare.
When the Plan provides benefits to a Member for which the Member is eligible under Medicare, the Plan shall be entitled to reimbursement from Medicare for such services. The Member shall take such action as is required to assure this reimbursement.
36 I. ADMINISTRATION OF BENEFIT HANDBOOK If you obtain care from non-HPHC Providers because of 1. COVERAGE WHEN MEMBERSHIP BEGINS such disagreement you do so with the understanding a. General Coverage Rules that HPHC and the Plan Sponsor have no obligations for If your membership begins while you are the cost or outcome of such care. You have the right to hospitalized, coverage begins from the time appeal benefit denials. membership is effective. To obtain coverage, you must call both your PCP and HPHC and allow 3. LIMITATION ON LEGAL ACTIONS HPHC to manage your care. This may include Any legal action against the Plan for failing to provide transfer to an HPHC affiliated facility, if medically Covered Benefits, must be brought within 2 years of the appropriate. Please see your Plan Sponsor for denial of any benefit. This does not apply to actions for information on enrollment and effective date of medical malpractice. coverage. All other terms and conditions of coverage under this Handbook will apply. 4. ACCESS TO INFORMATION
You agree that, except where restricted by law, the Plan b. Newborn Coverage Sponsor may have access to (1) all health records and When a newborn child is a Member, but either the medical data from health care providers providing mother is not a Member or an HPHC Provider did services covered under this Handbook, and (2) not perform the delivery, services are covered only if: information concerning health coverage or claims from • The child is born in the Enrollment Area; and all providers of motor vehicle insurance, medical payment policies, home-owners insurance and all types • HPHC is called within 48 hours of delivery to of health benefit plans. The Plan Sponsor will comply allow an HPHC PCP to manage the baby's care. with all laws restricting access to special types of medical information including, but not limited, to HIV c. Coverage for Members who live outside the test data, and drug and alcohol abuse rehabilitation and Enrollment Area mental health records. Information from a Member's medical record and information about a Member's You must live within the Enrollment Area to be physician patient and hospital patient relationships will eligible for full benefits under this Handbook. If you be kept confidential and will not be disclosed without live outside of the Enrollment Area you are eligible the Member's consent, except for: for coverage only for services required in a Medical Emergency as described in Section I.A.2.e. The a. use in connection with the delivery of care under this benefits available to Members temporarily traveling Handbook or in the administration of this Handbook, outside the Service Area, described in Section including utilization review and quality assurance; I.A.2.f. are not available to Members who live b. use in bona fide medical research in accordance with outside of the Enrollment Area. regulations of the U.S. Department of Health and Human Services and the Food and Drug Please refer to Section C, Student Dependent Administration for the protection of human subjects; Coverage, for coverage available to eligible student Dependents who are enrolled in an accredited c. use in education within HPHC facilities; and institution outside the Enrollment Area. d. where required by law. 2. DISAGREEMENT WITH RECOMMENDED TREATMENT You can request a copy of the Notice of Privacy Practices by calling the HPHC Member Services You enroll in the Plan with the understanding that Department at 1 888 333 4742 or through the Harvard HPHC Providers are responsible for determining treatment appropriate to your care. You may disagree Pilgrim internet site; www.harvardpilgrim.org. with the treatment recommended by HPHC Providers for personal or religious reasons. You may demand 5. NOTICE treatment or seek conditions of treatment that HPHC Any notice to a Member may be sent to the last address Providers judge to be incompatible with proper medical of the Member on file with HPHC. Notice to HPHC care. In the event of such a disagreement, you have the should be sent to 1600 Crown Colony Drive, Quincy, right to refuse the recommendations of the HPHC MA 02169. Providers. In such a case, the Plan shall have no further obligation to provide coverage for the care in question.
