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2008Personal Choice 65SMEvidence of CoverageAnd Disclosure InformationEffectiveJanuary 1, 2008throughDecember 31, 2008Bucks, Chester, Delaware, Montgomery,and Philadelphia CountiesH3909
Important Information about Personal Choice 65SMThe information in At A Glance will be useful when you use your benefits throughout the year. Take sometime to review these pages – you may even find out something new about your health care coverage!At A GlancePage Number4 Your ID CardYour Personal Choice 65 ID card contains important benefit and provider information. The illustration onpage 4 of At a Glance will help you understand the details included on your card.5 Your Explanation of BenefitsYour Explanation of Benefits is a statement sent to you after you have medical services. It confirms theservices you received, what the provider charged, and what the plan allowance is.8 Healthy LifestylesSMWhy not take advantage of the many services available to you through our Healthy Lifestyles programs?They can help you make positive changes to your life and your health. Read about our enhancedConnectionsSM Health Management Program, as well as other programs that can help you stop smoking,lose weight, and sleep better.10 Important Personal Choice 65 Telephone NumbersHave a question, a complaint, or a compliment? Call us! Refer to this section when you need to contactMember Services, Member Outreach, or Healthy Lifestyles, or if you need to get more information aboutMedicare Savings Programs.
Other Areas of InterestThe sections below provide a brief overview of a few important topics that your Evidence of Coverageaddresses. This is a quick reference to issues that might concern you, such as how to receive medicalcare when you are traveling and what services are covered under your plan. Please refer to the pagenumbers at the left to find the corresponding section (with expanded details) in your Evidence of Coverage.Evidence of CoveragePage Number19 How does my Personal Choice 65 Network work?Because Personal Choice 65 is a Medicare PPO (preferred provider organization), you can receive yourhealth care from either Personal Choice 65 plan (in-network) providers at low out-of-pocket costs or fromnon-plan (out-of-network) providers at higher out-of-pocket costs.19 What are plan (in-network) providers?“Providers” is the general term we use for doctors, health care professionals, hospitals, and other healthcare facilities that are licensed or certified by Medicare and the state to provide health care services.– Providers are considered plan (in-network) providers when they participate in the Personal Choice 65network. When we say that plan (in-network) providers participate in the Personal Choice 65 network,this means that your plan has made an agreement with those providers to coordinate or providecovered services to members of Personal Choice 65.– Providers are considered non-plan (out-of-network) providers when they are not part of the PersonalChoice 65 network.20 How do I get care when I travel?Personal Choice 65 will cover the cost of urgent or emergency care you receive when you are outside thefive-county service area but still within the United States. You will be covered at the in-network benefitlevel. All you pay is the applicable copayment. (Urgent or emergency care outside of the U.S. is covered atthe out-of-network benefit level.) If you have a medical emergency, go to the nearest emergency room orcall 911 for assistance. An emergency is when you reasonably believe that your health is in seriousdanger – when every second counts. A medical emergency includes severe pain, a bad injury, a seriousillness, or a medical condition that is quickly getting much worse.For Personal Choice 65 members, emergency, urgent, and dialysis services outside the United States arecovered at the non-plan (out-of-network) benefit level. Any non-emergency or non-urgent care you receivefrom a non-plan (out-of-network) provider within the United States will be covered at the out-of-networkbenefit level.If you have coverage through your former employer, Health and Welfare Fund or Association Group, yourpolicy and procedures may differ. In some cases, benefits may vary. Consult your Schedule of Copaymentsand Limitations or a Member Services representative for additional information.28 What are “covered services?”“Covered services” is the general term we use in this booklet to mean all of the health care ser vices andsupplies that Personal Choice 65 covers. Covered services are listed in the Benefits Chart in Section 3.Your plan also provides benefits if you choose to receive health care through a provider who is out-ofnetwork. However, the level of benefits will be reduced, and you will be responsible for a greater share ofout-of-pocket expenses. This includes deductibles and coinsurance. See Section 6 for a complete list ofexclusions and limitations.
