Pages 1--32 from Untitled

Compcare Health Services 2000
A Health Maintenance Organization

For changesin 3 benefitssee
page

Serving Southeast Northcentral and Northwestern Wisconsin
Enrollment in this Plan is limited see page 4 for requirements
Southeast Wisconsin enrollment codes
691 Self Only
692 Self and Family

Northcentral and Northwestern Wisconsin enrollment codes
6X1 Self Only
6X2 Self and Family

Visit the OPM Website at http www opm gov insure
and
our website at http www compcare uwz com

Authorized for distribution by the
United States Office of
Federal Employees
Personnel Health Benefits Program Management

RI 73 022 1
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Compcare Health Services Insurance Corporation 2000
Table of Contents

Introduction 1
Plain Language 1
How To Use This Brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How We Change For 2000 3
Section 3 How To Get Benefits 4
Section 4 What To Do If We Deny Your Claim Or Request For Service 9
Section 5 Benefits 11
Section 6 General Exclusions Things We Don't Cover 22
Section 7 Limitations Rules That Affect Your Benefits 23
Section 8 FEHB Facts 25
Inspector General Advisory Stop Healthcare Fraud 28
Summary of Benefits inside back cover
Premiums back cover 2
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Compcare Health Services Insurance Corporation 2000
Introduction
Compcare Health Services Insurance Corporation
401 W Michigan Street Milwaukee Wisconsin 53203

This brochure describes the benefits you can receive from Compcare under its contract CS1361 with the Office of Personnel
Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of
benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled
for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page
3 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the
public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to Compcare Health Services Insurance Corporation as this Plan throughout this brochure even though in other legal
documents you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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Compcare Health Services Insurance Corporation 2000
How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

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Compcare Health Services Insurance Corporation 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment

Section 2 How We Change For 2000
Program wide This year you have a right to more information about this Plan care management our networks
changes facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3
How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you may
add a brief statement to it If they do not provide you your records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer

Changes to this Enrollment Code 69 Your share of the non postal premium will increase by 9.1 for Self Only or
Plan 8 for Self and Family

Enrollment Code 6X Your share of the non postal premium will increase by 23.3 for Self Only or
23.3 for Self and Family

The Plan has expanded its service area by covering all of Manitowoc County and adding Waupaca
and Price counties Previously the Plan only covered a portion of Manitowoc County

Mental Conditions Substance Abuse Benefits have been clarified to show how you can access these
providers directly without a referral from your primary care doctor

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Compcare Health Services Insurance Corporation 2000
Section 3 How To Get Benefits
What is this Plan's To enroll with us you must live in our service area This is where our providers practice Our service
service area area is

Southeastern Region

Milwaukee area The counties of Milwaukee Ozaukee Racine Washington and Waukesha Also
portions of Dodge Fond du Lac Jefferson Kenosha Racine Sheboygan and Walworth counties
denoted by the zip codes on page 5

Waukesha area The counties of Milwaukee and Waukesha Also portions of Dodge Jefferson
Ozaukee Racine Walworth and Washington counties denoted by the zip codes on page 5

West Bend area The counties of Ozaukee and Washington Also portions of Dodge Fond du Lac
Jefferson Sheboygan and Waukesha counties denoted by the zip codes on page 5

Janesville area Rock County Also portions of Dane Green Jefferson Racine and Walworth
counties denoted by the zip codes on page 5

Racine area Racine and Kenosha Counties Milwaukee County south of the I 94 East West
Expressway Also portions of Walworth and Waukesha counties denoted by the zip codes on page 5

Burlington area Portions of Kenosha Milwaukee Racine Walworth and Waukesha counties
denoted by the zip codes on page 5

Sheboygan area Sheboygan and Manitowoc Counties Also portions of Fond du Lac Ozaukee and
Washington counties denoted by zip codes on page 5

Northcentral Region
The counties of Clark Forest Langlade Lincoln Marathon Oneida Portage Shawano Taylor Vilas
Waupaca and Wood

Northwestern Region
The counties of Ashland Bayfield Burnett Douglas Iron Pepin Pierce Polk Price Sawyer St
Croix and Washburn

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Compcare Health Services Insurance Corporation 2000
Section 3 How To Get Benefits continued
You may also enroll with us if you live or work in the following zip code locations
Southeastern Region
Milwaukee area
53002 04 53027 53075 53105 53148 49 53176 77
53010 53036 53091 53118 20 53152 53182
53013 53040 53101 53138 39 53159 53403
53021 53066