37 6. MODIFICATION OF THIS HANDBOOK medical devices and drugs. The team manages the evidence-based evaluation process from initial inquiry This Benefit Handbook, Schedule of Benefits, to final policy recommendation. The team researches Prescription Drug Brochure and applicable Riders, the safety and effectiveness of these new technologies may be amended by HPHC upon thirty (30) days by reviewing published medical reports, literature, written notice to your Plan Sponsor. Amendments do expert consultation with practitioners, and not require the consent of Members. benchmarking. The team presents its recommendations to internal policy committees This Benefit Handbook, including the Schedule of Benefits, responsible for making decisions regarding coverage Prescription Drug Brochure and applicable Riders, is the of the new technology under the Plan. entire contract between you and the Plan Sponsor. It can only be modified in writing by an authorized officer of the 10. MISSED APPOINTMENTS Plan Sponsor. No other action by HPHC or the Plan Sponsor, including the deliberate non-enforcement of any Providers may charge you for appointments you miss if benefit limit shall be deemed to waive or alter any part of you do not cancel before the scheduled appointment. You this Handbook or applicable brochures. can call the provider to find out how much advance notice is needed to cancel an appointment. Missed appointments do not count toward any Plan benefit limits. 7. RELATIONSHIP OF HPHC PROVIDERS AND HPHC The relationship of HPHC to providers, other than HPHC 11. UTILIZATION REVIEW PROCEDURES employees, is governed by separate agreements. They are HPHC uses the following utilization review procedures independent contractors. Such providers may not modify to evaluate the Medical Necessity of selected health care this Handbook or Schedule of Benefits brochure, services, and facilitate clinically appropriate, cost- Prescription Drug Brochure, and any applicable Riders, effective management of Members’ care: or create any obligation for the Plan. HPHC is not liable • Prospective utilization review (pre-certification) of for statements about this Handbook by them, their elective inpatient admissions, Surgical Day Care, and employees or agents. HPHC may change its arrangements outpatient/ambulatory procedures; and with service providers, including the addition or removal of providers, without notice to Members. • Concurrent utilization review of authorized admissions to hospitals and extended care facilities, For any questions regarding this Handbook, Members and skilled home health services. may contact HPHC at 1 888 333 4742. Active case management and discharge planning is
incorporated as part of the concurrent review process. 8. MAJOR DISASTERS Retrospective utilization review may be utilized in HPHC will try to provide or arrange for services under situations where services were provided before HPHC this Plan in the case of major disasters. These might authorization was obtained. include war, riot, epidemic, public emergency, or natural disaster. Other causes include the partial or complete Members who wish to determine the status or outcome destruction of the HPHC facility(ies) or the disability of of utilization review decisions should call Member service providers. If the Plan cannot provide or arrange Services toll-free at 1 888333 4742. such services due to a major disaster, HPHC is not responsible for the costs or outcome of its inability. 12. QUALITY ASSURANCE PROGRAMS
The goal of the HPHC Quality Program is to ensure the 9. EVALUATION OF NEW TECHNOLOGY provision of consistently excellent health care, health The Plan covers medical devices; diagnostic, medical information and service to Plan Members, enabling and surgical procedures and drugs as described in your them to maintain and improve their physical and Benefit Handbook, Schedule of Benefits, and if behavioral health and well-being. Some components of applicable, your Prescription Drug Brochure. This the quality program are directed to all Members and includes new devices, procedures and drugs, as well as others address specific medical issues and providers. those with new applications, as long as they are not Experimental or Unproven. Examples of quality activities in place for all Members include a systematic review and re-review of the HPHC has a dedicated team of corporate staff that credentials of HPHC Providers and contracted facilities, evaluates diagnostics, testing, interventional treatment, as well as the development and dissemination of clinical medical/behavioral therapies, surgical procedures, standards and guidelines in areas such as preventive
38 care, medical records, appointment access, Criteria and guidelines used to review other services are confidentiality, and the appropriate use of drug therapies also developed with input from physicians and other and new medical technologies. clinicians with expertise in the relevant clinical area. The development process includes review of relevant Activities affecting specific medical issues and clinical literature and local standards of practice. providers include disease management programs for those with chronic diseases like asthma, diabetes and HPHC’s Clinician Advisory Committees, comprised of congestive heart failure, and the investigation and actively practicing physicians from throughout the resolution of quality-of-care complaints registered by network, serve as the forum for the discussion of individual Members. specialty-specific clinical programs and initiatives, and provide guidance on strategies and initiatives to evaluate (Please note that some Plan Sponsor’s do not cover all or improve care and service. Clinician Advisory these disease management programs. Please check with Committees work in collaboration with Medical your Plan Sponsor or benefit administrator for a Management leadership to develop and approve description of programs available under your Plan.) utilization review criteria.
