member guidebook

Transcription

member guidebook

HDHP
■
2009
MEMBER GUIDEBOOK
CONNECTICARE® SOLO HIGH-DEDUCTIBLE HEALTH PLANS
FOR USE WITH HEALTH SAVINGS ACCOUNTS (HSAs)
HSAs are complex arrangements subject to various tax rules and regulations, which are not
explained in this brochure. Please read the “IMPORTANT NOTICE” at the end of this brochure.
MEMBER GUIDEBOOK FOR CONNECTICARE SOLO
HIGH-DEDUCTIBLE HEALTH PLANS
®
TABLE OF CONTENTS
Why ConnectiCare?
Top Reasons To Join ConnectiCare 2-3
Advantages of ConnectiCare SOLO High-Deductible Health Plans 4
HSA Information
Introducing Health Savings Accounts 5
First HSA—Our Preferred Administrator 6
HSA Questions and Answers 7
Case Studies in Savings 8-9
Applying for Coverage
Eligibility Requirements 10
Your Health History 11
Declinable Medications and Conditions 11-12
Steps To Apply for High-Deductible Health Plan 13-14
Rescissions 15
Renewability of Coverage 15
Steps To Apply for HSA 16
ConnectiCare SOLO HDHP Plan Designs
HMO HDHP Outlines of Coverage 18-26
Plan Deductible Information 27
Exclusions and Limitations 28-29
Important Information 30
POS HDHP Outlines of Coverage 31-39
Plan Deductible Information 40
Exclusions and Limitations 41-42
Important Information 43
Plan Comparisons 44-47
ConnectiCare’s Value-Added Resources
ConnectiCare Touchpoints 50
Healthy Alternatives 51-55
Health Management Programs 56
Web Site Resources 56-59
Health Plan Information
Vision Care Benefit 59
Pharmacy Benefits and Management 60
Coverage for Urgent and Emergency Care 61
No Referrals Needed 61
Participating Provider Availability 61
Pre-Authorization Required for Some Services 61
What Is Utilization Management? 62
Members’ Rights and Responsibilities 63
How To Contact Us
64
WHY CONNECTICARE?
TOP REASONS TO JOIN CONNECTICARE
Thank you for your interest in ConnectiCare®
SOLO individual health plans. We’re pleased to
offer our individual customers the same awardwinning personal service that we offer to our
employer group customers.
Plan Options as Individual as You
We believe that you should have a full range
of options to choose from. That’s why we offer
different ConnectiCare SOLO plan designs, each
featuring a broad range of benefits and convenient
access to more than 20,000 participating
providers, and every hospital in Connecticut.
Working with your agent or broker, you simply
pick the option that best fits your personal needs.
ConnectiCare SOLO plan options include:
HMO Plan Options:
ConnectiCare SOLO has two High-Deductible
Health Plan options that are compatible with
Health Savings Accounts (HSAs):
• HMO Open Access — High-Deductible Health
Plan: Allows you to see any participating specialist
without first obtaining a referral from your
Primary Care Physician (PCP). You must meet a
calendar-year individual deductible and family
deductible before the plan begins to provide benefits.
(Note: The calendar-year deductibles do not apply to
some preventive care. The deductible can be reached by
any combination of covered health services or covered
prescription drug services. The individual deductible
only applies if you are the sole policyholder on the contract.
If you have family coverage, then covered health services
and covered prescription drugs will be applied to the family plan deductible until the total amount is met without
regard to which family member uses the benefits.)
• Point-of-Service Open Access —
High-Deductible Health Plan: This product
provides you with the greatest freedom of choice
in-network and out-of-network. You can use our
participating providers to receive a generally
higher level of benefits, or you may choose to go
out-of-network to visit a doctor of your choice
and receive a generally lower level of benefits.
This plan has an up-front, in-network plan
deductible for individual and family, and a
separate out-of-network plan deductible for
individual and family. You must meet these
calendar-year deductibles before the plan begins
to provide benefits.
Note: The calendar-year deductibles do not apply to
some preventive care. The calendar-year deductibles
can be reached by any combination of covered health
services or covered prescription drug services. The
individual calendar-year deductible only applies if
you are the sole policyholder on the contract. If you
have family coverage, then covered health services
and
covered prescription drugs will be applied to the family
calendar-year deductible until the total amount is met
without regard to which family member uses the benefits.
Please refer to your Outline of Coverage for details.
Nationally Recognized Quality
ConnectiCare has received “Excellent” Accreditation
from NCQA with Distinction in Member
Connections, and Care Management
and
Health Improvement. NCQA
(National Committee for Quality
Assurance) is the industry standard
for quality. For more information,
see www.ncqa.org.
(This status does not include data for
the New York service area or the ConnectiCare
FlexPOS Plans since they were not included in
2
the assessments.)
WHY CONNECTICARE?
Superior Service
ConnectiCare, Inc. received a higher member
satisfaction score for customer service than any of
its competitors, according to the 2007 Consumer
Assessment of Health Plans Survey (CAHPS).
(Competitors include: Aetna, Anthem Blue Cross
and Blue Shield, CIGNA, Health Net, Oxford
Health Plans and United HealthCare.)
Health-Related Discounts
As a ConnectiCare member you’ll enjoy discounts
on a host of products and services that can help
you stay healthy, including LASIK eye surgery,
fitness center memberships, massage therapy,
weight management programs, and much more.
(See the following section on Healthy Alternatives.)
Credit Card Acceptance
With ConnectiCare SOLO you’re able to make
your monthly premium payments online for
added convenience using VISA® or MasterCard®.
See page 14 for information on how to register
and set up your account for credit card payment..
3
WHY CONNECTICARE?
ADVANTAGES OF
CONNECTICARE SOLO
HIGH-DEDUCTIBLE
HEALTH PLANS
ConnectiCare SOLO High-Deductible Health
Plans (HDHPs) are compatible with Health
Savings Accounts (HSAs). Combining your health
plan with an HSA may help reduce your overall
health plan costs. Funds in your HSA can be used
to pay for qualified health care expenses, including
those applied to your health plan deductible. HSA
funds also may be used to pay for other things,
such as coinsurance or qualified medical expenses
not covered by the health plan.
PLEASE SEE “IMPORTANT NOTICE” ON THE INSIDE
BACK COVER.
4
HSA INFORMATION
INTRODUCING
HEALTH SAVINGS
ACCOUNTS
Health Savings Accounts (HSAs) work in concert
with a qualified High-Deductible Health Plans
(HDHPs), and have a number of unique features:
• You fund the account—and you own it. You
may place pre-tax money into your account to
meet your deductible. It is a personal savings
account that earns tax-free interest. If you ever
switch health plans or HSA administrators, you
take the HSA account with you.
• Contributions to the account may now exceed
the plan deductible. The maximum annual
amount you are allowed to contribute in 2008
is $2,900 for self-only coverage and $5,800 for
family coverage (subject to maximum amounts
set by the IRS). The maximum contribution
amount for 2009 is $3,000 for self-only coverage
and $5,950 for family coverage.
• Be aware of premium due date and grace
period.
Once you are approved, your premium due date
will be the first of the month with a grace period
of one calendar month (i.e. if the premium due
date is January 1st, the last day to make the
premium payment is January 31st). Otherwise,
your policy will be terminated and all
premiums will be owed up to, and including,
the termination date.
• Terminating a policy.
Requests to terminate a policy must be made in
writing to ConnectiCare 30 days in advance of
the termination date so ConnectiCare can cease
invoicing, Electronic Funds Transfer (EFT), and
related functions.
• There are tax benefits. When you deposit
money into the account, it’s on a pre-tax basis.
Please consult with your tax advisor on the tax
benefits of an HSA account.
• You can pay for a variety of medical expenses.
You can use HSA funds to pay for qualified
medical expenses, including those applied to
the health plan deductible, as well as over-thecounter drugs, eyeglasses, prescriptions and
other medical supplies.
• You can carry over your funds.
Unused dollars can be saved and carried over
year after year. In doing so, these dollars are
invested and earn tax-deferred interest.
5
HSA INFORMATION
FIRST HSA–
OUR PREFERRED
ADMINISTRATOR
ConnectiCare has selected one of the nation’s leading administrators of HSAs as a preferred administrator that can manage, administer and service
your HSA. First HSA has worked with members
of Congress in the development of today’s HSA
rules. (Please note that you are free to choose your
own HSA administrator if you prefer.)
First HSA provides a full range of administrative
and technical services for its HSA customers,
including:
• Account setup and administration
• Flexible and convenient contribution options
• Free monthly administrative fees for members of
a ConnectiCare SOLO High-Deductible Health
Plan with a First HSA account
• An option for a VISA debit card
• Automated telephone banking 24 hours a day,
seven days a week
• Monthly account statements that detail
contributions, withdrawals, interest earned
and ending balance
• Year-end tax statements
• Internet access to account information at
www.1hsa.com
• Periodic newsletter
• Integrated investment options
• Competitive interest rates
For more information on First HSA, call toll-free
1-888-769-8696 or go to www.1hsa.com.
HSA
First HSA
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TM
HSA INFORMATION
HSA QUESTIONS
AND ANSWERS
5.How much can be contributed to
the HSA?
The annual maximum contribution amount
is subject to limits set by the IRS. The 2008
1.What is an HSA?
contribution levels are set at a maximum of
A Health Savings Account (HSA) is a tax-favored
$2,900 for an individual and $5,800 under
savings account established to pay for qualified
qualifying circumstances for a family covered by
medical expenses. HSA account holders enroll
a HDHP. The maximum contribution amounts
in a qualifying High-Deductible Health Plan
for 2009 are $3,000 for self-only coverage and
(HDHP) and contribute pre-tax funds to the
$5,950 for family coverage.
HSA that can be used to cover qualified medical
expenses, including those subject to the health
6.What can HSA funds be used for?
plan deductible. Unused dollars earn tax-deferred
HSAs were established to provide funding for
interest and can be rolled over from year to year.
qualified medical expenses. Funds withdrawn
for any purpose other than distributions for
2.Who is eligible to open an HSA?
eligible expenses are taxable and subject to a
Once you are accepted into a qualified HDHP,
10% penalty by the IRS. To pay for medical
you can open an HSA, subject to IRS rules
expenses with an HSA, the account must be
and restrictions.
opened before the date the claim is incurred.
It’s recommended that you open the account
3.Who is ineligible to open an HSA?
even if you don’t intend to fund it right away.
Individuals covered by another health plan,
You’ll have until April 15th of the following
such as someone covered by a spouse’s plan for
year to fund up to the maximum amount set
primary coverage, and those individuals covered
by the IRS.
by Medicare and Medicaid. Other IRS rules
and restrictions may apply.
4.Who contributes money to an HSA?
Important: do not open the HSA until
your application for individual coverage under
the health plan has been approved.
Typically, the individual contributes funds to
the HSA. The individual can make deposits at
anytime until April 15th of the following year,
for prior-year contributions. Deposits can be
made by check, electronic funds transfer (EFT),
direct deposit or with Automatic Clearing House
(ACH) transfer. (ACH transfer is the U.S.
Federal Reserve system for electronic processing
of checks and inter-bank transactions.)
For HSA administration questions, please
contact First HSA
at 1-888-769-8696.
7
HSA INFORMATION
CASE STUDIES IN SAVINGS
The following illustrations show how an individual and a family, rolling over unused funds, might use a typical
HSA over a three-year period. All cost information below is for example purposes only and does not necessarily
reflect actual charges, your plan rules or HSA account rules. Administrative fees may be charged on account
balances. The illustrations are based on hypothetical health plans.
Case Study 1
Mary has a $1,500 High-Deductible Health Plan and an HSA that she contributes $1,500 to annually.
YEAR 1
$1,500
-$300
HSA contribution
Medical expenses applied to the
deductible and paid by the HSA
HSA balance to be rolled over
into year 2
In year 1, Mary sees her physician in his office
several times for a minor medical problem and
has $300 applied to the deductible. She uses
$300 from her HSA, leaving a balance of
$1,200 in unused HSA funds that will be rolled
over into year 2.
HSA rollover from year 1
Contribution for year 2
HSA balance for year 2
Prescription coinsurance
amount paid by HSA
HSA balance
Medical expenses not covered
by plan but paid by HSA
into year 3
In year 2, the $1,200 rollover is combined with
the year 2 total annual contribution of $1,500
for a balance of $2,700. During the year Mary
has an inpatient hospital stay for an elective
surgical procedure, for which $1,500 is applied
to her deductible. In addition, she has $225
in prescription coinsurance costs for drugs she
gets from her local pharmacy following her
hospital stay. Mary also incurs $700 in medical
costs for over-the-counter medications and
contact lenses, which are not covered by her
health plan but are considered qualified HSA
expenses. The $1,500 applied to her deductible
for her hospital stay, $225 in prescription
coinsurance costs, and $700 in other
non-covered but HSA-qualified expenses
are reimbursed from her HSA, leaving a balance
of $275 to be rolled over to year 3.
$275
$1,500
$1,775
In year 3, the year 2 rollover of $275 is added
to the year 3 total annual contribution of
$1,500 for a starting balance of $1,775.
$1,200
YEAR 2
$1,200
+$1,500
$2,700
-$1,500
-$225
$975
-$700
$275
YEAR 3
8
HSA INFORMATION
Case Study 2
The next illustration is a family plan. Bob, his wife Jane, and their two children have a $5,000
High-Deductible Health Plan and contribute $4,000 annually to their HSA.