51 How do I file an appeal or grievance?You can file an appeal with Personal Choice 65 if you believe that your plan failed to provide or pay forservices that you think should have been covered. For more details, please refer to Section 8 of yourEvidence of Coverage.You can file a grievance with Personal Choice 65 about problems you encountered with one of ourproviders. You may also file a grievance about problems you experience with Personal Choice 65. Weencourage you to let us know if you have concerns; we have Member Services Representatives who areavailable to help you with your questions. Call us at the number listed on the back of your ID card. Or, tofile a grievance, review the procedures in Section 7 of your Evidence of Coverage.71 DefinitionsThis section explains some of the terms used in this booklet and in the Evidence of Coverage. Health carecan be confusing – we hope these definitions help you to understand your coverage with PersonalChoice 65.
Your ID CardYour Personal Choice 65 ID card provides important information about your health care coverage; youshould check your card to make sure all the information is correct. On the reverse side of the card, you’llfind instructions on prior authorization, as well as how to contact Member Services. You should carryyour card with you at all times, and remember to show it at your physician’s office when you have anappointment. Call Personal Choice 65 Member Services if you lose your ID card, or if anything on the cardis incorrect. The following illustration should help you understand the components of your ID card.PERSONAL CHOICE 65 ID CARD SAMPLEYour IDNumberPrimary CareCopaymentCERTAIN SERVICES PROVIDED THROUGH HIGHMARK BLUE SHIELDSAMPLE, JOHN QQCM12345678 00PCP[ 20] SPEC[ 35] ER[ 40] THX[ 35]IP[ 100] OPSURG[ 150] AMBL[ 100]MEDICAREADVANTAGEPPOBS Plan 814 BC Plan 314ISSUER: 80840CMS - H3909-XXXXInpatientCopaymentFutureScripts Secure RXBIN:012353 RXPCN:03820000TMSubmit paper prescription claims to FutureScripts Secure, P.O. Box 37694, Philadelphia, PA rgency RoomCopayment/CoinsuranceAmbulanceCopaymentMember: Present this card to providers when seeking care. You are responsible for priorauthorization of inpatient admissions and selected outpatient services obtained from theBlue Cross/Blue Shield providers not participating in the Personal Choice Network, and forservices obtained from non-PPO providers. Medicare charge limitations may apply.Member Services:Prior Authorization:Mental Health/Substance 8-19111-888-857-4816Submit paper medical claims to: P.O. Box 890016, Camp Hill, PA 17089-0016Provider: Prior authorization is required for non-emergency admissions, elective services andsurgical procedures. For prior authorization 1-800-332-2566. Out-of-network providerssubmit claims to your local Blue Cross /Blue Shield Plan.Please send all written inquires to:Personal Choice 65, 1901 Market Street, 3rd Floor, Philadelphia, PA 19103.Benefits underwritten or administered by QCC Insurance Company, a subsidiary ofIndependence Blue Cross—an independent licensee of the Blue Cross and Blue ShieldAssociation.For benefits information, visit our Web site at www.site65.com
YOUR EXPLANATION OF MEDICAL BENEFITS (EOB)Whenever a claim is filed on your behalf, you will receive an Explanation of Benefits (EOB) statement thatexplains how each claim was processed. Your EOB gives you a personal record of: Provider charges. The plan allowance. The covered benefit amount. Any claims not paid and why they were not paid. Your responsibilities, such as copay, coinsurance, deductible amount applied (if applicable) and anyamount not covered.You should keep your Explanation of Benefits in case you have questions about benefits or services you havereceived. Please review the image below for a better understanding of any Explanation of Benefits you mayreceive in the future.Any questions? Callthe Member ServicesDepartment at 1-888718-3333 (TTY/TDD:1-888-857-4816),seven days a week,from 8 a.m. to 8 p.m.Place of ServiceDescriptionRemark CodeDescriptionsMember’sResponsibilityThere will bea page thatdescribes place ofservice includedwith your EOBstatement.If applicable, therewill be a separatepage describingthe Remark Codeincluded with yourEOB statementdescriptions.Please note that youare responsible topay for any amountsnoted in the copay,coinsurance,deductible and noncovered columns.