13. PROCEDURES USED TO EVALUATE 15. HIPAA CERTIFICATE OF EXPERIMENTAL/INVESTIGATIONAL DRUGS, CREDITABLE COVERAGE DEVICES, OR TREATMENTS In compliance with the Health Insurance Portability and HPHC uses a standardized process to evaluate inquiries Accountability Act of 1996 (HIPAA), Members are and requests for coverage received from internal and/or entitled to a Certificate of Creditable Coverage, which external sources, and/or identified through authorization verifies the most recent period of coverage under the or payment inquiries. The evaluation process includes: Member's Plan Sponsor. • Determination of the FDA approval status of the device/product/drug in question, The Certificate shows how many months of coverage a Member has, up to a maximum of eighteen (18) months. • Review of relevant clinical literature, and It also shows the date coverage ended. It may be used to prove to a new employer the number of days of “credit” • Consultation with actively practicing specialty care a person has from a prior health plan. If there has not providers to determine current standards of practice. been a gap in coverage of sixty-three (63) days or more, preexisting condition exclusion periods in a new Decisions are formulated into recommendations for employer’s health plan must be reduced by the number changes in policy, and forwarded to HPHC management of days of coverage shown on the Certificate. for review and final implementation decisions.
If requested by your Plan Sponsor, HPHC will send this 14. PROCESS TO DEVELOP CLINICAL GUIDELINES certificate to Members upon termination of membership. AND UTILIZATION REVIEW CRITERIA However, Members may call the Member Services HPHC uses clinical review criteria and guidelines to Department at 1 888 333 4742 at any time within two make fair and consistent utilization management (2) years from the date coverage ended to request a free decisions. Criteria and guidelines are developed in copy of their Certificate from HPHC. accordance with standards established by The National Committee for Quality Assurance (NCQA), and reviewed (and revised, if needed) at least biennially, or more often if needed to accommodate current standards of practice.
HPHC uses the nationally recognized InterQual criteria to review elective surgical day procedures, and services provided in acute care hospitals. InterQual criteria are developed through the evaluation of current national standards of medical practice with input from physicians and clinicians in medical academia and all areas of active clinical practice. InterQual criteria are reviewed and revised annually.
39 J. GLOSSARY Copayment Level 2 The Copayment that applies to most outpatient specialty This section lists the words with special meaning in this services. Please refer to your Schedule of Benefits for Benefit Handbook. additional information on Covered Benefits subject to Copayment Level 2. Activities of Daily Living The normal functions of daily life, including walking, Cost Sharing speaking, sleeping, eating, drinking, and using the toilet. The financial responsibility of Members for certain Activities of Daily Living do not include special Covered Benefits. Cost Sharing may include functions needed for occupational purposes or sports. Deductible and Copayments. Please refer to your
Schedule of Benefits for the specific Cost Sharing Anniversary Date amounts that apply to your Plan. The date agreed to by HPHC and your Plan Sponsor upon which the yearly Plan Sponsor administration fees Covered Benefits are adjusted and benefit changes become effective. The health-care services and supplies for which a
Member is covered at the benefit level provided in the Behavioral Health Access Center Benefit Handbook. Covered Benefits under this Plan are The organization, designated by HPHC, responsible for described in Section B. coordinating services for Members in need of mental health, or drug or alcohol rehabilitative care. If you need Custodial Care mental health or drug and alcohol rehabilitation care, call the Behavioral Health Access Center at 1 888 777 4742. Services that are furnished mainly to assist a person in Activities of Daily Living. Examples of such services Behavioral Health Provider include: room and board, routine nursing care, help in personal hygiene, and supervision in daily activities. A provider who is a licensed physician specializing in the