Waukesha area
53003 53036 38 53092 53120 21 53150 53182
53012 53047 53094 95 53126 53156 53185
53017 53059 60 53103 53130 53157 53190
53022 53066 53105 53137 53176 53538
53027 53076 78 53108 53138 39 53178 53549
53033 34 53086 53118 19 53148 49

West Bend area
53001 07 53023 53039 40 53059 60 53077 79 53099
53009 11 53026 27 53043 553064 66 53085 53209
53013 53029 53046 48 53070 53087 53217 18
53016 17 3031 32 53050 51 53072 73 53089 91 53219
53021 53034 36 53056 57 53075 53093 94 53223 25
53935

Janesville area
53114 15 53138 53180 53502 53538 53574 75
53120 21 53147 48 53184 85 53508 53549 50 53585
53125 53156 57 53190 91 53520 21 53566 53589
53128 53176 53195 53523 53570

Racine area
53103 53120 53130 53148 50 53157 53176
53105 53128 53138

Burlington area
53101 53120 21 53138 39 53159 53176 53185
53104 05 53125 26 53147 50 53167 68 53179 53191 92
53108 09 53128 53152 53170 53181 82 53194
53115 53130 53157

Sheboygan area
53004 53021 53040 53057 53060 62 53079

Northcentral Region
54401 54439 43 54462 3 54484 5 54548 54566
54403 54445 49 54465 7 54487 90 54554 54568
54405 14 54451 52 54469 71 54531 54558 54746
54418 28 54454 57 54473 6 54539 41 54561 2 54776
54433 37 54460 54479 81

Northwestern Region
54514 54546 7 54814 54834 6 54859 54880
54517 54550 54816 7 54838 9 54861 2 54888
54525 54559 54820 1 54842 7 54864 5 54890 1
54527 8 54565 54827 8 54849 50 54867 54893
54534 54801 54832 54854 6 54870 6 54896
54536 54806

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Compcare Health Services Insurance Corporation 2000
Section 3 How To Get Benefits continued
Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health care
services particularly those of specialists unless they are obtained through your Primary Care
Physician Chiropractic services oral surgery and mental health and substance abuse services are
covered without a referral when performed by one of our plan providers

If you or a covered family member move outside of our service area you can enroll in another plan If
your dependents live out of the area for example if your child goes to college in another state they
may be able to receive benefits under our Away From Home Care guest membership program This
program provides care for routine follow up urgent and emergency situations just as your home Plan
does If you or a family member move you do not have to wait until Open Season to change plans
Contact your employing or retirement office

How much do I You must share the cost of some services This is called either a copayment a set dollar amount or
pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for pre natal office visits and all necessary medical and surgical care in a

hospital or extended care facility from Plan providers
Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments
which are required for a few benefits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the

service Either OPM or we can extend this deadline if you show that circumstances beyond your
control prevented you from filing on time

Who provides my Compcare Health Services is a mix of both medical groups and individual doctors In Burlington
health care Janesville Racine Sheboygan Waukesha and West Bend the Plan has medical groups In Milwaukee and the Northcentral and Northwestern regions the Plan has both medical groups and individual

doctors Each medical group consists of doctors from different specialties who practice in a common
center or centers The individual doctors are generally available to Plan members in groupings
commonly known as Individual Practice Associations IPAs which consist of doctors of different
specialties who practice in their own offices

The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this doctor that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care doctor to
obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization See How do I get specialty care below for services that you can
receive without a referral from your primary care doctor

Please note
If you want to enroll in a certain medical group or IPA you must reside within the area in which that
group or IPA practices For example the Milwaukee area providers IPA doctors and medical groups
are available only to people who live in the enrollment area for the Milwaukee region shown on page
4 The areas in which the various Plan providers practice and are available for selection are shown in
detail in the Plan's provider directory
Members within the same family may choose physicians from different networks For example a
member can belong to one medical group IPA a spouse can belong to a different medical group IPA
and a child can belong to yet another medical group IPA

Our provider directory lists primary care doctors family practitioners pediatricians and internists
with their locations and phone numbers and notes whether or not the doctor is accepting new patients
Directories are updated on a regular basis and are available at the time of enrollment or upon request by