QAuestions&n s w e rsQuestion: What happens to my health care coverage if I want to join a Medicare stand-alone prescriptiondrug plan (PDP)?Answer: Medicare regulations require that a Medicare beneficiary may not be enrolled with a MedicareAdvantage Plan (such as Personal Choice 65) and a prescription drug plan at the same time. Therefore,if you choose to enroll in a stand-alone prescription drug plan, Medicare requires us to disenroll you fromPersonal Choice 65. As your health care insurer, we urge you to be aware of this regulation, and to callMember Services at 1-888-718-3333 (TTY/TDD: 1-888-857-4816) seven days a week, from 8 a.m. to8 p.m., if you have questions or concerns.Question: What drugs are covered under Part B (your medical benefit), and what drugs are covered underPart D?Answer: This can be confusing for our Medicare beneficiaries, and we want to keep this distinction assimple and straightforward as possible. The following are covered under Part D: prescription drugs,biological products, most vaccines, insulin, and the medical supplies that are associated with the injectionof insulin (e.g. syringes, needles, alcohol swabs, and gauze). Smoking cessation agents are also coveredunder Part D.Drugs that are covered under Part B include: Hemophilia factor drugs usually not self-administered by the patient and that are injected whilereceiving physician services. Drugs taken using durable medical equipment (e.g., nebulizers). Immunosuppressive drugs (if the member had an organ transplant covered by Medicare). Injectable osteoporosis drugs (if the member is homebound and cannot self-administer). Antigens. Oral cancer drugs (for which there is an IV equivalent). Intravenous immune globulin (IVIG). Certain drugs for dialysis, including heparin, Epogen (epoetin alfa), erythropoietin (EPO), andAranesp (darboetin alfa).Also, please be aware that the Centers for Medicare & Medicaid Services (CMS) require that some drugsbe covered under Part B or Part D, depending on the diagnosis or place of ser vice. For example, thehepatitis B vaccine is covered under Part B if the member is at “high or intermediate risk”; Part D coversall other instances. Please call Member Services at 1-888-718-3333 (TTY/TDD: 1-888-857-4816) sevendays a week, from 8 a.m. to 8 p.m., if you have questions about your drug coverage under MedicarePart D.
Question: How are my bills paid in the Personal Choice 65 plan?Answer: When you get services covered by Personal Choice 65, you will pay your copayment orcoinsurance at the time of services and your provider sends the remainder of the bill to Personal Choice65. After Personal Choice 65 processes the bill, you will get an EOB (Explanation of Benefits) in the mail.Please check the notice to be sure Personal Choice 65 was not billed for services or supplies that you didnot get.Question: What should I do when I have paid a medical bill from someone other than a Personal Choice 65provider?Answer: Please forward any medical bills that you have already paid (other than your monthly pre miumfrom Personal Choice 65) to:Personal Choice 65 ClaimsP.O. Box 890016Camp Hill, PA 17089-0016
Radiology Quality Initiative ProgramEffective January 1, 2006, Independence Blue Cross implemented a Radiology Quality Initiative foroutpatient diagnostic imaging services. Our decision to introduce this initiative was consistent with arecommendation from the American College of Radiology. This organization concluded that there is animmediate need for “nationally accepted, scientifically based appropriateness criteria” to guide radiolo gistsand referring physicians in “making appropriate imaging decisions.”Over the last few years, health plans throughout the U.S. and many in the Philadelphia area haveintroduced prior authorization programs for diagnostic imaging as a way to promote appropriateutilization based on evidence-based criteria. Like other programs across the country, our Radiology QualityInitiative program requires prior authorization (approval in advance) for certain diagnosticimaging services: Computed Tomography (e.g. CT/CTA). Magnetic Resonance Imaging (e.g. MRI/MRA). Nuclear Cardiology Studies. Positron Emission Tomography (e.g. PET).If you need one of these outpatient diagnostic imaging services in-network, your Personal Choice 65plan (in-network) physician will handle the prior authorization process. This program does not apply toimaging services provided during emergency room visits or inpatient admissions. Personal Choice 65has communicated the specifics of this program to our network physicians who are required to contactAmerican Imaging Management, Inc. (AIM) for requests from network physicians for prior authorization(approval in advance) of scheduled services. If you need one of these services out-of-network, werecommend that you obtain prior authorization, or you may be responsible for charges.Please note: The guidelines used in the Radiology Quality Initiative program to assess the appropriate nessof diagnostic imaging services are based on recommendations from experts in radiology and medi cine.The program is aimed at curbing the use of discretionary scans for diagnostic screening. It is not intendedto interfere with scans that are essential in the treatment of critical or life-threatening illnesses.Healthy LifestylesSMLive Healthy!Since you’re a member of Personal Choice 65, why not take advantage of the services we offer throughour Healthy Lifestyles programs? These programs can help you make positive changes to your life.SilverSneakers *Independence Blue Cross is introducing a new fitness program to our Personal Choice 65 members. Thisnew program will give Medicare members access to the SilverSneakers Fitness Program, which is thenation’s leading fitness program designed exclusively for Medicare eligibles. Membership to SilverSneakersis free and is provided to members at no additional cost beyond their monthly premium. Members applyto receive a basic fitness membership with access to amenities and fitness classes including the signatureSilverSneakers classes designed to improve muscular strength, endurance, mobility, flexibility, range ofmotion, balance, agility, and coordination.To locate a participating SilverSneakers gym, please visit them online at www.silversneakers.com or callour Member Services department at 1-888-718-3333 (TTY/TDD: 1-888-857-4816), seven days a weekfrom 8 a.m. to 8 p.m.