practice of psychiatry, a licensed psychologist, a licensed Deductible independent clinical social worker (LICSW), a licensed mental health counselor, psychiatric social worker, or a A Deductible is a specific dollar amount that you pay licensed nurse mental health clinical specialist. for Covered Benefits received each calendar year before benefits subject to the Deductible are payable by the Benefit Handbook (or Handbook) Plan. Deductible amounts are incurred on the date of This legal document, including the Schedule of service. You may have more than one Deductible under Benefits, and the Prescription Drug Brochure, and any your Plan. Your specific Deductible amounts are listed applicable Riders which sets forth the services covered in your Schedule of Benefits. by the Plan, the exclusions from coverage and the conditions of coverage for Members. Each Member must pay the individual Deductible amount for Covered Benefits each calendar year. No family Copayment Member will pay more than the individual Deductible in a A Copayment is a fixed dollar amount that you must pay calendar year. for certain Covered Benefits. Copayments are due at the time of service or when billed by the Provider. In some instances, a family Deductible applies. The Copayment amounts specific to your Plan are stated in family Deductible is met when any combination of your Schedule of Benefits. Members in a family reach the family Deductible Amount. Once the family Deductible has been met in a Please note: In very limited cases the Copayment may calendar year, the Deductible is met by all Members for exceed the contract rate payable by HPHC for a service. the remainder of the calendar year. If the Copayment is greater than the contract rate, you are responsible for the full Copayment, and the provider Dependent keeps the entire Copayment. A Member of the Subscriber's family who meets the
Copayment Level 1 eligibility requirements for coverage through a The Copayment that applies to certain covered Subscriber as agreed upon by the Plan Sponsor and outpatient services. Please refer to your Schedule of HPHC. This eligibility is documented as part of the Benefits for additional information on the covered contract between the Plan Sponsor and HPHC. Please outpatient services subject to Copayment Level 1. see your Plan Sponsor’s Benefits Office for details on the agreement between HPHC and your Plan Sponsor.
40 Elective Procedures Harvard Pilgrim Health Care, Inc. (HPHC) Any procedure that is scheduled to be performed at least Harvard Pilgrim Health Care, Inc. is a Massachusetts 48 hours in advance. This applies only to Members who corporation that is licensed as a Health Maintenance are able to return to the service area by non-medical Organization (HMO). HPHC provides or arranges for transportation. health care benefits to Members through its network of Primary Care Physicians, specialists and other providers. Enrollment Area Under self insured plans such as this one, HPHC adjudicates and pays claims, and manages benefits on A list of cities and towns where HPHC Providers are behalf of the Plan Sponsor. available to manage Members' care. Members, except for a Dependent child attending an accredited Harvard Vanguard Medical Associates educational institution or a child under a Qualified Medical facilities providing primary care, specialty care Medical Support Order, must maintain residence in the and pharmacy services that are owned and operated by Enrollment Area and live there at least nine months of Harvard Vanguard Medical Associates. the year. HPHC may add cities and towns to Enrollment
Area from time to time. HPHC Provider
Experimental or Unproven Medical professionals who are employed by HPHC, or who are under contract to provide care to Plan Members. A service, procedure, device, or drug will be deemed HPHC providers include, but are not limited to, hospitals, Experimental or Unproven by HPHC on behalf of the skilled nursing facilities and medical professionals Plan under this Benefit Handbook, Prescription Drug including: physicians, psychiatrists, nurse practitioners, Brochure and Schedule of Benefits, including any physician's assistants, psychiatric social workers, certified applicable Riders, for use in the diagnosis or treatment psychiatric nurses, certified nurse midwives, certified of a particular medical condition if any of the following registered nurse anesthetists, licensed mental health is true: professionals including psychologists, clinical social workers, marriage and family therapists, a. The service, procedure, device, or drug is not psychiatric/mental health advanced registered nurse recognized in accordance with generally accepted practitioners, alcohol and drug counselors, clinical mental medical standards as being safe and effective for the health counselors, and pastoral psychotherapists (except use in the evaluation or treatment of the condition in when providing services to a Member of his church or question. In determining whether a service has been