6 calling the Member Services Department at 1 800 492 4049 or 414 276 2273 in the Southeast region 8
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Compcare Health Services Insurance Corporation 2000
Section 3 How To Get Benefits continued
by calling 1 800 258 5299 in the Northcentral region or by calling 1 800 368 4453 in the
Northwestern region you can also find out if your doctor participates with our Plan by calling these
numbers If you are interested in receiving care from a specific provider who is listed in the directory
call the provider to verify that he or she still participates in the Plan and is accepting new patients

Important note When you enroll in our Plan services except for emergency benefits are
provided through the Plan's delivery system the continued availability and or participation of
any one doctor hospital or other provider cannot be guaranteed

If you enroll you will be asked to let us know which primary care doctor s you've selected for you
and each member of your family by sending a selection form to us If you need help in choosing a
doctor call us Members may change their doctor selection by notifying us 30 days in advance

If you are receiving services from a doctor who leaves the Plan we will pay for covered services until
we can arrange with you for you to be seen by another participating doctor

What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan

What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or authorized
to go into the hospital specialist will make the necessary hospital arrangements and supervise your care

What do I do if I'm in First call our customer service department at 1 800 492 4049 or 414 276 2273 in the Southeastern
the hospital when region 1 800 258 5299 in the Northcentral region or 1 800 368 4453 in the Northwestern region If
I join this Plan you are new to the FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and are switching to us your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will arrange your referral to a specialist
specialty care Except in a medical emergency or in case of the exceptions mentioned on page 6 or when a primary

care doctor has designated another doctor to see his or her patients you must receive a referral from
your primary care doctor before seeing any other doctor or obtaining special services Referral to a
participating specialist is given at the primary care doctor's discretion if non Plan specialists or
consultants are required the primary care doctor will arrange appropriate referrals Services of other
providers are covered only when you have been referred by your primary care doctor with the
following exceptions Chiropractic services oral surgery and mental health and substance abuse
services are covered without a referral when performed by a Plan provider A woman may also select
an obstetrician gynecologist as a secondary primary care doctor this selection must be made from her
primary care doctor's medical group or IPA A woman may see her plan obstetrician gynecologist for
her annual routine examination without a referral Certified nurse practitioners are covered when under
the supervision of a Plan medical doctor

When you receive a referral from your primary care doctor you must return to the primary care doctor
after the consultation unless your doctor authorizes additional visits All follow up care must be provided
or authorized by the primary care doctor Do not go to the specialist for a second visit unless your
primary care doctor has arranged for and we have issued an authorization for the referral in advance

If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan and will require our approval before beginning the treatment 7 9
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Compcare Health Services Insurance Corporation 2000
Section 3 How To Get Benefits continued
What do I do if I am If you are already under the care of a specialist who is a Plan participant you must still obtain a
seeing a specialist referral from a Plan primary care doctor for the care to be covered by the Plan If the doctor who
when I enroll originally referred you to this specialist is now your Plan primary care doctor you need only call to explain that you are now a plan member and ask that you be referred for your next appointment

If you are selecting a new primary care doctor and want to continue with this specialist you must
schedule an appointment so that the primary care doctor can decide whether to treat the condition
directly or refer you back to the specialist Generally we will not pay for you to see a specialist who
does not participate with our Plan

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive
specialist leaves the services from your current specialist until we can make arrangements for you to see someone else
Plan

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue
serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
provider leaves the provider unless the termination is for cause If you are in the second or third trimester of pregnancy
Plan or this Plan you may continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide your
care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If
you are in your second or third trimester your new plan will pay for the OB GYN care you receive
from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist or
medical services recommending follow up care Before giving approval we consider if the service is medically necessary to prevent diagnose or treat your illness or condition and if it follows generally accepted

medical practice

How do you decide if a Determinations are made by the Plan Medical Director Various sources are used to assist the Medical
service is experimental Director in the decision making process These sources include peer reviewed medical literature
or investigational Medicare Policy established by the Medicare Part B Carrier Advisory Committee technology evaluations or clinical guidelines published by nationally recognized professional or government

organizations and consultation with independent board certified medical specialists

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Compcare Health Services Insurance Corporation 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM
to review a denial will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a serious Call us at 1 800 492 4049 or 414 276 2273 in the Southeastern region 1 800 258 5299 in the
or life threatening Northcentral region or 1 800 368 4453 in the Northwestern region and we will expedite our review
condition and you
haven't responded to
my request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
care and my condition health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening
is serious or life conditions are ones that cause permanent loss of bodily functions or death if they are not
threatening treated as soon as possible