Smoking Cessation*If you smoke, quitting is one of the best things you can do for your health. Better yet, when you kick thehabit, we’ll help you foot the bill up to 200. Members are encouraged to complete the smoking cessationprogram, but not required.Weight Management*You will get up to 200 for the cost of Weight Watchers or any network hospital weightmanagement program.1Mammography and Pap Test ScreeningWhen it comes to breast cancer and cervical cancer, early detection is key. That’s why we’ve sent nearlyfour million educational reminders to our female members that emphasize not only early detection, butalso prevention and treatment. You can also request personal reminders for these tests on our website.Stay Healthy!Care Management and CoordinationIt can be difficult and even intimidating, to find your way around the health care system. You might bescheduling elective surgery, such as a hip or knee replacement, or trying to manage complex home healthcare services. If that’s the case, call on our staff of registered nurses to work with your health care providerand help coordinate your care.Individual Support from the ConnectionsSM Health Management ProgramIf you have a condition such as diabetes, lung or breathing problems, heart conditions, or other recur ringhealth concerns, our Connections program can help you lead a healthier life. Connections can also helpif you’re facing a significant medical decision such as treatment options for back or joint pain, breast orprostate cancer, or surgery, including weight-loss surgery.Connections provides: Access to a Health Coach to talk to anytime, day or night, 24 hours a day, seven days a week. Personalized check-in calls from your Health Coach about your chronic condition or other healthconcerns. Educational materials mailed to your home. Health reminders about important tests and information to help you take better control of your health. Access to an encyclopedia of health information—our Healthwise Knowledgebase gives youwell-organized health information on the Web, on audiotape, or through the mail in collaboration withyour Health Coach.We offer Connections for free. The program can help you work with your health care provider and get thesupport you need to manage your health. Call a Connections Health Coach anytime, day or night, 24 hoursa day, seven days a week, at 1-800-ASK-BLUE and see how we can help you.*These programs require enrollment.1Weight Watchers is a registered trademark of Weight Watchers International, Inc. Silver Sneakers is a registered mark of Healthways Health Support, Inc.