congregation in the course of his or her duties as a pastor, recognized as safe or effective in accordance with minister or staff person) and early intervention specialists generally accepted medical standards, primary reliance who are credentialed and certified by the Massachusetts will be placed upon data from published reports in Department of Public Health. HPHC Providers are listed authoritative medical or scientific publications that in the Provider Directory. are subject to peer review by qualified medical or scientific experts prior to publication. In the absence Individual Coverage of any such reports, it will generally be determined Coverage for a Subscriber only (No coverage for that a service, procedure, device or drug is not safe Dependents is provided). and effective for the use in question. Medical Emergency b. In the case of a drug, the drug has not been approved A Medical Emergency means a medical condition, by the United States Food and Drug Administration whether physical or mental, manifesting itself by (FDA) (This does not include off-label uses of FDA symptoms of sufficient severity, including severe pain, approved drugs). that the absence of prompt medical attention could c. For purposes of the treatment of infertility only, the reasonably be expected by a prudent layperson who service, procedure, drug or device has not been possesses an average knowledge of health and medicine, recognized as a "non-experimental infertility to result in placing the health of the Member or another procedure" under the Massachusetts Infertility person in serious jeopardy, serious impairment to body Benefit Regulations at 211 CMR Section 37.00 et. seq. function, or serious dysfunction of any body organ or part. With respect to a pregnant woman who is having contractions, Medical Emergency also means that there Family Coverage is inadequate time to effect a safe transfer to another Coverage for a Member and one or more Dependents. hospital before delivery or that transfer may pose a threat to the health or safety of the woman or the unborn child.
41 Examples of Medical Emergencies are: heart attack or Employee Retirement Income Security Act (ERISA). A suspected heart attack, stroke, shock, major blood loss, child Dependent enrolled under a QMSO is subject to choking, severe head trauma, loss of consciousness, the same terms and limitations stated in this Handbook, seizures and convulsions Schedule of Benefits, Prescription Drug Brochure and
any applicable Riders. A QMSO does not entitle a child Medically Necessary or Medical Necessity Dependent with a permanent residence outside of the Those medical services which are (a) essential for the Enrollment Area to the benefits described in the Student treatment of a Member's medical condition, (b) in Dependent section. accordance with generally accepted medical practice, and (c) provided at an appropriate facility and at the appropriate level of care for the treatment of a Member's Referral(s) medical condition in accordance with generally accepted An instruction from your Primary Care Physician (PCP), standards in the medical community. or his or her designee, to obtain a Covered Benefit from another provider. In most cases, a Referral will be given Member to receive care from an HPHC Provider who is affiliated Any Subscriber or Dependent covered by this Handbook. with the same hospital as your PCP or who has a working relationship with your PCP. Although Referrals may be Out-of-Pocket Maximum given orally or in writing, depending on the An Out-of-Pocket Maximum is a limit on the amount of circumstances, the presence of your PCP's current Cost Sharing that you must pay for Covered Benefits in HPHC provider number on the claim submission will a calendar year. This excludes any amounts that you be evidence from the HPHC Provider, when required by pay for prescription drugs. Out-of-Pocket Maximum the Plan, that a Referral was given for the Covered amounts are listed in your Schedule of Benefits. Your Benefit that is the subject of the claim. Plan may have one or more Out-of-Pocket Maximums. Rehabilitative Services Plan Health care services designed to restore a person’s ability A package of health care benefits known as The to perform Activities of Daily Living after a disabling Harvard Pilgrim HMO that is administered by HPHC on injury or illness. Only the following Rehabilitative behalf of your Plan Sponsor. HPHC or your Plan Services are covered: physical therapy; speech therapy; Sponsor may take any action on behalf of the Plan. For occupational therapy; cardiac rehabilitation; or an coverage under this Plan, Covered Benefits must be organized program of these services. obtained from an HPHC Provider.