YEAR 1
$4,000
-$1,000
$3,000
YEAR 2 $3,000
+$4,000
$7,000
-$5,000
-$225
$1,775
-$1,000
$775
YEAR 3
$775
$4,000
$4,775
HSA contribution
into year 2
In year 1, the children see their pediatricians
for annual exams and the health plan covers
the expense at 100% with no deductible. In
addition, the family has $1,000 in expenses
for an emergency room visit and other physician visits applied to the deductible. The HSA
is used to reimburse Bob and Jane for the
$1,000 in emergency room expenses, but not
the other physician visits applied to the
deductible, leaving an HSA balance of $3,000
to be rolled over into year 2.
Prescription coinsurance
amount paid by HSA
HSA balance
Medical expenses not covered
by plan but paid by HSA
into year 3
In year 2, the $3,000 in rollover funds is
combined with the year 2 total annual
contribution of $4,000 for an HSA balance of
$7,000. Jane is hospitalized for an elective
surgical procedure and the family incurs
$5,000 in medical expenses applied to the
deductible. In addition, the family has
prescriptions that result in coinsurance costs
of $225. The family also incurs $1,000 in
other medical expenses not covered by the
health plan but considered qualified HSA
expenses, including eyeglasses, over-thecounter medications, and acupuncture treatment. Bob and Jane use the HSA account for
reimbursement of the $5,000 deductible,
$225 in prescription coinsurance, and $1,000
in other medical expenses from the HSA,
leaving $775 to be rolled over into year 3.
In year 3, the year 2 rollover of $775 is added
to the year 3 total annual contribution of
$4,000 for a total beginning HSA balance of
$4,775.
9
APPLYING FOR COVERAGE
ELIGIBILITY
REQUIREMENTS
ConnectiCare SOLO
Individuals may apply for ConnectiCare SOLO if
they are:
• Legal residents of Connecticut
• Under age 65
• Not enrolled in Medicare
• Single, married, or part of a civil
union/domestic partnership
Families are also eligible to apply for coverage for
unmarried dependent children under age 26.
10
DECLINABLE MEDICATIONS AND CONDITIONS
YOUR HEALTH HISTORY
It is important to know that not everyone will
qualify for an individual policy with ConnectiCare.
ConnectiCare will consider the health history of
each individual who applies. This process is
known as medical underwriting. If the applicant
(or any dependents) has used/is currently using
any of the following medications or has had/
currently has a condition mentioned on the
Declinable Conditions list below, the application
will be automatically declined.
Please be aware that while the following lists identify
medications and conditions that are automatically
declinable, there are other reasons why an application
may be declined due to underwriting review. The
following lists are not all-inclusive, and are subject
to change:
DECLINABLE MEDICATIONS*
ABATACEPT
CYCLOSPORINE
MEPRON
REMICADE
ABILIFY
DIPYRIDAMOLE
METHADONE
REMINYL
ACCUTANE
ENBREL
METHOTREXATE
REMODULIN
AGGRENOX
EPOGEN
MIRAPEX
RENAGEL
AGRYLIN
ETHAMBUTOL
MYFORTIC
REQUIP
ALDURAZYME
EXELON
NAMENDA
RIFAMPIN
AMEVIVE
FABRAZYME
NEORAL
RILUTEK
APOKYN
FEMARA
NEULASTA
RISPERDAL
ARANESP
FLOLAN
NEUPOGEN
SANDOSTATIN
ARAVA
FRAGMIN
NITROGLYCERIN
SELEGILINE HCL
ARICEPT
GEODON
ORGARAN
SENSIPAR
ARIXTRA
GLEEVEC
OTHOCLONE OKT3
SEROQUEL
AROMASIN
GROWTH HORMONE
PARLODEL
SINEMET CR
AVONEX
HEPARIN SODIUM
PEGASYS
STALEVO
AZATHIOPRINE
HUMIRA
PEG-INTRON
SUBOXONE
BETASERON
IMMUNE GLOBULIN (IVIG)
PERGOLIDE MESYLATE
SYNVISC/HYLAN G F20
BROMOCRIPTINE MESYLATE
INFERGEN
PLAVIX
TEMODAR
BUPHENYL
INSULIN
PLETAL
THALOMID
CARBIDOPA/LEVODOPA
INTRON A
PROCRIT
TICLOPIDINE HCL
CASODEX
IRESSA
PROGRAF
TRACLEER
CELLCEPT
ISONIAZID
PULMOZYME
XELODA
CLOZAPINE
LEUKINE
PURINETHOL
XOLAIR
COGNEX
LITHIUM
RAPAMUNE
XYREM
COMTAN
LOVENOX
RAPTIVA
ZYPREXA
COPAXONE
LUPRON (MALES ONLY)
REBIF
*Prior use of any of the drugs listed above will be subject to medical underwriting.
11
DEDUCTABLE CONDITIONS
DECLINABLE
CONDITIONS
AIDS/HIV
Amyotrophic Lateral Sclerosis
(ALS or Lou Gehrig’s Disease)
Alzheimer’s Disease
Angina
Angioplasty
Ankylosing Spondylitis
Any Artery or Vein Bypass –
including Heart
Bipolar disorder
(manic depression)
Cancer (current)
Carcinoid Syndrome
Chronic Lung Disease,
including Emphysema,
Chronic Bronchitis & COPD
Cirrhosis of the Liver
Congestive Heart Failure
Coronary Heart Disease
Crohn’s Disease
Cystic Fibrosis
Diabetes
Gastric Bypass or any
Intestinal Bypass or bariatric
(obesity) surgery
Gaucher’s Disease or other
lipid storage disease
Heart Attack
Hemiplegia
Hemophilia
Hepatitis B or C
Interstitial Cystitis
Ischemic Heart Disease
12
Leukemia
Major Depression
Morbid Obesity – current
or present
Multiple Sclerosis
Muscular Dystrophy
Myocardial Infarction
(Heart Attack)
Obsessive-Compulsive
Disorder (OCD)
Pacemaker/defibrillator
Paraplegia
Parkinson’s Disease
Polycystic Kidneys
Pregnancy/expectant parent
Psychosis
Pulmonary Fibrosis
Pulmonary Hypertension
Pulmonary Stenosis
Quadriplegia
Renal Failure
Rheumatoid Arthritis
(Juvenile/Adult)
Sickle Cell Anemia
Sideroblastic Anemia
Sleep Apnea
Spina Bifida
Stroke
Systemic Lupus
Thalassemia Major
Any Transplant except
Corneal
(Cardiac) Valve Replacement
STEPS TO APPLY FOR
HIGH-DEDUCTIBLE HEALTH PLAN
ONLINE:
If you prefer using the Internet rather than paper forms, you can apply for ConnectiCare SOLO online. Applying
online has these advantages:
• It expedites the application process.
• No postage is required.
• It helps us be more “green” in our business practices. When more people use the Internet, we print fewer
forms and conserve paper.
For more information on applying online, contact your agent or broker, who will send you an e-mail invitation that
kicks off the process. Once you’ve submitted your application electronically, you’ll be able to check your application
status online as well.
PAPER:
1. Accurately and fully complete the Individual Application Change Form—PART 1– no more than 60 days prior
to the requested effective date. Be sure to:
a.) Check the box for the medical plan being selected.
b.) Select a Primary Care Physician (PCP) for each family member applying for coverage and write the PCP
name in the appropriate box. For a complete list of participating providers, go to “Find a Doctor” at
www.connecticare.com or see our print directory.
2. Accurately and completely answer all questions on the Individual Health Statement — PART 2— for each
family member applying for coverage.
3. Complete, sign and date the Underwriting Authorization Form—PART 3.
4. For applicants under the age of 18, the application must have a parent/guardian’s signature and date – and the
parent/guardian’s full name must be printed on the application.
PREMIUM PAYMENTS:
5a. You do not have to submit your first premium payment with your application. However, once you are
approved, all premiums from the date of approval back to the effective date are due by the first month
following the date of your approval letter. This could mean that you may owe us more than one month of
premium. This applies to all payment methods (check, Electronic Funds Transfer (EFT), and credit card).
5b. Paying your premium via Electronic Funds Transfer (EFT). There are two EFT options to choose from:
1. You can sign up for EFT along with your initial application . All you have to do is complete the EFT form
and attach a voided check or statement savings deposit slip with your application. Complete and sign the
Electronic Funds Transfer Form — FORM 4. Be sure to include a check marked “Void”. It will take
approximately 30-60 days from the date your EFT application is submitted for the service to become
effective. Until you receive the Confirmation of Electronic Funds Transfer, please pay your monthly premium
by submitting a check to the address on your premium payment voucher.
13
2. You can wait to sign up for EFT until after you are accepted by and enrolled in ConnectiCare SOLO. This
could mean that you may owe us more than one month of premium. All you need to do is sign the front
of the first invoice voucher and return it with your premium payment. For future payment drafts, we will
use the checking account number that appears on the check you submit for the initial premium payment.
You do not need to submit a separate form when enrolling in EFT this way.
5c. Complete and sign the Credit Card Payment Form—FORM 5—if you choose this method of payment.
ConnectiCare will be authorized to initiate a transaction to your credit card to pay all premiums
due going back to the effective date. Please be aware that this could include more than one month
of premium. No charge will be made against your credit card unless your application for individual
health insurance is approved by ConnectiCare.
To continue to pay by credit card, you must register at the ConnectiCare SOLO section on www.connecticare.com
and initiate the transaction each month. Please see the instructions below for monthly credit card payments.
HOW TO ACCESS CREDIT CARD PAYMENTS ONLINE
•
Log onto www.connecticare.com and click “Members.”
•
Click “Managing Your Account.”
•
Click “Billing Invoice & Credit Card Payment” under “Get Information About Your Plan.”
• Enter your username and password. If you are not a registered member, click “Not Registered?” to obtain
your username and password.
• Click “Sign On”, which takes you to “Billing Information.”
• Click “Pay Now” to complete your payment transaction.
For added convenience, recurring credit card payments are coming soon.
5d. If paying by check, all premium payments should be mailed to:
ConnectiCare, Inc.
P.O. Box 30726
Hartford, CT 06150
6. If applicable, complete the Domestic Partner Verification Form or other satisfactory certification as we determine.
7. Optional: Broker Authorization Form—must be completed and received prior to the release of any status
information to broker that includes the applicant’s personal health information.
8. All completed forms must be signed, dated and submitted to your agent or broker. Complete forms must
be received by ConnectiCare by the last day of the month for an effective date on the 1st of the next month.
(i.e. A complete application received by January 31st would be eligible for a February 1st effective date. A
complete application received on February 1st would be eligible for a March 1st effective date.)
9. Effective dates for coverage are the first of the month following underwriting approval.
Acceptance into the plan is based on our review of the Individual Health Statement(s) and the applicant meeting
the eligibility requirements and underwriting criteria. As part of our medical underwriting, ConnectiCare may need
access to your medical records and other medical information. It is the applicant’s responsibility to provide us access
to that medical information and to pay for any costs your physician’s office may charge to copy and send us those
records. If we do not have complete medical information, your application will be incomplete, and will be withdrawn
if you do not arrange to have the medical records provided to us within 45 days of the request. For additional copies
of ConnectiCare SOLO forms, contact your agent or broker, or call Member Services at 1-800-251-7722.
14
RESCISSIONS
In making a determination whether to issue a
policy to an applicant, ConnectiCare will review
and rely on the statements made by you or your
authorized representative on the fully completed
application and health statement. Any material
omission, misrepresentation or misstatement about
medical history, planned treatment or surgeries,
weight/height or other information on the
application or health statement will result in
rescission of the policy and denial of an otherwise
valid claim. Premiums paid will be used to offset
claims paid by ConnectiCare on your behalf.
RENEWABILITY OF
COVERAGE
You are required to make the payment on or
before the first of each month, or before expiration
of the grace period. Your policy remains in force
during this period. Each time you send us the
premium that is due, we will renew your policy.
Note: If you are declined coverage, or if your
membership is terminated for non-payment of
premium, you must wait 12 months to re-apply
for coverage
15
STEPS TO APPLY FOR HSA WITH
CONNECTICARE’S PREFERRED ADMINISTRATOR
We’ve selected First HSA as our preferred HSA administrator to make the process convenient.
(See “Important Notice” on the inside back cover.) Individuals must be accepted into and covered by
a qualified High-Deductible Health Plan (HDHP) to open an HSA, which is subject to IRS rules
and restrictions.
To apply with First HSA, follow these steps:
1. Complete the First HSA application.
2. Determine your method of contribution and fee payment.
3. Submit application(s) to First HSA upon receipt of your acceptance into one of ConnectiCare’s HDHPs.
4. First HSA will process the application(s) and mail a welcome packet to you.
For questions about your HSA application, contact First HSA at 1-888-769-8696.
16
PLAN DESIGNS
CONNECTICARE SOLO PLAN DESIGNS
HMO Outlines of Coverage
18-26
Plan Deductible Information
Exclusions and Limitations
Important Information
POS Outlines of Coverage
27
28-29
30
31-39
Plan Deductible Information
Exclusions and Limitations
Important Information
Plan Comparisons
40
41-42
43
44-47
Enrollment Materials
Steps to Apply
48-49
Individual Application/Change Form
Individual Health Statement
52-54
Underwriting Authorization Form
EFT Form
50-51
55
57
Credit Card Payment Form
Broker Authorization Form
59
61-62
17
OUTLINE OF COVERAGE
HMO HIGH DEDUCTIBLE HEALTH PLAN —
$1,500 INDIVIDUAL/$3,000 FAMILY
For use with a Health Savings Account (HSA)
Read Your Policy Carefully – This outline of coverage provides a very brief description of the important features
of your policy. This is not the insurance contract and only the actual policy provisions will control. The policy
itself sets forth in detail the rights and obligations of both you and your insurance company. Upon enrollment,
it is therefore important that you read your policy carefully!