IMPORTANT PERSONAL CHOICE 65 TELEPHONE NUMBERSPersonal Choice 65 Member Services 1-888-718-3333 (TTY/TDD: 1-888-857-4816)If you have questions about your coverage or premium bill, would like to make a change to yourben efits, or need to update your address, call Member Services seven days a week, from 8 a.m.to 8 p.m.Healthy LifestylesSM 1-800-ASK-BLUE (toll free: 1-800-275-2583; TTY/TDD: 1-888-857-4816)Take advantage of Healthy Lifestyle reimbursement programs like Weight Watchers , or call HealthyLifestyles for help with smoking cessation. Enroll in the Connections Health Management programif you have a condition such as diabetes, lung or breathing problems, heart conditions, or otherrecurring health concerns. You can reach Healthy Lifestyles Monday–Friday at 1-800-ASK- BLUE from8 a.m. to 6 p.m. Talk to a Connections Health Coach anytime, day or night, 24 hours a day, sevendays a week.Medicare Savings Programs 1-877-393-6733There are state and federally funded assistance programs for which certain members may qualify. Tosee if you are eligible for these programs, call Managed Care Programs at the number listed aboveMonday – Friday, from 8:30 a.m. to 5 p.m.10
EVIDENCE OF COVERAGE:Your Medicare Health Benefits and Services as a Member of Personal Choice 65January 1 – December 31, 2008This booklet gives the details about your Medicare health coverage and explains how to get the health careyou need. This booklet is an important legal document. Please keep it in a safe place.Personal Choice 65 Member Services:For help or information, please call Member Services or go to our plan website at www.site65.com.1-888-718-3333 (Calls to these numbers are free)TTY/TDD users call: 1-888-857-4816Hours of Operation: Seven day a week, 8 a.m. to 8 p.m.11
TABLE OF CONTENTSSection 1Introduction. 14Section 2How You Get Care. 19Section 3Covered Benefits. 28Section 4What You Must Pay. 42Section 5Your Rights and Responsibilities as a Member of Our Plan. 44Section 6General Exclusions. 49Section 7How to File a Grievance. 51Section 8What to Do if You have Complaints About Your Part C Medical Services and Benefits. 53Section 9Ending Your Membership. 66Section 10 Legal Notices. 68Section 11 Provider Reimbursement Information. 69Section 12 Definition of Some Words Used in This Book. 7112
Welcome to Personal Choice 65!We are pleased that you’ve chosen our plan.Personal Choice 65 is a Preferred Provider Organization (PPO) for people with Medicare.Thank you for your membership in our plan; you are getting your health care coverage through our plan.This plan is not a “Medigap” Medicare Supplement Insurance policy.Throughout the remainder of this Evidence of Coverage, we refer to Personal Choice 65 as “plan” or“our plan.”This Evidence of Coverage explains how to get your health care through our plan.This Evidence of Coverage, together with your enrollment form, riders (including optional supplementalbenefit brochures), formulary, and amendments that we may send to you, is our contract with you.It explains your rights, benefits, and responsibilities as a member of our plan. The information in thisEvidence of Coverage is in effect for the time period from January 1, 2008 to December 31, 2008.You are still covered by Medicare, but you are getting your Medicare services as a member of our plan.This Evidence of Coverage will explain to you: What is covered by our plan and what isn’t covered. How to get the care you need including some rules you must follow. What you will have to pay for your health care. What to do if you are unhappy about something related to getting your covered services. How to leave our plan.If you need this Evidence of Coverage in a different format (such as in Spanish, Braille, or audio tapes),please call us so we can send you a copy.13
Section 1 – IntroductionContact InformationTelephone numbers and other information for referenceHow to contact our plan Member ServicesIf you have any questions or concerns, please call or write to our plan Member Services. We will be happyto help you.CALL1-888-718-3333. This number is also on the cover of this booklet for easy reference.Hours of operation are: seven days a week, 8 a.m. to 8 p.m. Calls to this number are free.TTY/TDD1-888-857-4816. This number requires special telephone equipment. Calls to this numberare free.FAX1-888-289-3008WRITEPO Box 7759Philadelphia, PA19101-7759VISIT1901 Market Street1st FloorPhiladelphia, PA 19103WEBSITEwww.site65.comContact Information for Grievances, Organization Determinations,and AppealsCALL1-800-645-3965. Our business hours are seven days a week, 8 a.m. to 8 p.m. Calls to thisnumber are free.TTY/TDD1-888-857-4816. This number requires special telephone equipment. Calls to this numberare free.FAX1-888-289-302914