Plan Sponsor Schedule of Benefits (or Summary of Benefits) The entity that has contracted with HPHC to provide A document which outlines your Cost Sharing and any health care services and supplies for its employees and benefit limits that apply to your benefit plan. their dependents under the Plan. Plan Sponsor is the issuer and insurer of the health care coverage. Service Area
Primary Care Physician (PCP) The state in which a Member lives. When you are in Service Area you must call your PCP for care unless you A specialist in internal medicine, family practice, have a Medical Emergency or you seek the special general practice, or pediatrics who is employed by services that do not require a Referral. Harvard Pilgrim Health Care or its affiliates, or under contract to provide and authorize Members' care. A Special Level 1 Services Primary Care Physician may designate other HPHC Providers to provide or authorize a Member's care. The covered outpatient services that are subject to Copayment Level 1. Please refer to your Schedule of Provider Directory Benefits for additional information on Special Level 1 Services. A directory that identifies HPHC providers. HPHC may revise the Provider Directory from time to time without Subscriber notice to Members. The person who meets the eligibility requirements Qualified Medical Support Order (QMSO) described in this Benefit Handbook or as agreed to by A court order providing for coverage of a child under a the Plan Sponsor and HPHC. group health plan that meets the requirements of the
42 Surgical Day Care A surgery or procedure in a day surgery department, ambulatory surgery department or outpatient surgery center that requires operating room, anesthesia and recovery room services.
Terminal Illness A Terminal Illness is an illness that is likely to cause death within six months.
Usual, Customary and Reasonable Charge
An amount that is consistent, in the judgment of HPHC – since HPHC is handling claims adjudication - with the normal range of charges by health care providers for the same, or similar, products or services in the geographical area where the product or service was provided to a Member. HPHC utilizes the Health Insurance Association of America (HIAA) fee schedule to determine the appropriate reimbursement for each geographic area. The Member may request information regarding reimbursement for a specific service by contacting the HPHC Member Services Department at 1 888 333 4742. If HPHC cannot reasonably determine the normal range of charges where the product or services were provided, HPHC will utilize the normal range of charges in Boston, Massachusetts. The Usual, Customary and Reasonable Charge is the maximum amount that HPHC will pay for Covered Benefits.
43
II. PATIENT RIGHTS This section describes your rights as a patient.
• In the case of a patient suffering from breast cancer, As a patient you are entitled by law to the following patient rights from your health care provider: to be provided with complete information on alternative treatments that are medically appropriate. • To request and obtain the name and specialty, if any, of the physician or other person responsible for your If you believe that any of your rights have been violated care or the coordination of your care; by a participating provider, you have the right to file a complaint with HPHC or its designee. All complaints • To have all your medical records and must be submitted in writing and addressed to HPHC or communications kept confidential to the extent one of the regulatory offices listed below: provided by law;
• To have all reasonable requests answered promptly Appeals Coordinator and adequately within the capacity of the treating Harvard Pilgrim Health Care provider; Member Services Department 1600 Crown Colony Drive • To obtain a copy of any rules or regulations which Quincy, MA 02169 apply to your conduct as a patient;
• To request and receive any information a provider For Massachusetts Physicians: has available regarding financial assistance and free Board of Registration in Medicine health care; 10 West Street Boston, MA 02111 • To inspect your medical records and to receive a copy (617) 727-3086 of your records for a reasonable fee;
• To refuse to be examined, observed, or treated by For New Hampshire Physicians: students or any other staff without jeopardizing Board of Medicine access to medical care and attention; 2 Industrial Park Drive Suite #8 • To refuse to serve as a research subject and to refuse Concord, NH 03301-8520 any care or examination the primary purpose of which is educational rather than therapeutic; For Vermont Physicians: • To have privacy during medical treatment within the Vermont Board of Medical Practice capacity of the provider's office; 109 State Street Montpelier, VT 05609-1106 • To prompt life-saving treatment in an emergency without discrimination based on economic status or source of payment; and without delaying treatment to For Rhode Island Physicians: discuss source of payment, unless delay will not Rhode Island Department of Public Health cause risk to your health; Licensure and Discipline 3 Capitol Hill, Room 205 • To informed consent to the extent provided by law; Providence, RI 02908 (401) 222-2231 • To request and receive an itemized copy of your bill
or statement of charges, if any, including third party For Maine Physicians: payments towards the bill, regardless of the sources Board of License in Medicine of payment; 137 State House Station • To request and receive an explanation of the Augusta, ME 04333 relationship, if any, of the physician to any health care facility or educational institutions if this relationship relates to your care or treatment; and
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III. MEMBER RIGHTS & RESPONSIBILITIES This section describes your rights and responsibilities as a Member.