Major Medical Expense Coverage – Policies of this category are designed to provide, to persons insured, coverage
for major hospital, medical, and surgical expenses incurred as a result of a covered accident or sickness. Coverage
is provided for daily hospital room and board, miscellaneous hospital services, surgical services, anesthesia services,
in-hospital medical services, and out-of-hospital care, subject to any deductibles, Copayment provisions, or
other limitations, which may be set forth in the policy.
MEMBER COST:
PLAN DEDUCTIBLES
■ Individual Plan Deductible
(Plan Deductible is combined for health services and prescription drugs)
■ Family Plan Deductible
■
Individual Out-of-Pocket Maximum
(includes Plan Deductible and prescription drugs)
■ Family Out-of-Pocket Maximum
DAILY HOSPITAL ROOM AND BOARD
■ Hospitalization for Maternity, Illness or Injury
(includes semi-private room and board)
■ Skilled Nursing and Rehabilitation Facilities
(up to 90 days)
MISCELLANEOUS HOSPITAL SERVICES
■ Emergency Room
■ Walk-In/Urgent Care Centers
SURGICAL SERVICES
Ambulatory Services (Outpatient)
(includes services performed in a Hospital or
ambulatory facility)
$1,500
$3,000
$3,000
$6,000
No Member cost after Plan Deductible
■
ANESTHESIA SERVICES
■ Anesthesia and oxygen services
Included in Hospital Services
continued on page 17
18
CCI/OOC/HMO/IND 01 (1/2008)
OUTLINE OF COVERAGE
HMO HIGH DEDUCTIBLE HEALTH PLAN — $1,500 INDIVIDUAL/$3,000 FAMILY, CONT.
MEMBER COST:
IN-HOSPITAL MEDICAL SERVICES
■ Inpatient medical services
OUT-OF-HOSPITAL CARE
Primary Care Physician Office Services
(includes services for illness, injury, sickness,
follow-up care and consultations)
(The Plan Deductible does not apply to some
preventive care services. Refer to Plan Deductible
Information for details.)
■ Specialist Office Services
■ Gynecological Preventive Exam Office Services
(one per year)
■ Maternity Care Office Services
■
OTHER BENEFITS
Ambulance Services
■ Home Health Services
(up to 100 visits)
■ Laboratory Services
(includes services performed in a Hospital or laboratory
facility)
■ Non-Advanced Radiology
(includes services performed in a Hospital or radiology
facility)
■ Advanced Radiology
(includes services for MRI, PET and CAT Scan, and Nuclear
Cardiology performed in a Hospital or radiology facility)
■ Chiropractic Services
(up to 10 visits)
■ Outpatient Rehabilitative Therapy
(up to 20 visits combined for physical, speech, and
occupational therapy)
■ Routine Vision Exam
(one per year)
■ Disposable Medical Supplies
(up to $300)
■ Durable Medical Equipment Including Prosthetics
(up to $1,500)
■ Ostomy Supplies and Equipment
(up to $1,000)
■
No Member cost
No Member cost
19
OUTLINE OF COVERAGE
MEMBER COST:
PRESCRIPTION DRUGS
Covered prescription drugs through retail Participating Pharmacies or our mail order service. Generics are
dispensed unless the Member pays the Generic Drug Cost-Share plus the difference in price between the
Generic Equivalent and the Brand Name Drug.
■
Individual Plan Deductible
$1,500
$3,000
The Calendar Year Plan Deductible can be reached by any combination of covered Health Services or
covered prescription drug services.
If you have Family Coverage, then covered Health Services and covered prescription drugs will be applied
to the Family Plan Deductible until the total amount is met without regard to which family Member uses
the benefits.
■ Individual Pharmacy Cost-Share Maximum
$1,500
(Maximum does not include Deductible)
■ Family Pharmacy Cost-Share Maximum
$3,000
■ Prescription Drug Benefit Limit
Unlimited
RETAIL PHARMACY (UP TO A 30 DAY SUPPLY PER PRESCRIPTION)
■ Tier 1 drugs
$15 Copayment after Plan Deductible
up to Pharmacy Cost-Share Maximum
■ Tier 2 drugs
■ Tier 3 drugs
MAIL ORDER PHARMACY (UP TO A 90 DAY SUPPLY PER PRESCRIPTION)
■ Tier 1 drugs
■ Tier 2 drugs
■ Tier 3 drugs
LIFETIME MAXIMUM
20
Unlimited
OUTLINE OF COVERAGE
MEMBER COST:
PLAN DEDUCTIBLES
(Plan Deductible is combined for health services
and prescription drugs)
■
Individual Out-of-Pocket Maximum
(up to 90 days)
■ Emergency Room
SURGICAL SERVICES
■ Ambulatory Services (Outpatient)
ANESTHESIA SERVICES
$3,000
$6,000
$4,500
$9,000
21
OUTLINE OF COVERAGE
MEMBER COST:
(one per year)
■
OTHER BENEFITS
Ambulance Services
(up to 100 visits)
facility)
facility)
(up to 10 visits)
(one per year)
(up to $300)
(up to $1,500)
(up to $1,000)
■
No Member cost
No Member cost
22
OUTLINE OF COVERAGE
MEMBER COST:
PRESCRIPTION DRUGS
■
$3,000
$6,000
the benefits.
$1,500
$3,000
Unlimited
■ Tier 1 drugs
■ Tier 2 drugs
■ Tier 3 drugs
■ Tier 1 drugs
■ Tier 2 drugs
■ Tier 3 drugs
LIFETIME MAXIMUM
Unlimited
23
OUTLINE OF COVERAGE
MEMBER COST:
PLAN DEDUCTIBLES
■ Individual Out-of-Pocket Maximum
(up to 90 days)
■ Emergency Room
SURGICAL SERVICES
$5,000
$10,000
$5,000
$10,000
■
ANESTHESIA SERVICES
24
OUTLINE OF COVERAGE
MEMBER COST:
■ Primary Care Physician Office Services
(one per year)
OTHER BENEFITS
Ambulance Services
(up to 100 visits)
facility)
facility)
(up to 10 visits)
(one per year)
(up to $300)
(up to $1,500)
(up to $1,000)
■
No Member cost
No Member cost
25
OUTLINE OF COVERAGE
MEMBER COST:
PRESCRIPTION DRUGS
■
■
■
$5,000
Family Plan Deductible
$10,000
to the Family Plan Deductible until the total amount is met without regard to which family member uses
the benefits.
Prescription Drug Benefit Limit
Unlimited
Tier 1 drugs
No Member Cost after Plan Deductible
■ Tier 2 drugs
■ Tier 3 drugs
■
Tier 1 drugs
■ Tier 2 drugs
■ Tier 3 drugs
■
LIFETIME MAXIMUM
26
Unlimited
OUTLINES OF COVERAGE
PLAN DEDUCTIBLE INFORMATION
The Plan Deductible does not apply to the following covered health services when they are rendered by a
Participating Provider. Please note that the limitation provisions detailed below only show you when those
services do not apply to the Plan Deductible for the identified in-network services.
• Colorectal cancer screenings, fecal occult blood test, sigmoidoscopy or colonoscopy
(including an associated biopsy performed during a colonoscopy), age 50 or older,
one per year
• Gynecological preventive exam, one per year
• Immunizations for:
Children - Chickenpox, Diphtheria, Hemophilus Influenza B, Hepatitis A,
Hepatitis B, Measles, Mumps, Pertussis, Pneumococcus, Polio, Rubella, and
Tetanus
Adults - Chickenpox, Influenza, Pneumococcus, and Tetanus
• Mammography screenings, age 40 or older, one per year
• Newborn well baby visits
• Outpatient laboratory services (one per year) associated with preventive exams
limited to:
– Cervical cancer screening - Pap tests
– Cholesterol screening
– Fasting plasma glucose
– Hematocrit or hemaglobin
– Lead screening
– Urinalysis
• Preventive exams for adult (one per year) and pediatric exams as coded by the most
current edition of the American Medical Association’s Current Procedural Terminology
Coding Manual, including an electrocardiogram
• Prostate cancer screening and associated laboratory tests, age 50 and older,
one per year
• Routine vision exam, one per year
27
OUTLINE OF COVERAGE
EXCLUSIONS AND
LIMITATIONS
The following is a list of services, supplies, etc., that are
excluded under the policy unless otherwise noted.
• Abdominoplasty
• All assistive communication devices
• Any treatments or services related to the provision of
a non-covered benefit, as well as evaluations and
medical complications resulting from receiving services
that are not covered (“Related Services”), unless
BOTH of these conditions are met: the Related
Services are Medically Necessary acute inpatient care
services needed by the Member to treat complications
resulting from the non-covered benefit when such
complications are life threatening at the time the
Related Services are rendered, as determined by us;
and the Related Services would be a Health Service if
the non-covered benefit were covered by the Plan
• Any treatment for which there is Insufficient
Evidence Of Therapeutic Value for the use for which
it is being prescribed is not covered
• Attorney fees
• Benefits for services rendered before the Member’s
effective date under this Plan and after the Plan has
been rescinded, suspended, canceled, or interrupted
or terminated
• Blood donation expenses incurred by the Member’s
relatives or friends for their blood donated for use by
the Member. Also, whole blood, blood plasma, and
other blood derivatives and donor services, which are
provided by the Red Cross
• Cardiac rehabilitation for Phase III, unless the
Member meets the criteria for enrollment into our
HeartCare health management program, is being
actively case managed and the rehabilitation is
approved by us. Phase IV cardiac rehabilitation is
always excluded
• Care provided by home health aides that is not
patient care of a medical or therapeutic nature or
care provided by non-licensed professionals
• Care, treatment, services or supplies to the extent the
Member has obtained benefits under any applicable
law, government program, public or private grant, or
for which there would be no charge to the Member
in the absence of this Plan, except where benefits are
obtained in a Veteran’s Home or Hospital for a non
service connected disability or as required by applicable law. However, care treatment or services that are
otherwise Medically Necessary and provided in a
Veteran’s Hospital are covered.
• Conditions with the following diagnoses: caffeinerelated disorders; communication disorders; learning
disorders; mental retardation; motor skills disorders;
relational disorders; sexual deviation; and other
conditions that may be a focus of clinical attention
not defined as mental disorders in the most recent
edition of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders
28
• Contraceptive drugs and devices, except to the extent
applicable insurance law requires coverage for these
items
• Cord blood retrieval and storage
• Cosmetic Treatments and procedures, including, but
not limited to: any medical or Hospital services related
to Cosmetic Treatments or procedures; benign nevus
or any benign skin lesion removal except when the
nevus or skin lesion causes significant impairment
of physical or mechanical function; benign seborrhic
keratosis; blepharoplasty, unless the upper eye lid
obstructs the pupil, and blepharoplasty would result
in significant improvement of the upper field of
vision; breast augmentation (except or as described in
the “Reconstructive Surgery” and “Durable Medical
Equipment (DME) Including Prosthetics” subsections
of the “Benefits” section of the policy or as otherwise
required by applicable law); dermabrasion; excision
of loose or redundant skin and/or fat after the
Member has had a substantial weight loss; hemangioma; liposuction; otoplasty; scar revision following
surgery or injury (except when the scar causes a
significant impairment or physical or mechanical
function); septoplasty, septorhinoplasty, and
rhinoplasty, unless necessary to alleviate a significant
nasal obstruction; skin tag removal; spider vein
removal (including sclerotherapy); tattoo removal;
treatment of craniofacial disorders; and vascular
birthmark removal (except when the vascular
birthmark causes significant impairment of physical
or mechanical function)
• Custodial Care, convalescent care, domiciliary care,
and rest home care
• Dental services, including but not limited to:
anesthesia, except as otherwise required by applicable
law; bite appliances or night guards; bone grafts;
correction of congenital malformation, including
osteotomies; correction of oral malocclusion; dental
implants; prosthetic devices, except as otherwise
provided herein; and repair, restoration or re-implantation of teeth following an injury
• Experimental or Investigational medical, surgical and
other health care treatments and procedures
• Eyeglasses and contact lenses
• Eye surgeries and procedures primarily for the
purpose of correcting refractive defects of the eyes
• Health and behavior assessments that are used to
identify the psychological, behavioral, emotional,
cognitive and social factors important to the
prevention, treatment, or management of physical
health problems
• Hearing aids except as otherwise required by
applicable law
• Infant formulas, food supplements, nutritional
supplements and enteral nutritional therapy, except
as provided in the “Nutritional Supplements And
Food Products” subsection of the “Benefits” section
of the policy
OUTLINE OF COVERAGE
• Infertility services not specifically covered under the
“Infertility Services” section of the Policy, including
any Riders and our Prescription Drug Rider (if your
Plan has this supplemental coverage), are excluded,
including but not limited to the following: cryopreservation (freezing) or banking of eggs, embryos,
or sperm; genetic analysis and testing, except as
described in the Policy or any Riders; medications
for sexual dysfunction; recruitment, selection and
screening and any other expenses of egg, embryo and
sperm donors; reversal of surgical sterilization; reversal
of voluntary sterilization; and surrogacy and all charges
associated with surrogacy.