WRITEPO Box 13652Philadelphia, PA19101-3652SHIP – a state program that gives free local health insurancecounseling to people with Medicare“SHIP”- State Health Insurance Assistance Program, is a state program that gets money from the federalgovernment to give free local health insurance counseling to people with Medicare. Your SHIP can explainyour Medicare rights and protections, help you make complaints about care or treatment, and helpstraighten out problems with Medicare bills. Your SHIP has information about Medicare Advantage Plans,Medicare Prescription Drug Plans, Medicare Cost Plans, and about Medigap (Medicare supplementinsurance) policies. This includes information about whether to drop your Medigap policy while enrolledin a Medicare Advantage Plan. This also includes special Medigap rights for people who have tried aMedicare Advantage Plan for the first time.You may contact the SHIP in your state at:AppriseState Health Insurance Assistance ProgramPA Department of Aging555 Walnut Street, 5th FloorHarrisburg, PA 17101Phone: 1-800-783-7067You may also find the website for your local SHIP at www.medicare.gov on the Web. Under “Search Tools,”select “Helpful Phone Numbers and Websites.”Quality Improvement Organization – a group of doctors and healthprofessionals in your state that reviews medical care and handlescertain types of complaints from patients with Medicare“QIO” stands for Quality Improvement Organization. The QIO is paid by the federal government to checkon and help improve the care given to Medicare patients. There is a QIO in each state. QIOs have differentnames, depending on which state they are in. The doctors and other health experts in the QIO reviewcertain types of complaints made by Medicare patients. These include complaints about quality of careand appeals filed by Medicare patients who think the coverage for their hospital, skilled nursing facility,home health agency, or comprehensive outpatient rehabilitation stay is ending too soon. See Section 8 formore information about complaints, appeals, and grievances.You may contact the QIO in your state at:Quality Insights of Pennsylvania2601 Market Place StreetSuite 320Harrisburg, PA 17110Phone: 1-800-322-191415
How to contact the Medicare programMedicare is health insurance for people age 65 or older, under age 65 with certain disabilities, and anyage with permanent kidney failure (called End-Stage Renal Disease or ESRD). The Centers for Medicare& Medicaid Services (CMS) is the Federal agency in charge of the Medicare Program. CMS contractswith and regulates Medicare plans (including our plan). Here are ways to get help and information aboutMedicare from CMS: Call 1-800-MEDICARE (1-800-633-4227) to ask questions or get free information booklets fromMedicare. TTY users should call 1-877-486-2048. Customer service representatives are available 24hours a day, including weekends. Visit www.medicare.gov. This is the official government website for Medicare information. This websitegives you up-to-date information about Medicare and nursing homes and other current Medicareissues. It includes booklets you can print directly from your computer. It has tools to help you compareMedicare Advantage Plans and Medicare Prescription Drug Plans in your area. You can also searchunder “Search Tools” for Medicare contacts in your state. Select “Helpful Phone Numbers andWebsites.” If you don’t have a computer, your local library or senior center may be able to help youvisit this website using its computer.Other organizations (including Social Security and Medicaid, a stategovernment agency that handles health care programs for peoplewith limited resources)Medicaid helps with medical costs for some people with limited incomes and resources. Some peoplewith Medicare are also eligible for Medicaid. Medicaid has programs that can help pay for your Medicarepremiums and other costs, if you qualify. To find out more about Medicaid and its programs, contact:Department of Public WelfareOffice of Medical AssistanceP.O. Box 2675Harrisburg, PA 17105-2675Phone: 1-800-692-7462Social SecuritySocial Security programs include retirement benefits, disability benefits, family benefits, survivors’ benefits,and benefits for the aged and blind. You may call Social Security at 1-800-772-1213. TTY users shouldcall 1-800-325-0778. You may also visit www.ssa.gov on the Web.Railroad Retirement BoardIf you get benefits from the Railroad Retirement Board, you may call your local Railroad Retirement Boardoffice or 1-800-808-0772. TTY users should call 312-751-4701. You may also visit www.rrb.gov onthe Web.Employer (or “Group”) CoverageIf you or your spouse get your benefits from your current or former employer or union, or from yourspouse’s current or former employer or union, call your employer’s or union’s benefits administrator orMember Services if you have any questions about your employer/union benefits, plan premiums, or theopen enrollment season. Important Note: You (or your spouse’s) employer/union benefits may change,16
or you or your spouse may lose the benefits, if you or your spouse enrolls in Medicare Part D. Call youremployer’s or union’s benefits administrator or Member Services to find out whether the benefits willchange or be terminated if you or your spouse enrolls in Part D.Report Fraud, Waste and AbuseHealth care fraud is a violation of state and/or federal law. The U.S. Chamber of Commerce estimates thatthree percent to ten percent of health care cost is attributed to fraud annually. The Corporate and FinancialInvestigations Department helps to protect members and providers from fraudulent and abusive practices.If you know of or susp
Because Personal Choice 65 is a Medicare PPO (preferred provider organization), you can receive your health care from either Personal Choice 65 plan (in-network) providers at low out-of-pocket costs or from non-plan