• Members have a right to receive information about Harvard Pilgrim, its services, its practitioners and providers, and Members’ rights and responsibilities.
• Members have a right to be treated with respect and recognition of their dignity and right to privacy.
• Members have a right to participate with practitioners in decision-making regarding their health care.
• Members have a right to a candid discussion of appropriate or medically necessary treatment options for their conditions, regardless of cost or benefit coverage.
• Members have a right to voice complaints or appeals about Harvard Pilgrim or the care provided.
• Members have a right to make recommendations regarding the organization’s Members’ right and responsibilities policies.
• Members have a responsibility to provide, to the extent possible, information that Harvard Pilgrim and its practitioners and providers need in order to care for them.
• Members have a responsibility to follow the plans and instructions for care that they have agreed on with their practitioners.
• Members have a responsibility to understand their health problems and participate in developing mutually agreed upon treatment goals to the degree possible.
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IV. CONFIDENTIALITY STATEMENT
HPHC is committed to ensuring and safeguarding the You can request a copy of the Notice of Privacy Practices confidentiality of its Members' information in all settings, by calling the HPHC Member Services Department at including personal and medical information. HPHC staff 1 888 333 4742 or through the Harvard Pilgrim internet access, use and disclose Member information only in site; www.harvardpilgrim.org. connection with providing services and benefits and in accordance with HPHC's confidentiality policies. HPHC permits only designated employees, who are trained in the proper handling of Member information, to have access to and use of your information. HPHC sometimes contracts with other organizations or entities to assist with the delivery of care or administration of benefits. Any such entity must agree to adhere to HPHC's confidentiality and privacy standards.
When you enrolled with HPHC, you consented to certain uses and disclosures of information which are necessary for the provision and administration of services and benefits, such as: coordination of care, including Referrals and authorizations; conducting quality activities, including Member satisfaction surveys and disease management programs; verifying eligibility; fraud detection and certain oversight reviews, such as accreditation and regulatory audits. When HPHC discloses Member information, it does so using the minimum amount of information necessary to accomplish the specific activity.
HPHC discloses its Members' personal information only: (1) in connection with the delivery of care or administration of benefits, such as utilization review, quality assurance activities and third-party reimbursement by other payers, including self-insured employer groups; (2) when you specifically authorize the disclosure; (3) in connection with certain activities allowed under law, such as research and fraud detection; (4) when required by law; or (5) as otherwise allowed under the terms of your Benefit Handbook. Whenever possible, HPHC discloses Member information without Member identifiers and in all cases only discloses the amount of information necessary to achieve the purpose for which it was disclosed. HPHC will not disclose to other third parties, such as employers, Member-specific information (i.e. information from which you are personally identifiable) without your specific consent unless permitted by law or as necessary to accomplish the types of activities described above.
In accordance with applicable law, HPHC and all of its contracted health care providers agree to provide Members access to, and a copy of, their medical records upon a Member's request. In addition, your medical records cannot be released to a third party without your consent or unless permitted by law.
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1600 Crown Colony Drive Quincy, MA 02169
1-888-333-4742 www.harvardpilgrim.org
cc 1512/hmo/si/ma 05/06