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time limits denial or refusal of service You may also ask OPM to review your claim if

1 We did not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we do not answer within 30 days
In this case OPM must receive your request within 120 days of the date we asked you for
additional information

What do I send Your request must be complete or OPM will return it to you You must send the following
to OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to
which claim 9 11
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Compcare Health Services Insurance Corporation 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service continued
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with
the review request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim Contract Division IV P O Box 436 Washington D C 20044
to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third

year after the year in which you received the disputed services or supplies

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the

Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record

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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits
Medical and Surgical Benefits
All care must be received from or arranged by Plan doctors

What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay 10 per office visit 25 per
visit to an outpatient facility Within your Service Area house calls will be provided if in the judgement
of the Plan doctor such care is necessary and appropriate you pay a 10 copay for a doctor's house call
or for home visits by nurses and health aides You pay a 25 copay for services rendered in an
outpatient treatment facility

The following services are included and are subject to office visit copays unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during
these five years for women age 40 through 49 one mammogram every one or two years for women
age 50 through 64 one mammogram every year and for women age 65 and above one mammogram
every two years In addition to routine screening mammograms are covered when prescribed by the
doctor as medically necessary to diagnose or treat your illness

Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and x rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor The copay is waived for all prenatal office visits The mother at her
option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a
caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is
terminated during pregnancy benefits will not be provided after coverage under the Plan has ended
Ordinary nursery care of the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self and Family enrollment
other care of an infant who requires definitive treatment will be covered only if the infant is covered
under a Self and Family enrollment

Voluntary sterilization family planning services
Diagnosis and treatment of diseases of the eye eye exams and refractions as necessary
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Kidney cornea heart heart lung liver single lung double lung and pancreas transplants allogeneic
donor bone marrow transplants autologous bone marrow transplants autologous stem cell and
peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced
neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer testicular mediastinal
retroperitoneal and ovarian germ cell tumors Donor costs are covered when the recipient is covered
by the Plan you pay 20 of charges

Physical and occupational therapy speech therapy for impairments of organic origin
Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 13
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
Chiropractic services from a participating chiropractor a referral from your primary care doctor is not
necessary

Home health services of nurses and health aides including intravenous fluids and medications when
prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
other Plan providers at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and
excision of tumors and cysts and surgical treatment of temporomandibular joint TMJ pain
dysfunction syndrome The extraction of seven or more fully erupted teeth is covered under Dental
care page 20 The following oral surgery procedures are also covered when performed by a Plan
provider

Surgical removal of impacted teeth
Apicoectomy alveolectomy frenectomy vestibuloplasty
Residual root removal root amputation
Periodontal surgery
Excision of exostoses of the jaws and hard palate
External incision and drainage of cellulitis
Incision of accessory sinuses salivary glands or ducts

All other procedures involving the teeth or intra oral areas surrounding the teeth are not covered
including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction
syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending
physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance

Diagnosis and treatment of infertility including artificial insemination is covered You pay nothing for
the first 2,000 of infertility testing and treatment per member per lifetime and 50 of charges
thereafter The following types of artificial insemination are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI Cost of donor sperm is not
covered Fertility drugs are covered under the Prescription Drug Benefit Other assisted reproductive
technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation Phase I and II following a heart transplant bypass surgery or a myocardial
infarction is provided in full You pay nothing

Orthopedic devices such as braces prosthetic devices such as artificial limbs breast prosthesis and
surgical bras ostomy supplies and lenses implanted following cataract surgery and durable medical
equipment such as wheelchairs glucose monitors and hospital beds are covered You pay a 25
deductible per member per year nothing thereafter One insulin infusion pump per calendar year for
diabetes is covered under this benefit provided you use it successfully for 30 days prior to coverage

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services custodial care
Hearing aids
Transplants not listed as covered
Orthopedic shoes except for reverse and straight last shoes shoes attached to a brace and Thomas heels
Vision supplies including eyeglasses or contact lenses and their fitting except when lenses are
implanted during cataract surgery external lenses following cataract surgery are not covered

Foot orthotics

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
Hospital Extended Care Benefits
What is covered
Hospital care We provide a comprehensive range of benefits with no dollar or day limit when you are hospitalized
under the care of a Plan doctor You pay a 100 copay per admission subject to an annual maximum of
200 per member per year All necessary services are covered including

Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units

Extended care We provide a comprehensive range of benefits for up to 30 days per member per year when full time
skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate
as determined by a Plan doctor and approved by us You pay nothing All necessary services are
covered including

Bed board and general nursing care
Biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility
when prescribed by a Plan doctor Drugs are covered under the prescription drug benefit See page 18

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility
Services include inpatient and outpatient care and family counseling these services are provided under
the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life
expectancy of six months or less

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay 25
per incident

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need
procedures for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
hospitalization but not the cost of the professional dental services Conditions for which hospitalization
would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a
condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate
See page 17 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that a prudent
emergency layperson would believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly

they might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes poisonings
gunshot wounds or sudden inability to breathe There are many other acute conditions that we may
determine are medical emergencies what they all have in common is the need for quick action

Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if
the service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel

that you are a Plan member so they can notify us You or a family member must notify your Plan
primary care physician within 48 hours or on the first working day following your admission to
arrange for any necessary follow up care It is your responsibility to ensure that your primary care
physician has been timely notified

If you need to be hospitalized we must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify us within that time If you are
hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan
hospital you will be transferred when medically feasible with any ambulance charges covered in full

Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition

For services to be covered by this Plan any follow up care recommended by non plan providers must
be approved by us or provided by Plan providers

We pay Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers

You pay 25 per member per hospital emergency room visit or urgent care center visit for emergency services
which are covered benefits of this Plan Inpatient admissions are subject to the hospital deductible of
100 per admission subject to an annual maximum of 200 per member per year If you are admitted
as an inpatient the 25 copayment will be waived and the inpatient deductible will apply If you have
met your annual maximum the 25 copay will apply

Emergencies outside Benefits are available for any medically necessary health service that is immediately required because
the service area of injury or unforeseen illness

If you need to be hospitalized we must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify us within that time If a Plan
doctor believes care can be better provided in a Plan hospital you will be transferred when medically
feasible with any ambulance charges covered in full

For services to be covered by this Plan any follow up care recommended by non plan providers must
be approved by us or provided by Plan providers

We pay Reasonable charges for emergency care services to the extent the services would have been covered if
received from Plan providers

You pay 25 per member per hospital emergency room visit or urgent care center visit for emergency services
which are covered benefits of this Plan Inpatient admissions are subject to the hospital deductible of
100 per admission subject to an annual maximum of 200 per member per year If you are admitted
as an inpatient the 25 copayment will be waived and the inpatient deductible will apply If you have
met your annual maximum the 25 copay will apply

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 17
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by us

What is Elective care or non emergency care
not covered Emergency care provided outside the service area if the need for care could have been foreseen before
leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the Service
Area

Filing claims for With your authorization we will pay benefits directly to the providers of your emergency care upon
non Plan providers receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to us along with an explanation

of the services and the identification information from your ID card Payment will be sent to you or
the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which
denial was based If you disagree with our decision you may request reconsideration in accordance
with the disputed claims procedure described on page 10

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits
Important Note A primary care doctor referral is not required for members to access mental conditions substance abuse providers To
find out who your provider is call our Customer Service Department at the phone numbers listed on page 7 or your medical group's
patient coordinator or you may refer to our medical group listing in the Plan's Provider Directory

Mental Conditions
What is covered To the extent shown below we provide the following services necessary for the diagnosis and treatment
of acute psychiatric conditions including the treatment of mental illness or disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care All necessary outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
year you pay nothing for first 20 visits or up to 1,800 in visit charges whichever is greater 20 of
charges thereafter

Inpatient care Up to 120 days of hospitalization including related doctors charges each calendar year you pay
nothing for first 30 days 20 of charges for days 31 120 all charges after 120 days

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate

Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition

Substance Abuse
What is covered We provide medical and hospital services such as acute detoxification services for the medical nonpsychiatric
aspects of substance abuse including alcoholism and drug addiction the same as for any other
illness or condition and to the extent shown below the services necessary for diagnosis and treatment

Outpatient care All necessary outpatient visits to Plan provider for treatment you pay nothing for first 35 covered visits
or up to 1,800 in visit charges whichever is greater 20 of charges thereafter

Inpatient care All necessary substance abuse rehabilitation intermediate care in an alcohol detoxification or
rehabilitation center approved by us you pay nothing