• Massage, except when part of a prescribed physical or
occupational therapy program if that program is a
covered benefit
• Medical supplies or equipment that are not considered
to be durable medical equipment or disposable
medical supplies or that are not on our covered list of
such equipment or supplies
• Neuropsychological and neurobehavioral testing,
except when it is performed by an appropriately
licensed neurologist, psychologist, or psychiatrist
and when required by applicable law
• New Treatments for which we have not yet made a
coverage policy
• Non-durable equipment such as orthopedic or
prosthetic shoes, foot orthotics, and prophylactic
anti-embolism stockings, (such as jobst stockings
except when the Member has a history of deep
vein thrombosis)
• Over-the-counter (OTC) devices of any kind, including but not limited to home testing or other kits and
products, except as provided in the “Benefits” section
of the Policy
• Peak flow meters, unless the Member is enrolled in
our asthma health management program, is being
actively case managed and the use of a peak flow
meter is approved by us as part of a health
management program value-added service or benefit
• Personal convenience or comfort items of any kind
• Private room accommodations and private duty
nursing in a facility
• Routine foot care and treatment, unless Medically
Necessary for neuro-circulatory conditions
• Routine physical exams and immunizations and
follow-up care at an Urgent Care Center or an
emergency room, except for suture removal at the
same facility that applied the sutures
• Sensory and auditory integration therapy, unless
covered under the “Birth To Three Program (Early
Intervention Services)” subsection of the “Benefits”
section of the Policy
• Services and supplies exceeding the applicable benefit
maximums
• Services or supplies rendered by a physician or provider
to himself or herself, or rendered to his or her family
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
members, such as parents, grandparents, spouse,
children, step-children, grandchildren or siblings
Sex change services
Smoking cessation products, except as otherwise
required by applicable law and when the product is
obtained with a prescription and Pre-Authorized
by us
Solid organ transplants and bone marrow that are
Experimental or Investigational
Speech therapy for stuttering, lisp correction, or any
speech impediment not related to illness or injury,
except as required by applicable law
Surgical treatment for morbid obesity
Temporomandibular joint (TMJ) dysfunction or
temporomandibular disease (TMD) syndrome: any
non-surgical treatment, including but not limited to
appliances, behavior modification, physical therapy,
and prosthodontic therapy
Third party coverage, such as other primary
insurance, workers’ compensation and Medicare
will not be duplicated
Transportation, accommodation costs, and other
non-medical expenses related to Health Services
(whether they are recommended by a physician
or not)
Vision and hearing examinations, except as set
forth in the “Eye Care” and “Hearing Screenings”
subsections of the policy
Vision therapy and vision training
War related treatment or supplies, whether the war
is declared or undeclared
Web visits, e-visits, and other on-line consultations,
health evaluations using internet resources and
telephone consultations
Wigs, hair prosthetics, scalp hair prosthetics and
cranial prosthetics, except for a wig as prescribed by
an oncologist when the wig is required in connection
with hair loss suffered as a result of chemotheraphy.
Services, supplies, vaccinations and medications
required by third parties or obtained for foreign or
domestic travel (e.g., employment, school, camp,
licensing, insurance and travel)
Services and supplies not specifically included in
the policy. These include but are not limited to:
non-medical supportive counseling services
(individual or group); education services, including
testing, training, rehabilitation for educational
purposes and screening and treatment associated
with learning disabilities; health club membership,
exercise equipment; hypnosis (except as an integral
part of psychotherapy), biofeedback (except when
ordered by a physician to treat urinary incontinence),
acupuncture, and certain holistic practices; weight
loss/control treatment, programs and medications
29
OUTLINE OF COVERAGE
IMPORTANT
INFORMATION
Eligibility
To become eligible for benefits under this Benefit
Program, the applicant must:
Premium Rates
The amount, time and manner of payment of
premium shall be determined by ConnectiCare
and shall be subject to the approval of the State
of Connecticut Insurance Department.
In the event of any change in premium, the
• Be a resident of the State of Connecticut
subscriber will be given notice at least 30 days
• Be under age 65
prior to such change. Payment of the premium
by the subscriber shall serve as notice of the
Renewal Provision
subscriber’s acceptance of the change.
We will renew your policy each time you send us
the premium. Payment must be made on or before
the due date or by the end of the calendar month
the premium is due. Your policy stays in force
If you have questions regarding this plan,
please contact your insurance agent or call us at
(860) 674-5757 or 1-800-251-7722.
during this time. We can refuse to renew your
policy only when we refuse to renew all individual
plans in this State. Nonrenewal will not affect an
existing claim.
30
CICI/OOC/POS/IND 01 (1/2008)
OUTLINE OF COVERAGE
POS HIGH DEDUCTIBLE HEALTH PLAN —
IN-NETWORK
MEMBER COST
CALENDAR YEAR COST SHARE
$1,500
$3,000
$3,000
(includes Plan Deductible, Coinsurance and Prescription Drugs)
$6,000
■ Out-of-Network Reimbursement
None
Hospitalization for Illness or Injury
(includes semi-private room and board;
excludes all maternity-related services)
(up to 90 days)
■
■ Emergency Room
■
Walk-In/Urgent Care Centers
SURGICAL SERVICES
(includes services performed in a Hospital
or ambulatory facility)
■
ANESTHESIA SERVICES
OUT-OF-NETWORK
MEMBER COST
$3,000
$6,000
$4,500
$9,000
Plan will reimburse up to the
Maximum Allowable Amount
No Member cost
after Plan Deductible
30% after Plan Deductible
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
Included in Hospital
Services
Services
31
OUTLINE OF COVERAGE
POS HIGH DEDUCTIBLE HEALTH PLAN — $1,500 INDIVIDUAL/$3,000 FAMILY, CONT.
IN-NETWORK
MEMBER COST
(includes services for illness, injury,
sickness, follow-up care and consultations)
in-network preventive care services. Refer to
Plan Deductible Information for details.)
(one per year)
■
OTHER BENEFITS
■ Ambulance Services
■
Home Health Services
(up to 100 visits)
laboratory facility)
or radiology facility)
(includes services for MRI, PET and CAT Scan,
and Nuclear Cardiology performed in a Hospital
(up to 10 visits)
(up to 20 visits combined for physical,
speech, and occupational therapy)
(one per year)
(up to $300)
■ Durable Medical Equipment
Including Prosthetics
(up to $1,500)
(up to $1,000)
OUT-OF-NETWORK
MEMBER COST
Services
Services
No Member cost
No Member cost
No Member cost
Not a covered benefit
No Member cost after
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
32
OUTLINE OF COVERAGE
MEMBER COST:
PRESCRIPTION DRUGS
dispensed unless the Member pays the Generic Drug Cost Share plus the difference in price between the
■
$1,500
(Combined in-network and out-of-network Benefit Limit)
$3,000
the benefits.
$1,500
$3,000
Unlimited
IN-NETWORK
MEMBER COST
RETAIL PHARMACY (UP TO A 30-DAY SUPPLY PER PRESCRIPTION)
Tier 1 drugs
up to Pharmacy Cost-Share maximum
■ Tier 2 drugs
■ Tier 3 drugs
■
OUT-OF-NETWORK
MEMBER COST
30% Coinsurance after Plan
Deductible
Deductible
Deductible
MAIL ORDER PHARMACY (UP TO A 90-DAY SUPPLY PER PRESCRIPTION)
Tier 1 drugs
■ Tier 2 drugs
■ Tier 3 drugs
■
LIFETIME MAXIMUM
Unlimited
$1,000,000
33
OUTLINE OF COVERAGE
IN-NETWORK
MEMBER COST
CALENDAR YEAR COST SHARE
$3,000
$6,000
$4,500
$9,000
None
■ Hospitalization for Illness or Injury
(up to 90 days)
■ Emergency Room
■
SURGICAL SERVICES
or ambulatory facility)
■
ANESTHESIA SERVICES
OUT-OF-NETWORK
MEMBER COST
$6,000
$12,000
$9,000
$18,000
Plan will reimburse up to the
Maximum Allowable Amount
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
Services
Services
34
OUTLINE OF COVERAGE
IN-NETWORK
MEMBER COST
(includes services for illness, injury,
sickness, follow-up care and consultations)
Plan Deductible Information for details.)
(one per year)
■
OTHER BENEFITS
■
(up to 100 visits)
(up to 10 visits)
(one per year)
(up to $300)
(up to $1,500)
(up to $1,000)
OUT-OF-NETWORK
MEMBER COST
Services
Services
No Member cost
No Member cost
No Member cost
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
35
OUTLINE OF COVERAGE
MEMBER COST:
PRESCRIPTION DRUGS
■
$3,000
$6,000
the benefits.
$1,500
$3,000
Unlimited
IN-NETWORK
MEMBER COST
■ Tier 1 drugs
■ Tier 2 drugs
■ Tier 3 drugs
OUT-OF-NETWORK
MEMBER COST
Deductible
Deductible
Deductible
Tier 1 drugs
■ Tier 2 drugs
■ Tier 3 drugs
■
LIFETIME MAXIMUM
36
Unlimited
$1,000,000
OUTLINE OF COVERAGE
IN-NETWORK
MEMBER COST
PLAN DEDUCTIBLES
$5,000
$10,000
$5,000
$10,000
None
(up to 90 days)
■
■ Emergency Room
■
SURGICAL SERVICES
■
ANESTHESIA SERVICES
OUT-OF-NETWORK
MEMBER COST
$7,000
$14,000
$10,000
$20,000
Plan will reimburse
up to the Maximum
Allowable Amount
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
Services
Services
37
OUTLINE OF COVERAGE
IN-NETWORK
MEMBER COST
the Plan Deductible Information for details.)
(one per year)
■
OTHER BENEFITS
■
(up to 100 visits)
(up to 10 visits)
(one per year)
(up to $300)
(up to $1,500)
(up to $1,000)
OUT-OF-NETWORK
MEMBER COST
Services
Services
Plan Deductible
30% after Plan
Deductible
Plan Deductible
30% after Plan
Deductible
No Member cost
30% after Plan
Deductible
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
Plan Deductible
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
No Member cost
38
OUTLINE OF COVERAGE
MEMBER COST:
PRESCRIPTION DRUGS
■
$5,000
$10,000
the benefits.
Unlimited
IN-NETWORK
MEMBER COST
Tier 1 drugs
No Member Cost after
Plan Deductible
■ Tier 2 drugs
Plan Deductible
■ Tier 3 drugs
Plan Deductible
■
OUT-OF-NETWORK
MEMBER COST
Deductible
Deductible
Deductible
Tier 1 drugs
Plan Deductible
■ Tier 2 drugs
Plan Deductible
■ Tier 3 drugs
Plan Deductible
■
LIFETIME MAXIMUM
Unlimited
$1,000,000
39
OUTLINE OF COVERAGE
PLAN DEDUCTIBLE INFORMATION
The Plan Deductible does not apply to the following covered health services when they are rendered by a
Participating Provider. Please note that the limitation provisions detailed below only show you when those
services do not apply to the Plan Deductible for the identified in-network services.
• Colorectal cancer screenings, fecal occult blood test, sigmoidoscopy or colonoscopy
(including an associated biopsy performed during a colonoscopy), age 50 or older,
one per year
• Gynecological preventive exam, one per year
• Immunizations for:
Children - Chickenpox, Diphtheria, Hemophilus Influenza B, Hepatitis A,
Hepatitis B, Measles, Mumps, Pertussis, Pneumococcus, Polio, Rubella,
and Tetanus
Adults - Chickenpox, Influenza, Pneumococcus, and Tetanus
• Mammography screenings, age 40 or older, one per year
• Newborn well baby visits
• Outpatient laboratory services (one per year) associated with preventive exams
limited to:
– Cervical cancer screening - Pap tests
– Cholesterol screening
– Fasting plasma glucose
– Hematocrit or hemaglobin
– Lead screening
– Urinalysis
• Preventive exams for adult (one per year) and pediatric exams as coded by the most
current edition of the American Medical Association’s Current Procedural Terminology
Coding Manual, including an electrocardiogram
• Prostate cancer screening and associated laboratory tests, age 50 and older,
one per year
• Routine vision exam, one per year
40
OUTLINE OF COVERAGE
EXCLUSIONS AND
LIMITATIONS
The following is a list of services, supplies, etc.,
that are excluded under the policy unless otherwise
noted.
• Abdominoplasty
• All assistive communication devices
• Any treatments or services related to the provision
of a non-covered benefit, as well as evaluations
and medical complications resulting from
receiving services that are not covered (“Related
Services”), unless BOTH of these conditions are
met: the Related Services are Medically
Necessary acute inpatient care services needed by
the Member to treat complications resulting
from the non-covered benefit when such
complications are life threatening at the time the
Related Services are rendered, as determined by
us; and the Related Services would be a Health
Service if the non-covered benefit were covered
by the Plan
• Attorney fees
• Benefits for services rendered before the
Member’s effective date under this Plan and
after the Plan has been rescinded, suspended,
canceled, or interrupted or terminated
• Blood donation expenses incurred by the
Member’s relatives or friends for their blood
donated for use by the Member. Also, whole
blood, blood plasma, and other blood derivatives
and donor services, which are provided by the
Red Cross
• Cardiac rehabilitation for Phase III, unless the
Member meets the criteria for enrollment into
our HeartCare health management program, is
being actively case managed and the rehabilitation
is approved by us. Phase IV cardiac rehabilitation
is always excluded
• Care provided by home health aides that is not
patient care of a medical or therapeutic nature
or care provided by non-licensed professionals
• Care, treatment, services or supplies to the
extent the Member has obtained benefits under
any applicable law, government program, public
or private grant, or for which there would be no
charge to the Member in the absence of this Plan
• Conditions with the following diagnoses:
caffeine-related disorders; communication
disorders; learning disorders; mental retardation;
motor skills disorders; relational disorders; sexual
deviation; and other conditions that may be a
focus of clinical attention not defined as mental
disorders in the most recent edition of the
American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders
• Contraceptive drugs and devices, except to the
extent applicable insurance law requires coverage
for these items
• Cord blood retrieval and storage
• Cosmetic Treatments and procedures, including,
but not limited to: any medical or Hospital
services related to Cosmetic Treatments or
procedures; benign nevi or any benign skin
lesion not causing a significant mechanical
problem, except for the treatment of warts;
benign seborrhic keratosis; blepharoplasty, unless
the upper eye lid obstructs the pupil, and
blepharoplasty would result in significant
improvement of the upper field of vision; breast
augmentation (except or as described in the
“Reconstructive Surgery” and “Durable Medical
Equipment (DME) Including Prosthetics”
subsections of the “Benefits” section of the policy
or as otherwise required by applicable law);
dermabrasion; excision of loose or redundant
skin and/or fat after the Member has had a
substantial weight loss; hemangioma; liposuction;
otoplasty; scar revision following surgery or
injury (except when the scar causes a significant
mechanical deficit); septoplasties, septorhinoplasties,
and rhinoplasties, unless necessary to alleviate a
significant nasal obstruction; skin tag removal;
spider veins (including sclerotherapy); and
treatment of craniofacial disorders
• Custodial Care, convalescent care, domiciliary
care, and rest home care
• Dental services, including: anesthesia, except as
otherwise required by applicable law; bite
appliances or night guards; bone grafts; correction
of congenital malformation, including
osteotomies; correction of oral malocclusion;
dental implants; prosthetic devices, except as
otherwise provided herein; and repair, restoration
or re-implantation of teeth following an injury
• Experimental or investigational medical, surgical
and other health care treatments and procedures
• Eyeglasses and contact lenses
• Eye surgeries and procedures primarily for the
purpose of correcting refractive defects of the eyes
• Health and behavior assessments that are used to
identify the psychological, behavioral, emotional,
cognitive and social factors important to the
prevention, treatment, or management of
physical health problems
• Hearing aids except as otherwise required by
applicable law
41
OUTLINE OF COVERAGE
• Infant formulas, food supplements, nutritional
supplements and enteral nutritional therapy,
except as provided in the “Nutritional
Supplements And Food Products” subsection of
the “Benefits” section of the policy
• Infertility services not specifically covered under
the “Infertility Services” section of the Policy,
including any Riders and our Prescription Drug
Rider (if your Plan has this supplemental coverage),
are excluded, including but not limited to the
following: cryopreservation (freezing) or banking
of eggs, embryos, or sperm; genetic analysis and
testing, except as described in the Policy or any
Riders; medications for sexual dysfunction;
recruitment, selection and screening and any other
expenses of the egg, embryo and sperm donors;
reversal of surgical sterilization; reversal of
voluntary sterilization; and surrogacy and all
charges associated with surrogacy.
• Massage, except when part of a prescribed physical
or occupational therapy program if that program
is a covered benefit
• Maternity care and treatment (pre-natal and
post-natal) including home births, except that care
related to complications of pregnancy is covered.
• Medical supplies or equipment that are not
considered to be durable medical equipment or
disposable medical supplies or that are not on
our covered list of such equipment or supplies
• New technology: services or supplies that are
new or recently emerged and new or recently
emerged uses of existing services and supplies,
unless and until we determine to cover them
• Non-durable equipment such as orthopedic or
prosthetic shoes, foot orthotics, and prophylactic
anti-embolism stockings, (such as jobst stockings
except when the Member has a history of deep
vein thrombosis)
• Peak flow meters, unless the Member is enrolled
in our asthma health management program, is
being actively case managed and the use of a
peak flow meter is approved by us as part of a
health management program, value-added
service or benefit
• Personal convenience or comfort items of any kind
• Private room accommodations and private duty
nursing in a facility
• Reversal of surgical sterilization
• Routine foot care and treatment, unless Medically
Necessary for neuro-circulatory conditions
• Routine physical exams and immunizations and
follow-up care at an Urgent Care Center or an
emergency room, except for suture removal at
the same facility that applied the sutures
• Services and supplies exceeding the applicable
benefit maximums
• Services or supplies rendered by a physician or
provider to himself or herself, or rendered to
his or her family members, such as parents,
42
grandparents, spouse, children, step-children,
grandchildren or siblings
• Sex change services
• Smoking cessation products, except as otherwise
required by applicable law and when the product
is obtained with a prescription and Pre-Authorized
by us
• Solid organ transplants and bone marrow that
are Experimental or Investigational
• Speech therapy for stuttering, lisp correction, or
any speech impediment not related to illness or
injury, except as required by applicable law
• Surgical treatment for morbid obesity
• Temporomandibular joint (TMJ) dysfunction or
temporomandibular disease (TMD) syndrome:
any non-surgical treatment, including but not
limited to appliances, behavior modification,
physical therapy, and prosthodontic therapy
• Third party coverage, such as other primary
insurance, workers’ compensation and Medicare
will not be duplicated
• Transportation, accommodation costs, and other
non-medical expenses related to Health Services
(whether they are recommended by a physician
or not)
• Treatment services and supplies in a Veteran’s
Hospital or any Federal Hospital, except as
required by applicable law
• Vision and hearing examinations, except as set
forth in the “Eye Care” and “Hearing Screenings”
subsections of the policy
• Vision therapy and vision training
• War related treatment or supplies, whether the
war is declared or undeclared
• Web visits, e-visits, and other on-line consultations, health evaluations using internet resources
and telephone consultations
• Wigs, hair prosthetics, scalp hair prosthetics and
cranial prosthetics, except for a wig as prescribed
by an oncologist when the wig is required in
connection with hair loss suffered as a result of
chemotherapy.
• Services, supplies, vaccinations and medications
required by third parties or obtained for foreign
or domestic travel (e.g., employment, school,
camp, licensing, insurance and travel)
• Services and supplies not specifically included in
the policy. These include but are not limited to:
non-medical supportive counseling services
(individual or group); education services,
including testing, training, rehabilitation for
educational purposes and screening and treatment
associated with learning disabilities; health club
membership, exercise equipment; hypnosis
(except as an integral part of psychotherapy),
biofeedback (except when ordered by a physician
to treat urinary incontinence), acupuncture, and
certain holistic practices; weight loss/control
treatment, programs and medications
OUTLINE OF COVERAGE
IMPORTANT
INFORMATION
Eligibility
Premium Rates
The amount, time and manner of payment of
premium shall be determined by ConnectiCare
and shall be subject to the approval of the State
of Connecticut Insurance Department.
To become eligible for benefits under this Benefit
Program, the applicant must:
In the event of any change in premium, the
• Be a resident of the State of Connecticut
subscriber will be given notice at least 30 days
• Be under age 65
prior to such change. Payment of the premium
by the subscriber shall serve as notice of the
Renewal Provision
subscriber’s acceptance of the change.
We will renew your policy each time you send us
If you have questions regarding this plan,
the premium. Payment must be made on or before
please contact your insurance agent or call us at
the due date or by the end of the calendar month
(860) 674-5757 or 1-800-251-7722.
the premium is due. Your policy stays in force
during this time. We can refuse to renew your
policy only when we refuse to renew all individual
plans in this State. Nonrenewal will not affect an
existing claim.
This plan is issued on an individual basis and is regulated as an individual health insurance plan.
43
$3,000 / $6,000
$4,500 / $9,000
Not applicable
$1,500 / $3,000
$3,000 / $6,000
Not applicable
In-Network
$3,000 / $6,000
$1,500 / $3,000
Unlimited
Not applicable
In-Network
$15 / $25 / $40
Copayment after Plan Deductible
In-Network
$30 / $50 / $80
In-Network
$1,500 / $3,000
$1,500 / $3,000
Unlimited
Not applicable
In-Network
$15 / $25 / $40
In-Network
$30 / $50 / $80
In-Network
Member Cost
No Member cost (Plan Deductible waived)
HMO HDHP $3,000/$6,000
In-Network
HMO HDHP $1,500/$3,000
In-Network
HMO coverage is underwritten by ConnectiCare, Inc. This plan is issued on an individual basis and is regulated
as an individual health insurance plan. This plan is not available to groups.
Preventive care services are exempt from the calendar-year plan deductible. See reverse side for additional information.
MAIL ORDER PHARMACY (Up to a 90-Day supply per prescription)
Tier 1 / Tier 2 / Tier 3
PRESCRIPTION DRUG COST-SHARE
Individual / Family Plan Deductible
(combined for health services and prescription drugs)
Individual / Family Pharmacy Cost-Share Maximum
(Maximum does not include the Plan Deductible)
Prescription Drug Benefit Limit
Member Coinsurance
RETAIL PHARMACY (Up to a 30-Day supply per prescription)
COVERED HEALTH SERVICES (Cost-shares for the following services
are the same for all three plan options.)
Preventive Care Services (Refer to back side for more information)
Primary Care Physician Office Services
Specialist Office Services
Pre- and Post-Natal Maternity Care
Outpatient Laboratory and Radiology Services
Outpatient Rehabilitative Therapy (up to 20 visits)
Chiropractic Services (up to 10 visits)
Walk-In / Urgent Care Services
Emergency Room
Emergency Ambulance Services
Home Health Services (up to 100 visits)
Skilled Nursing and Rehabilitation Facilities (up to 90 days)
Disposable Medical Supplies (up to $300)
Durable Medical Equipment (up to $1,500)
Ostomy Supplies and Equipment (up to $1,000)
CALENDAR YEAR COST-SHARE
Individual / Family Out-of-Pocket Maximum
(includes deductible, coinsurance and prescription drugs)
Member Coinsurance
For use with Health Saving Account (HSA)
SOLOHMOHDHP 02/08
Not applicable
Unlimited
Not applicable
In-Network
No Member cost
In-Network
No Member cost
$5,000 / $10,000
In-Network
$5,000 / $10,000
Not applicable
$5,000 / $10,000
HMO HDHP $5,000/$10,000
In-Network
Individual HMO High Deductible Health Plan Options
Ostomy Supplies and Equipment
Emergency Room Services
•
•
Immunizations for Adults, limited to:
- Chickenpox, Influenza, Pneumococcus and Tetanus
Laboratory services associated with a Preventive Office exam, limited to:
- Cervical Cancer Screening - Pap tests
- Cholesterol Screening
- Fasting plasma glucose
- Hematocrit or hemaglobin
- Lead Screening
- Urinalysis
Gynecological Preventive Exam (one per year)
Routine Vision Exam (one per year)
Mammography Screenings, age 40 or older (one per year)
Colonoscopy, age 50 or older (one per year)
Prostate Screening, age 50 or older (one per year)
•
•
•
•
•
•
•
This is a general description of benefits. Please refer to the detailed benefit summaries or
applicable individual policy for benefit limits, exclusions and other details. Producers can
access benefit summaries at www.connecticare.com. The policy will prevail for all benefits,
conditions, limitations and exclusions.
Disposable Medical Supplies
•
Immunizations for Children, limited to:
- Chickenpox, Diphtheria, Hemophilus Influenza B,
Hepatitis A, Hepatitis B, Measles, Mumps, Pertussis,
Pneumococcus, Polio, Rubella, and Tetanus
•
Outpatient Rehabilitative Therapy
Skilled Nursing and Rehabilitative Facilities
Inpatient and Outpatient Mental Health, Alcohol and Substance Abuse
Prescription Drugs
•
•
•
•
•
SOLOHMOHDHP 02/08
Chiropractic Services
•
Durable Medical Equipment
•
Pediatric Preventive Office Exams
•
Walk-in / Urgent Care Center Services
Diagnostic X-ray and Laboratory Services
•
Newborn well baby visits
•
•
Inpatient and Outpatient Hospital Services
•
•
Physician Office Visits (related to illness, injury or sickness)
•
Adult Preventive Office Exam (one per year)
Subject to Plan Deductible*
•
NOT Subject to Plan Deductible*
(HSA Compatible)
How ConnectiCare’s Individual High Deductible Health Plans Work
30%
Not applicable
Not applicable
Unlimited
30%
Out-of-Network
30% after
Plan Deductible
$1,500 / $3,000
Unlimited
Not applicable
In-Network
$15 / $25 / $40
Copayment after
Plan Deductible
In-Network
$30 / $50 / $80
Copayment after
Plan Deductible
Out-of-Network
Not a
covered benefit
Out-of-Network
$3,000 / $6,000
In-Network
$1,500 / $3,000
HMO coverage is underwritten by ConnectiCare, Inc. This plan is issued on an individual basis and is regulated as
an individual health insurance plan. This plan is not available to groups.