What is not covered Treatment that is not authorized by a Plan doctor

Transitional care
What is covered In addition to our inpatient and outpatient care for the treatment of both mental conditions and
substance abuse we will provide transitional care up to the greater of 10 days of treatment or charges
of 2,700 per person per year This care consists of community based residential care for persons who
have been treated in institutions for either mental conditions or substance abuse You pay nothing for
the first 10 days of treatment or the first 2,700 of charges whichever is greater all charges thereafter

What is not covered Treatment that is not authorized by a Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17 19
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply You pay a 7 copay per prescription unit or refill for up to a 34

day supply or 100 unit supply whichever is less 240 milliliters of liquid 8 oz 60 grams of ointment
creams or topical preparation or one commercially prepared unit i e one inhaler one vial ophthalmic
medication or insulin for generic drugs or 12 for name brand drugs when generic substitution is not
permissible or available When generic substitution is permissible i e a generic drug is available and
the prescribing doctor does not require the use of a name brand drug but you request the name brand
drug you pay the price difference between the generic and name brand drug as well as the 7 copay
per prescription unit or refill

Drugs are prescribed by plan doctors and dispensed in accordance with our managed drug formulary
We make the determination to include exclude specific drugs on its formulary based on the benefit
design of coverage medical policy on therapy protocols and managed formulary decisions such as
identical products or drugs considered less than effective Should a physician ask for prior approval
or a denied drug claim is appealed our Pharmacy Services department will request patients medical
and pharmacy history and will request a physician consultant's opinion A full medical review will be
done if necessary

Covered medications Drugs for which a prescription is required by Federal law
and accessories Full range of FDA approved drugs prescriptions and devices for birth control injectable
include contraceptive drugs subject to the office visit co pay Norplant is covered you pay nothing for the implantation You must pay the cost of its removal if for whatever reason the Norplant is surgically

removed before three years have elapsed from the date of its insertion
Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedicts
solution or equivalent glucose monitor supplies and acetone test tablets one month's supply of each
item purchased at one time may be obtained for one copay

Nitroglycerin phenobarbital or Thyroid U S P
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use
Drugs to treat sexual dysfunction are limited Contact us for dose limits You pay the applicable
copayment up to the dosage limits and all charges above that

Limited benefits The following drugs are only available through the designated Plan pharmacy
Self injectable medications except for insulin glucagon epinephrine kits and Imitrex
Prescriptions which exceed 150 in cost
Growth hormones
Fertility drugs you pay 50 of charges after the 2,000 per member infertility treatment limit is
reached See page 18

A 90 day supply of maintenance drugs You pay three copays
Mail order pharmacy benefit
Mail orders will be filled when necessary Call 1 800 522 3636 for information

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 20
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Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19 21
21 Page 22 23
Compcare Health Services Insurance Corporation 2000
Section 5 Benefits continued
Other Benefits
Dental care
What is covered We will cover the extraction of seven 7 or more fully erupted natural teeth at one time You pay 20
of charges For other covered oral surgery see page 12

Accidental injury Restorative services and supplies necessary to promptly repair or initially replace sound natural teeth
benefit are covered The need for these services must result from an accidental injury occurring while the
member is covered under the FEHB Program you pay 20 of charges

What is not covered Other dental services not shown as covered

Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the
eye annual eye refractions to provide a written lens prescription for eyeglasses may be obtained from
Plan providers You pay a 10 copay per visit

What is not covered Corrective lenses or frames
Eye exercises
External lenses following cataract removal

20 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 22
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Compcare Health Services Insurance Corporation 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but
are made available to all enrollees and family members who are members of this Plan The cost of the benefits
described on this page is not included in the FEHB premium and any charges for these services do not count toward
any FEHB deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB
disputed claims procedure

Expanded dental Choose Dentacare 160 for quality coverage convenience and choice
benefits Valuable dental coverage

No deductible before benefits begin
No annual dollar maximum
No claim forms
No waiting periods
No pre existing condition limitations

No pre authorization requirements

Available at low monthly cost
Only 12.18 for Self Only coverage
Only 35.56 for Self and Family coverage
Billed directly to you on a quarterly basis

100 percent coverage for preventive and diagnostic care
100 for regular exams
100 for regular cleanings
100 for x rayst

60 percent coverage for
Restorative Services
Endonics
Periodontics
Prosthodontics
Oral Surgery

Orthodonics covered at 50 up to a lifetime maximum per person of 1,250 for
dependents only through age 19 or age 23 if 50 support and full time student

Professional quality Over 70 professional dental centers
care at convenient Locations throughout Wisconsin
locations Select the center most convenient for your family One center services you and all eligible family members