Unlimited
Not applicable
In-Network
$15 / $25 / $40
Copayment after
Plan Deductible
In-Network
$30 / $50 / $80
Copayment after
Plan Deductible
$1,500 / $3,000
In-Network
$3,000 / $6,000
In-Network
Member Cost
No Member cost (Plan Deductible waived)
Not a covered benefit
Not applicable
$4,500 / $9,000
$4,500 / $9,000
$3,000 / $6,000
Not applicable
$5,000 / $10,000
Out-of-Network
Not a
covered benefit
Unlimited
30%
Out-of-Network
30% after
Plan Deductible
Not applicable
In-Network
No Member cost
Unlimited
Not applicable
In-Network
No Member cost
Not applicable
In-Network
$5,000 / $10,000
SOLOPOSHDHP 02/08
Out-of-Network
Not a
covered benefit
Unlimited
30%
Out-of-Network
30% after
Plan Deductible
Not applicable
Out-of-Network
$7,000 / $14,000
30%
$10,000 / $20,000
POS HDHP $5,000/$10,000
In-Network
Out-of-Network
$5,000 / $10,000
$7,000 / $14,000
Out-of-Network
Member Cost
Not a covered benefit
Out-of-Network
$6,000 / $12,000
30%
$9,000 / $18,000
POS HDHP $3,000/$6,000
In-Network
Out-of-Network
$3,000 / $6,000
$6,000 / $12,000
POS HDHP $1,500/$3,000
In-Network
Out-of-Network
$1,500 / $3,000
$3,000 / $6,000
Preventive Care Services are exempt from the calendar-year plan deductible. See reverse side for additional information.
MAIL ORDER PHARMACY (Up to a 90-Day supply per prescription)
PRESCRIPTION DRUG COST-SHARE
Individual / Family Pharmacy Cost-Share Maximum
(Maximum does not include the Plan Deductible)
Prescription Drug Benefit Limit
Member Coinsurance
RETAIL PHARMACY (Up to a 30-Day supply per prescription)
COVERED HEALTH SERVICES (Cost-shares for the following services
are the same for all three plan options.)
Preventive Care Services (Refer to back side for more information)
Primary Care Physician Office Services
Specialist Office Services
Pre- and Post-Natal Maternity Care
Outpatient Laboratory and Radiology Services
Outpatient Rehabilitative Therapy (up to 20 visits)
Chiropractic Services (up to 10 visits)
Walk-In / Urgent Care Services
Emergency Room
Hospitalization for Illness or Injury (excludes maternity)
Home Health Services (up to 100 visits)
Skilled Nursing and Rehabilitation Facilities (up to 90 days)
Disposable Medical Supplies (up to $300)
Durable Medical Equipment (up to $1,500)
Ostomy Supplies and Equipment (up to $1,000)
CALENDAR YEAR COST-SHARE
Individual / Family Out-of-Pocket Maximum
(includes deductible, coinsurance and prescription drugs)
Member Coinsurance
For use with Health Saving Account (HSA)
Individual POS High Deductible Health Plan Options
Ostomy Supplies and Equipment
Emergency Room Services
•
•
Immunizations for Adults, limited to:
- Chickenpox, Influenza, Pneumococcus and Tetanus
Laboratory services associated with a Preventive Office exam, limited to:
- Cervical Cancer Screening - Pap tests
- Cholesterol Screening
- Fasting plasma glucose
- Hematocrit or hemaglobin
- Lead Screening
- Urinalysis
Gynecological Preventive Exam (one per year)
Routine Vision Exam (one per year)
Mammography Screenings, age 40 or older (one per year)
Colonoscopy, age 50 or older (one per year)
Prostate Screening, age 50 or older (one per year)
•
•
•
•
•
•
•
This is a general description of benefits. Please refer to the detailed benefit summaries or
applicable individual policy for benefit limits, exclusions and other details. Producers can
access benefit summaries at www.connecticare.com. The policy will prevail for all benefits,
conditions, limitations and exclusions.
Disposable Medical Supplies
•
Immunizations for Children, limited to:
- Chickenpox, Diphtheria, Hemophilus Influenza B,
Hepatitis A, Hepatitis B, Measles, Mumps, Pertussis,
Pneumococcus, Polio, Rubella, and Tetanus
•
Outpatient Rehabilitative Therapy
Skilled Nursing and Rehabilitative Facilities
Inpatient and Outpatient Mental Health, Alcohol and Substance Abuse
Prescription Drugs
•
•
•
•
•
SOLOHMOHDHP 02/08
Chiropractic Services
•
Durable Medical Equipment
•
Pediatric Preventive Office Exams
•
•
Diagnostic X-ray and Laboratory Services
•
Newborn well baby visits
•
Walk-in / Urgent Care Center Services
Inpatient and Outpatient Hospital Services
•
•
Physician Office Visits (related to illness, injury or sickness)
•
Adult Preventive Office Exam (one per year)
Subject to Plan Deductible*
•
NOT Subject to Plan Deductible*
(HSA Compatible)
How ConnectiCare’s Individual High Deductible Health Plans Work
Individual Application/Change Form
Part 1
, Inc. & Affiliates
STEPS TO APPLY
ONLINE:
If you prefer using the Internet rather than paper forms, you can apply for ConnectiCare SOLO online. Applying online has these
advantages:
• It expedites the application process.
• No postage is required.
• It helps us be more “green” in our business practices. When more people use the Internet, we print fewer
forms and conserve paper.
For more information on applying online, contact your agent or broker, who will send you an e-mail invitation that kicks off the
process. Once you’ve submitted your application electronically, you’ll be able to check your application status online as well.
PAPER:
1. Accurately and fully complete the Individual Application Change Form—PART 1– no more than 60 days prior to the
requested effective date. Be sure to:
a.) Check the box for the medical plan being selected.
b.) Select a Primary Care Physician (PCP) for each family member applying for coverage and write the PCP name in the
appropriate box. For a complete list of participating providers, go to “Find a Doctor” at www.connecticare.com or see
our print directory.
2. Accurately and completely answer all questions on the Individual Health Statement — PART 2— for each family member
applying for coverage.
3. Complete, sign and date the Underwriting Authorization Form—PART 3.
4. For applicants under the age of 18, the application must have a parent/guardian’s signature and date – and the parent/guardian’s full name must be printed on the application.
PREMIUM PAYMENTS:
5a. You do not have to submit your first premium payment with your application. However, once you are approved, all
premiums from the date of approval back to the effective date are due by the first month
following the date of your approval letter. This could mean that you may owe us more than one month of
premium. This applies to all payment methods (check, Electronic Funds Transfer (EFT), and credit card).
5b. Paying your premium via Electronic Funds Transfer (EFT). There are two EFT options to choose from:
1. You can sign up for EFT along with your initial application . All you have to do is complete the EFT form and attach
a voided check or statement savings deposit slip with your application. Complete and sign the Electronic Funds
Transfer Form — FORM 4. Be sure to include a check marked “Void”. It will take approximately 30-60 days
from the date your EFT application is submitted for the service to become effective. Until you receive the
Confirmation of Electronic Funds Transfer, please pay your monthly premium by submitting a check to the address on
your premium payment voucher.
48
2. You can wait to sign up for EFT until after you are accepted by and enrolled in ConnectiCare SOLO. This could mean
that you may owe us more than one month of premium. All you need to do is sign the front of the first invoice voucher and return it with your premium payment. For future payment drafts, we will use the checking account number that
appears on the check you submit for the initial premium payment. You do not need to submit a separate form when
enrolling in EFT this way.
5c. Complete and sign the Credit Card Payment Form—FORM 5—if you choose this method of payment. ConnectiCare
will be authorized to initiate a transaction to your credit card to pay all premiums
due going back to the effective date. Please be aware that this could include more than one month
of premium. No charge will be made against your credit card unless your application for individual
health insurance is approved by ConnectiCare.
To continue to pay by credit card, you must register at the ConnectiCare SOLO section on www.connecticare.com and initiate
the transaction each month. Please see the instructions below for monthly credit card payments.
HOW TO ACCESS CREDIT CARD PAYMENTS ONLINE
•
Log onto www.connecticare.com and click “Members.”
•
Click “Managing Your Account.”
•
Click “Billing Invoice & Credit Card Payment” under “Get Information About Your Plan.”
• Enter your username and password. If you are not a registered member, click “Not Registered?” to obtain
your username and password.
• Click “Sign On”, which takes you to “Billing Information.”
• Click “Pay Now” to complete your payment transaction.
For added convenience, recurring credit card payments are coming soon.
5d. If paying by check, all premium payments should be mailed to:
ConnectiCare, Inc.
P.O. Box 30726
Hartford, CT 06150
6. If applicable, complete the Domestic Partner Verification Form or other satisfactory certification as we determine.
7. Optional: Broker Authorization Form—must be completed and received prior to the release of any status
information to broker that includes the applicant’s personal health information.
8. All completed forms must be signed, dated and submitted to your agent or broker. Complete forms must
be received by ConnectiCare by the last day of the month for an effective date on the 1st of the next month.
(i.e. A complete application received by January 31st would be eligible for a February 1st effective date. A
complete application received on February 1st would be eligible for a March 1st effective date.)
9. Effective dates for coverage are the first of the month following underwriting approval.
Acceptance into the plan is based on our review of the Individual Health Statement(s) and the applicant meeting
the eligibility requirements and underwriting criteria. As part of our medical underwriting, ConnectiCare may need access to
your medical records and other medical information. It is the applicant’s responsibility to provide us access to that medical information and to pay for any costs your physician’s office may charge to copy and send us those records. If we do not have complete
medical information, your application will be incomplete, and will be withdrawn if you do not arrange to have the medical
records provided to us within 45 days of the request. For additional copies of ConnectiCare SOLO forms, contact your agent or
broker, or call Member Services at 1-800-251-7722.
49
C O N N E C T I C A R E VALUE - A D D E D R E S O U R C E S
CONNECTICARE
TOUCHPOINTS
Make healthy choices
You’ll find information and guidance about ways
to improve your health status such as losing weight,
quitting smoking and dealing with stress.
The tools for a healthier life.
Right at your fingertips.
Watch for reminders
At ConnectiCare, your
health is at the heart
of everything we do.
That’s why we’re
pleased to offer
you ConnectiCare
Touchpoints, our comprehensive program of
services and information designed to empower you
to take an active role in your health, educate and
guide you to make informed health care decisions,
and offer you support services when you need them.
Keeping track of preventive health immunizations,
tests and screenings is important. ConnectiCare will
assist you by providing targeted communications –
informational mailings, phone calls, and reminder
post cards.
As a ConnectiCare SOLO member, you can take
advantage of everything in the Touchpoints program
at no cost beyond your monthly premium.
Touchpoints is organized in the categories below
to help guide you on the path that best suits your
health needs. For more information on these
categories, please see “Healthy Alternatives” on
page 63, “Website Resources” on page 68, and
“Health Management Programs” on page 70.
Or visit our Web site at www.connecticare.com.
Take stock and keep track
Take your own Health Risk Assessment. Establish
and maintain your Personal Health Record.
And, explore a range of preventive and health
maintenance guidelines, information and tools
at www.connecticare.com.
Manage your condition
Learn about the comprehensive programs
ConnectiCare offers to help you manage a specific
condition, such as asthma, diabetes, and heart
disease. Also learn about our programs designed to
assist members with their hospital stay and other
special health care needs.
Discover the discounts
Through our Healthy Alternatives program you’ll
find discounts on products and services that are up
to 30% of the provider’s usual and customary fee.
This program offers discounts on a wide range of
sources to enhance your well being — from alternative
therapies and nutritional supplements to weight
management programs and fitness centers.
Understand your benefits
You have to know what coverage you’ve got in order
to use it to your best advantage. You’ve got questions.
ConnectiCare is ready with online resources to give
you the answers, such as “Benefit Plan Documents”
and “Treatment Cost Estimator.”
Find out about doctors and hospitals
We’ll provide you with the information you need so
you can choose the right doctor and the right hospital
for the type of care you need. Online resources
include Hospital Safety Comparisons, Physician
Profiles and the Participating Provider Directory.
50
Know your medicine
Sometimes, understanding prescriptions and your
coverage for them can be confusing. We’ll give you
the information you need to help you sort it out.
Through our online Pharmacy Center you’ll find
information on topics such as Mail Order
Prescriptions, Generic Drugs and Medication Safety.
Educate yourself
It’s amazing how much useful information there is
today about health and wellness. Mining the internet
for health information is time-consuming unless
you make www.connecticare.com your first stop.
You can receive daily health updates through “Daily
Health News from WebMD” and “Webcasts from
Healthology ®.” You have access to many sources
of online health information, organized to help you
find what you need fast, such as “Health Topics A
to Z” and “Patient Safety Information.” There’s also
Subimo Healthcare AdvisorTM, an online suite of tools
that helps you be more informed and take an active
role in improving your health status.
HEALTHY
ALTERNATIVES
For many people, good health means more than
a regular doctor’s exam. It means actively seeking
out a wide range of sources to enhance their well
being—from alternative therapies and nutritional
supplements to weight management programs and
fitness centers. If this describes your outlook, you’ll
value and enjoy all the member discounts you can
receive through Healthy Alternatives.
Discounts for all Healthy Alternatives products and
services may be up to 30% of the provider’s usual
and customary fee. (This is the fee that an individual
provider most frequently charges for the specific
product or service.) Note: the following products
and services described in this section are not covered
benefits under your policy; the Healthy Alternatives
program provides discounts on these products
and services.
American WholeHealth
Participating Providers
To receive discounts on the following services, you must
present your ConnectiCare member ID card and use
an American WholeHealth provider from the Healthy
Alternatives Provider List. American WholeHealth
administers the Healthy Alternatives provider network.
For the most recent changes to the Healthy Alternatives
Provider List, visit www.connecticare.com (click on
“Members,” then “Managing Your Account,” and
“Healthy Alternatives.”) Or, call 1-877-243-2998.
51
Fitness Centers
Exercise is easier when it’s convenient. That’s why,
with American WholeHealth’s extensive network of
participating fitness centers, you can find locations
throughout New England and across the country—
an added convenience if you’re traveling for business or pleasure. Pick any participating facility you
want and check it out. If you choose to sign up,
present your ConnectiCare ID card and receive a
discounted rate for yourself and covered family
members. (Special restrictions apply so check with
the fitness center.)
Exercise/Movement/Fitness (including Yoga,
Pilates, Qi Gong and Tai Chi)
Led by an experienced instructor, you can relieve
stress and feel great by moving your body through
a gentle series of exercises that increase flexibility
and strength. Studies show that Yoga, Pilates,
Qi Gong and Tai Chi may have certain healing
qualities, besides their contribution to overall
wellness and good health. Please consult with your
doctor before starting an exercise/movement/fitness
program to discuss how it might meet your health
needs.To receive the discount from a participating
American WholeHealth provider, present your
ConnectiCare ID card at the exercise facility.
Massage/Bodywork
Who hasn’t felt the need for a good massage every
now and then? A licensed massage therapist can
skillfully manipulate your body to help improve
blood flow and even stimulate natural painkillers.
Even people who exercise regularly need to give their
bodies a break, and massage/bodywork is an excellent
way to help recover from the muscle-tightening
effects of stress. To receive the discount from a
participating American WholeHealth provider, present
your ConnectiCare ID card at your appointment.
Relaxation/Mind-Body Techniques
The power of the mind has been shown to influence
the body in many ways. Relaxation and Mind-Body
Techniques are two forms of holistic activities that
may complement your overall health and wellness
52
program. Through the visualization central to these
programs many individuals find comfort and relief
in dealing with specific health concerns. As always
consult your doctor to see if these services might be
beneficial for you. To receive the discount from a
participating American WholeHealth provider, present
your ConnectiCare ID card at your appointment.
Nutritional Counseling
With your full schedule, finding the time to eat a
well balanced diet can be a challenge. A trained
nutritional expert can help you identify ways to
modify your diet, and offer nutritional support for
general health and well being. To receive the discount
on nutritional counseling from a participating
American WholeHealth provider, just present your
ConnectiCare ID card at your appointment. Please
note: Your ConnectiCare health plan also provides
limited coverage for nutritional counseling services
(two visits per member, per calendar year). However,
the nutritional counseling services must be for illnesses
requiring therapeutic dietary monitoring, and must be
rendered by a dietician in a physician’s office in order
to be covered.
Spa Services
Members are offered a variety of spa services at
discounted rates through participating American
WholeHealth locations. For more information,
and to arrange services of interest to you, call the
participating spa directly.
Acupuncture
A centuries-old Chinese healing method, acupuncture
is used to treat disorders like migraines, muscle
spasms, asthma, arthritis and certain skin diseases.
Very fine, sterile needles are inserted into zones
throughout the body called “meridians,” triggering
your brain to respond with its own natural therapy.
To receive the discount from a participating American
WholeHealth provider, present your ConnectiCare ID
card at your appointment.
WholeHealthMD.com
Healthy Alternatives gives you access at no
additional member cost to American
WholeHealth’s award-winning, online education
tools via www.wholehealthMD.com. Here you’ll
find a wealth of health-related resources, including:
• The Healing Kitchen, a collection of healthy
recipes specifically designed to meet the dietary
needs of common medical conditions.
• A comprehensive Reference Library containing
nutritional information on foods, supplements,
prescriptions and over-the-counter medications,
as well as discussions on traditional and alternative
health and wellness therapies.
• A News & Perspectives section that features
articles on fitness, exercise, and complementary
medicine, as well as reviews of popular wellness
books and products.
• An online search feature for finding a health or
wellness facility, or a doctor who specializes in
services for seniors.
53
CONNECTIC ARE’S VALUE-ADDED RESOURCES
Discounts on Other Well
Known Products and
Services
LASIK Eye Surgery
LASIK is a surgical procedure intended to reduce
a person’s dependency on glasses or contact lenses.
Laser vision correction is an FDA-approved
procedure used by ophthalmologists to treat
nearsightedness, farsightedness and astigmatism.
ConnectiCare members are eligible to receive a
discount of up to 25% of the provider’s usual and
customary fees or up to 5% off any advertised
special at all providers affiliated with Davis Vision
LASIK. (Check with your provider to confirm
the discount prior to your appointment.) To find
the nearest Davis Vision LASIK provider, call
1-800-584-2866 or go to www.davisvision.com
and choose “Laser Vision Correction.” Check
with your doctor to determine if LASIK may
be right for you.
Please note that LASIK eye surgery is not a covered
benefit under your ConnectiCare plan. Davis Vision
LASIK providers may not be ConnectiCare participating providers, and ConnectiCare does not review the
credentials of Davis Vision LASIK providers.
New Addition! Jazzercise®
One week free and 15% off the monthly fee.
Jazzercise is a fusion of dance, resistance training,
Pilates, yoga, and kickboxing movements all set
to popular music in a 60-minute class. Some
locations offer a variety of class options, including
Jazzercise Lite, Body Sculpting, and a 30-minute
Jazzercise Express. Benefits include increased
cardiovascular endurance, strength, flexibility,
and an overall feel-good factor. Offer is valid at
participating locations.
For more information, go to jazzercise.com, or
call (800) FIT-IS-IT (800-348-4748).
54
Weight Management
New Addition! Jenny Craig®
Join Jenny Craig and
receive a FREE 30-day
program.* Providing
one-on-one support, Jenny Craig will design a
personalized program that fits your lifestyle.
Everyday your menu will include three meals and
snacks chosen from more than 80 delicious items.
As a Jenny Craig member you can choose from
several programs:
• Free 30-day trial program.* After 30 days, you
can upgrade using the employee discount to
one of the programs below.
• 25% off the Corporate VIP six-month program
or one-year Platinum program.*
• 20% off Jenny Rewards one-year program*:
Weekly food discounts will increase throughout
the year, based on active participation.
Log onto
www.jennycraig.com/corporatechannel/emblem.a
spx and print your coupon.
Bring it along with your employee ID to your
FREE consultation. Call 1-800-96-JENNY
(1-800-965-3669) to find the nearest center, or to
learn more about Jenny Direct, the at-home program.
* Plus the cost of food. Discounts apply to membership
fee only. Offer good at participating centers and
Jenny Direct in the U.S., Canada, and Puerto Rico.
New Addition! NutriSystem®
NutriSystem takes the
work out of weight loss
with food delivered
right to your home. You can eat five times a day,
and there is no counting points, calories, or carbs.
ConnectiCare members will receive two free weeks
of food, plus $30 off all program orders. Program
orders include:
• A full 28 days of NutriSystem foods for
breakfast, lunch, dinner and dessert
• An easy-to-follow daily meal planner
• Free exercise DVD
• Everything delivered to your door
• Free weight-loss counseling and member
website access to NutriSystem’s online tools,
articles, and more.
Weight Watchers®
Providing information,
knowledge, tools and
motivation, Weight Watchers helps you make the
right decisions about nutrition and exercise. The
registration fee to attend Weight Watchers meetings
is waived for ConnectiCare members. To find the
nearest meeting location, call 1-800-651-6000 or
visit www.weightwatchers.com.
Sign up online at http://nutrisystem.com/health
and enter promo code CCI08, or call toll-free
1-877-690-6533.
The Rob Nevins Plan
This customized healthy
eating plan can help you
lose weight and keep it off
through education about
sound nutritional eating.
There are no pills, powders or prepackaged foods
to buy — you learn to control your weight using
everyday foods. First, you’ll receive a complementary
45-minute initial, no-obligation consultation with
a trained nutritional counselor from Rob Nevins.
If you decide to sign up, you’ll receive a 15-percent
discount for being a ConnectiCare member. To enroll,
call 1-800-Y-FAT-LOSS or go to The Rob Nevins
Program Web site at www.robnevins.com.
55
HEALTH
MANAGEMENT
PROGRAMS
If you’re coping with a chronic illness or high-risk
pregnancy, our health management programs can
help. They can provide education and support
to help you understand and participate more
confidently in the management of your condition.
Our programs focus on conditions such as asthma,
chronic obstructive pulmonary disease (COPD),
diabetes, heart failure, coronary artery disease, and
high-risk pregnancy (only applies to plans with
maternity coverage). Each program is available
free of charge to members who have one or more
of these conditions. To learn more, call
1-800-390-3522 or go to the member page at
www.connecticare.com. Click on “Health
Management Center” and “Managing a Condition.”
WEB SITE
RESOURCES
Pull up a keyboard and type in
www.connecticare.com.
At www.connecticare.com, you’ll find more than
We were one of the first health plans in the nation
to receive a full, three-year accreditation from the
NCQA for all of our health management programs.
a well designed, easy-to navigate Web site. You’ll
find interactive tools to help you manage your
health care needs. You can do what used to
require a phone call, a letter, or a visit—all from
the convenience of a personal computer. To take
advantage of the interactive tools below, simply
register online. (It takes only a minute—make sure
to have your ConnectiCare member ID and group
numbers handy.) Then you can start using our
registered member site for all that it’s worth.
On our home page you’ll have access to “Find
A Doctor,” our online directory of participating
providers. This tool helps you find a PCP, specialist,
hospital or other type of provider quickly and
easily. You can even save and print the results of
your search in a user-friendly, personalized format.
On our member site you’ll find a wealth of other
resources, organized as follows:
56
Managing Your Account
Get Information about Your Plan
Member Services
• Benefit Plan Documents – Find basic cost-share
• Secure Messaging – A secure e-mail site for
ConnectiCare registered members. E-mails on
this site do not go over the Internet, but instead
are maintained on the secure ConnectiCare site
for members to retrieve.
information about your plan, including copayments,
• Online Forms – Instant access to the forms you
need, plus clear instructions for use.
deductibles, coinsurance and other information,
whenever you need to.
• Order ID Card/Print Temporary ID Card – Need
a temporary ID card right away? Need a replacement?
Our secure site allows you to order or print an ID
card quickly.
• Billing Invoice and Credit Card Payment –
• Healthy Alternatives – Offering discounts
on a variety of products and services, from
alternative therapies and nutritional
supplements to weight management programs
and fitness centers.
View your billing invoice and pay your monthly
premiums by credit card for added convenience
Your Medical History
• Claim History – Includes claim status, processed
date, charged amount, member responsibility
• Tell us about your Doctor – ConnectiCare
is pleased to offer you an opportunity to tell us
about your doctor.
Update Your Profile
• Change PCP/OBGYN/Change Address — Select
or change your Primary Care Physician or
(when applicable), and other details for you and
your dependents.
• Health Care Financial Summaries – Provides
information to help you monitor your health
care benefit use.
• Prescription Drug List – Print a list of your
Obstetrician/Gynecologist, or update your
medications from a secure site and bring it to
address, quickly and conveniently.
your next doctor’s visit.
• Update e-mail – Verify and update your e-mail
address online.
• Personal Health Record – Serves as a
confidential place for you and your family to
keep health records that you can print out and
bring to your doctor visits.
•Express Scripts Online – Manage your pharmacy
You can set personal health goals
and schedule reminders. Female
members, don’t leave ‘Maintain Your
Health’ without visiting our women’s
health module. You’ll learn about
women’s health — from body image
to menopause to heart disease.
benefits day or night.
57
Health Management Center
Resources and Tools
Maintain Your Health
• Health Risk Assessment (HRA) – provided by
WebMD®, this tool gives you a simple report
on your individual health risks, along with a
personalized plan to help reduce them. The
HRA is just one feature of the ConnectiCare
Personal Health Manager, a powerful suite of
tools created by doctors to help our members
manage their health.
• Men’s Health — Find cancer screening
guidelines, a Men’s Health Center and a
checklist for “Staying Healthy at any Age.”
• Women’s Health – Find information about
osteoporosis, heart disease, body image and
health, menopause and at-risk pregnancy, as
well as daily health news and links to other
women’s health resources.
• Staying Healthy – Find out about
ConnectiCare’s health education programs;
information about immunizations, antibiotics
and weight loss; and links to preventive health
guidelines, the Mayo Clinic Web site and
“Health Topics A-Z.”
Take Control of Your Health
• Live and Work Well – An excellent resource to
help you identify and manage stress, and other
issues related to life’s challenges.
• Find information about weight loss programs,
smoking cessation and patient safety.
Managing a Condition
• Link to information about depression and
ConnectiCare’s health management programs —
BREATHE, for asthma and chronic obstructive
pulmonary disease (COPD); DiabetiCare;
HeartCare and Birth Expectations.
• Personal Health Record – A confidential
place for you and your family to keep health
records that you can print out and bring to
your doctor visits.
• Health Topics A-Z – Find out about all things
health-related -- symptoms, detection, treatment
and prevention.
• Physician/Hospital Quality
Subimo Healthcare Advisor™ — A combined
suite of tools that helps you be more informed
and take an active role in improving your health
status. Tap into the “Decision Guide” and easily
navigate through the wealth of available information.
Compare hospitals based on their experience
with specific procedures. Research and compare
drug treatments for selected conditions.
Leapfrog Group — Find out which hospitals
disclose information about safety practices, and
how they compare in the areas of computerized
drug ordering, staffing for Intensive Care Units
(ICUs) and high-risk treatments.
You’ll also find tools in this section of the site
for comparing hospitals and finding extensive
information on Connecticut-licensed physicians.
• Health Trackers – Everyone needs a little help
keeping track of things. This section gives you the
tools to track cholesterol levels, immunizations,
weight and calories, and more.
58
HEALTH PLAN INFORMATION
Cost of Care
PlanCompare/CostCompare
• Provided by WebMD, this tool helps estimate
health benefit costs for a variety of services.
Plus, it generates a detailed report for
benefit-plan comparison.
Treatment Cost Resources
• Treatment Cost Estimator – Uses data from
millions of people to help you determine the
estimated costs for hundreds of common
conditions, procedures, tests and health care visits.
• Average Cost of Care – Provides examples of
services that are most frequently provided to
our members, and their associated costs.
• Pharmacy Center – Find out which drugs
your plan covers, locate a participating
pharmacy, save money with generic drugs,
research your drug options, and more.
Your privacy and the security of information are our top
priority. First, be sure to read our privacy policy on our
Web site to understand the steps we take to keep your
information private.
Second, we have stored information about you, including
your name, address, your doctor and benefit coverage
information in a secure database. To gain access to many
features of the member site, and to work with your information, you will need to register and log onto the site with
a user name and password that you will create. However,
if you do not want to register to use these services, and
would prefer us to delete your information from our secure
database, please notify us in writing at the following
address: Attn: Webmaster, ConnectiCare, Inc., 175 Scott
Swamp Road, Farmington, CT 06034-4050.
All information on our Web site is available in hard copy
by calling Member Services at (860) 674-5757 or
1-800-251-7722.
VISION CARE BENEFIT
ConnectiCare’s Vision Care benefit extends from
medical and surgical care to routine preventive
care. Covered services at participating providers
include:
• One routine eye exam per member, per calendar
year. Plan covers: 100% after applicable cost-share.
• Frames and lenses*
Lens options include:
Polycarbonate
Scratch-resistant coating
Ultra-violet coating
Anti-reflective coating
Solid tint
Gradient tint
Photochromic
Plan covers: 25% discount on frames and lenses at
or below $250; 30% discount over $250
• Prescription contact lenses* (discounts available
only if associated professional services are also
obtained)
– Hard or soft lenses: 25% discount at or
below $250
– Initial disposable lens package for a member
who has never worn disposable contact lenses:
30% discount over $250; 25% discount on
associated professional services (i.e., fittings)
• Additional coverage*
Sunglasses: 25% discount
– Prescription
– Non-prescription
Replacement lenses/frames
• Medical eye exam: medically necessary medical
and surgical diagnosis and the treatment of
diseases or other abnormal conditions of the
eye and adjacent structures. 100% after the
applicable cost-share. The cost-share depends
on where services are rendered.
* All discounts apply to eyewear purchased from examining
participating practitioner within 90 days of exam. Specific
benefits available are subject to change.
59
PHARMACY BENEFITS
AND MANAGEMENT
Prescription drugs and supplies are covered under
the ConnectiCare SOLO HMO plans. They’re
optional under the ConnectiCare SOLO POS
plans. If your plan includes benefits for prescription
drugs, the drugs are placed in a tiered system that
indicates what your cost-share amount will be.
Tier-one drugs have the lowest cost-share level,
tier-two drugs have an intermediate cost-share
level, and tier-three drugs have the highest
cost-share level. To find out whether a particular
medication is on ConnectiCare’s drug list, and
what tier it is, call 1-800-251-7722 or go to
“Pharmacy Center” at www.connecticare.com.
Please note that the drug list can change during
the year, so call the number above or check the
Web site for the latest information.
If you’re a member of one of the HMO plans,
you’ll be required to use a participating pharmacy.
(And if you’re a member of one of the POS plans,
you’ll make the most of your benefits if you use a
participating pharmacy.) To locate one near you, call
the phone number above or visit the Web site above.
Some medications covered by ConnectiCare
need prior authorization. You can view the
list of prescription drugs that require prior
authorization by clicking on “Pharmacy Center”
at www.connecticare.com, or by calling Member
Services at 1-800-251-7722.
ConnectiCare also has a Quality Management Drug
Program to limit certain medication quantities to
established amounts. This program is designed to
promote compliance with dosing recommendations
of the manufacturer and the Food and Drug
Administration, and to prevent abuse and misuse.
Reimbursement is limited to these quantities
unless ConnectiCare receives a medical necessity
request from the prescribing physician, and has
60
authorized the additional quantity. You can
view the list of drugs that have quantity limits
by clicking on “Pharmacy Center” at
www.connecticare.com, or by calling Member
Services at 1-800-251-7722.
POS Plan members, please note: If you have
declined the option for prescription drug coverage,
you are still eligible for discounts on your out-of-pocket
drug costs by showing your ConnectiCare member
ID card at participating retail pharmacies. This
discount is made available through an arrangement
between these retail pharmacies and Express Scripts,
our prescription drug vendor. For more information,
visit “Pharmacy Center” at www.connecticare.com
and click on “Express Scripts,” or call Member
Services at 1-800-251-7722.
COVERAGE FOR
URGENT AND
EMERGENCY CARE
PARTICIPATING
PROVIDER
AVAILABILITY
If an emergency ever occurs, don’t wait. Go to the
closest emergency room right away. Call 911 if
you need help getting there. If possible, let your
doctor know what’s happening.
As a member, you’ll have access to more than
20,000 participating providers in our tri-state
network, Including every Connecticut hospital.
To locate a participating physician, specialist or
other health care practitioner, consult our printed
participating provider directory. Or, for the most
recent updates, visit our online participating
provider directory, at www.connecticare.com.
Please notify us within 24 hours of your hospital
admission at 860-674-5870, or 1-800-251-7722.
(A friend or family member can call on your
behalf. If you can’t act that quickly, notify us
as soon as you or someone else is able.)
NO REFERRALS
NEEDED
Even though all ConnectiCare SOLO plans are
“open access,” you are still encouraged to choose a
Primary Care Physician (PCP) on your enrollment
form. Your PCP will assist you and coordinate
your care outside of his or her office. If you do not
choose a PCP, ConnectiCare will automatically
assign one for you that is located near your
home. However, we encourage you to select
your own PCP.
PCPs include doctors who maintain a general
practice, pediatricians, family practitioners,
and practitioners of internal medicine. Note: you
and your covered dependents do not need to have the
same PCP. Each of you can choose a different doctor.
If you’re a member of our Individual Point-ofService (POS) plan, you also have the freedom
to go outside the ConnectiCare participating
provider network for covered services. However,
keep in mind that benefits are paid at a lower level
when you use non-participating providers, and
they may bill you for any outstanding balance.
PRE-AUTHORIZATION
REQUIRED FOR
SOME SERVICES
Some services require our prior approval. Please
check your policy and any updates in our Housecall
newsletter, mailed twice a year to members. For
more information on covered services that require
pre-authorization or pre-certification, visit the
member section of www.connecticare.com, or
call Member Services at 1-800-251-7722.
61
WHAT IS UTILIZATION
MANAGEMENT?
“Utilization management” refers to the programs
and procedures we use to evaluate the quality,
medical necessity and efficiency of covered services.
Decisions about whether ConnectiCare will pay
for care are based on national standards, with local
physician input. We do not reward or offer financial
incentives to physicians or other individuals making
decisions about whether we will pay for health care
treatments, drugs or supplies.
Pre-Authorization/Pre-Certification
• For example, ConnectiCare requires pre-authorization or pre-certification of selected services.
Your physician may seek this authorization, but
it is your responsibility to make sure it has been
approved before you get the care or service. If
you are a member in one of the HMO plans,
all health care services and supplies must be
ordered, rendered and supplied by a participating
practitioner or provider facility—or the service
or supply may not be covered.
62
Concurrent review
• When you or your dependents are admitted
to the hospital or a skilled nursing facility, a
ConnectiCare nurse case manager may review
the care you receive and speak with your caregivers
during your stay. The purpose of this concurrent
review is to promote receipt of medically necessary
services at the appropriate level and to help plan
and coordinate services for your discharge home.
Concurrent review may be conducted if you
receive home care services.
Third-party administrators
• We may use outside companies to manage and
administer certain categories of benefits or
services under this plan. For example, mental
health and substance abuse care services are
managed by United Behavioral Health.
MEMBERS’ RIGHTS
AND
RESPONSIBILITIES
You have the biggest stake in your own health.
Shouldn’t you be involved in making decisions for
your care? We think so. To make the best choices,
you need the facts. Knowing your rights is
important. Refer to your policy for complete
plan information.
Your Rights
You are encouraged to actively participate in
decision-making with regard to managing your
health care. As a member of ConnectiCare SOLO,
you will enjoy certain rights and benefits. You
have a right to:
• Receive information about us, our services, and
our Participating Providers.
• Be treated with respect and recognition of your
dignity and right to privacy.
• Participate with practitioners in decision-making
regarding your health care.
• A candid discussion of appropriate or medically
necessary treatment options for your condition,
regardless of cost or benefit coverage.
• Refuse treatment and to receive information
regarding the consequences of such action.
• Voice complaints or appeals about us or the
care you are provided.
• Make recommendations regarding the
organization’s Members’ Rights and
Responsibilities policies.
• Refuse to authorize the transfer of records,
understanding that such action may terminate
your relationship with your physician, and may
result in the denial of benefits, and may cause
any associated Appeal Process to be terminated,
and may require you to disenroll from this Plan.
Your Responsibilities
While enjoying specific rights of membership,
you will also have the following responsibilities.
You will have a responsibility to:
• Select a Primary Care Physician (PCP).
• Provide, to the extent possible, information
that providers need to render care.
• Follow the plans and instructions for care that
you have agreed on with practitioners.
• Pay monthly premiums by the first day of
the month.
• Pay all premiums accumulated up to the date
of termination.
• Provide 30-day advance notice to terminate your
policy so that Electronic Funds Transfer (EFT),
recurring credit card payments, monthly billing,
and other related functions can be stopped.
• Understand your health problems and participate
in developing mutually agreed-upon treatment
goals to the degree possible.
• Be considerate of our participating providers,
and their staff and property, and respect the
rights of other patients.
• Read your policy, which describes the Plan’s
benefits and rules.
63
CONTACT US
HOW TO CONTACT US
Call Member Services at (860) 674-5757
or 1-800-251-7722 for assistance with
the following:
•
•
•
•
Claims
Policy-related issues
To verify pre-authorization or pre-certification
Pharmacy services
If you are submitting a claim — except
for mental/behavioral health—mail to:
ConnectiCare Claims
P.O. Box 546
Farmington, CT 06034-0546
If you are submitting a mental/
behavioral health claim, mail to:
ConnectiCare Claims
United Behavioral Health (UBH)
P.O. Box 30757
Salt Lake City, UT 84130-0757
If you are making a premium
payment, mail to:
ConnectiCare, Inc.
P.O. Box 30726
Hartford, CT 06150
If you have a question or complaint,
contact:
ConnectiCare Member Services
175 Scott Swamp Road
Farmington, CT 06034 or
www.connecticare.com or call 1-800-251-7722
If you have a question about Health
Savings Accounts:
call First HSA toll-free at 1-888-769-8696 or go
to www.1hsa.com
64
65
IMPORTANT NOTICE
There are some instances where your total health plan costs may be higher with a High-Deductible
Health Plan (HDHP) than with a non-HDHP.
When you meet the deductible under your health plan, the health plan will pay for all remaining
covered medical expenses for the calendar year, except that you may still be responsible for any
applicable cost-share for prescription drug expenses.
Please note: There may be some rare circumstances in which the fee that is contracted between
ConnectiCare and its providers can be higher than the billed rate. In these instances (less than 1%
of all cases) a member will be required to pay the amount for these covered services even though
the billed rate may be lower. This payment arrangement must be met to allow for the tax-qualified
status of his or her HDHP.
ConnectiCare’s HDHPs are intended to be appropriate for use with HSAs. The HDHPs have been
designed to conform with Federal Internal Revenue Service (IRS) guidelines. However, the IRS has
made no determination that the HDHPs are qualified. Whether or not an HSA used with these Plans
will provide a ConnectiCare member with a tax advantage depends on a number of circumstances,
including the member’s personal coverage situation, contributions to and withdrawals from the
HSA, other coverage a member or spouse may have, and changes to or interpretations of IRS rules.
Members should consult with a qualified tax advisor in determining whether and how this option
may provide them with a tax benefit. ConnectiCare cannot guarantee that tax benefits will accrue
to anyone covered under the HDHPs.
ConnectiCare provides only health plan coverage and administration. First HSA provides HSA
accounts and administration. The accounts are separate from ConnectiCare health plans and must
be set up and administered by organizations qualified to offer HSAs. ConnectiCare is not responsible
for the administration of any HSA or other financial accounts used in connection with its health
coverage products, and you are not required to use ConnectiCare’s preferred vendors to set up an
HSA. First HSA may charge you a fee for the set-up or administration of your HSA.
This brochure is only a general overview of some HSA information. It is not intended to provide
tax or legal advice of any kind, and neither the accuracy nor completeness of any information is
guaranteed. Consult a qualified tax or legal professional with any tax or legal questions you may
have. This is a brief summary of benefits and is not a guarantee of coverage. Refer to the appropriate
ConnectiCare policy for more detailed information, exclusions and limitations. The policy will
prevail for all benefits, conditions, limitations and exclusions.
HMO coverage is underwritten by ConnectiCare, Inc.; POS coverage is underwritten by
ConnectiCare Insurance Company, Inc.
HSAs are complex arrangements subject to various tax rules and regulations, which are not
explained in this brochure. Please read the “IMPORTANT NOTICE” at the end of this brochure.
175 Scott Swamp Road, Farmington, CT 06034
www.connecticare.com
HMO coverage is underwritten by ConnectiCare, Inc.; POS coverage is underwritten by ConnectiCare Insurance Company, Inc.
This plan is issued on an individual basis and is regulated as an individual health insurance plan.
This plan is not available to employer groups.
SOLOHDHP MG OCT 08

member guidebook

Transcription

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