Evening and Saturday hours at many centers
Each family member chooses own dentist at selected center

For more information Call our customer service department today
414 226 6744 in Milwaukee area
1 800 242 7312 toll free in Wisconsin

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Compcare Health Services Insurance Corporation 2000
Section 6 General Exclusions Things We Don't Cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover Services drugs or supplies that are not medically necessary
the following Services not required according to accepted standards of medical dental or psychiatric practice

Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
or eligible self referred services

Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would
be endangered if the fetus were carried to term

Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

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Compcare Health Services Insurance Corporation 2000
Section 7 Limitations Rules That Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is
responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want
to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833

Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever
is less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond our control them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for

our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military
TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

23 25
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Compcare Health Services Insurance Corporation 2000
Section 7 Limitations Rules That Affect Your Benefits continued

Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide

OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for

24 26
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Compcare Health Services Insurance Corporation 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right
information about to information about your health plan its networks providers and facilities You can also find out
your HMO about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website

www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 1 800 492 4049 or 414 276 2273 in the Southeastern
region 1 800 258 5299 in the Northcentral region or 1 800 368 4453 in the Northwestern region or
write to Compcare Health Services Insurance Corporation 401 W Michigan Street Milwaukee WI
53203 You may also contact us by fax at 414 226 2636 or visit our website at
www compcare uwz com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about
FEHB Program When you may change your enrollment

How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military
service or retire

When your enrollment ends and
The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
and premiums premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
effective premiums begin January 1

What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled
when I retire in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of

Coverage which is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for my unmarried dependent children under age 22 including any foster or step children your employing or
family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give
birth or add a child to your family You may change your enrollment 31 days before to 60 days after
you give birth or add the child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or becomes an eligible
family member

Your employing or retirement office will not notify you when a family member is no longer eligible to
receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan

25 27
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Section 8 FEHB FACTS continued
Are my medical and We will keep your medical and claims information confidential Only the following will have access to it
claims records OPM this Plan and subcontractors when they administer this contract
confidential This plan and appropriate third parties such as other insurance plans and the Office of Workers

Compensation Programs OWCP when coordinating benefit payment and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an

Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my
old plan

Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Your enrollment ends unless you cancel your enrollment or
Plan ends You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's

employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not
elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

26 28
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Compcare Health Services Insurance Corporation 2000
Section 8 FEHB FACTS continued
Key points You can pick a new plan
about TCC If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from
the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does
not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel
your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC
TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60
days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in
TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage
due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of
Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well
27 29
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Compcare Health Services Insurance Corporation 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 544 3873 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

28 30
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Compcare Health Services Insurance Corporation 2000
Summary of Benefits for Compcare Health Services Insurance Corporation 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your
enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan Pays Provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit
care Includes in hospital doctor care room and board general nursing care private room and private nursing care if medically necessary diagnostic tests drugs and medical

supplies use of operating room intensive care and complete maternity care You pay 100 per admission up to an annual maximum of 200 per member per year .14

Extended Care All necessary services for up to 30 days per member per year You pay nothing .14
Mental Conditions Up to 120 days of inpatient care per year for diagnosis and treatment of acute psychiatric conditions You pay nothing for first 30 days 20 of charges for

days 31 120 transitional care following discharge is available as described under Substance Abuse .17

Substance Abuse All necessary substance abuse treatment including up to the greater of 10 days of treatment or 2,700 in charges per member per year for care in a transitional facility
following discharge in combination with Mental Conditions benefit You pay nothing .17

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
care including specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and x rays complete

maternity care You pay a 10 copay for office visits or house calls by a doctor copays waived for prenatal visits 25 per member per visit in an outpatient

treatment facility .11
Home Health Care All necessary visits by nurses and health aides You pay a 10 copay per visit .12
Mental Conditions All necessary outpatient visits You pay nothing for first 20 visits per year 20 of charges thereafter .17

Substance Abuse All necessary outpatient visits You pay nothing for first 35 visits per year 20 of charges thereafter .17

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 25 per member per visit and charges for services that are
not covered benefits of this Plan .15
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 7 copay per generic prescription 12 for name brand prescription unit or refill .18

Dental care Accidental injury benefit you pay 20 of charges .20
Vision care One refraction annually you pay a 10 copay per visit .20
Out of pocket limit Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments that are required for a few benefits

29 31
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Compcare Health Services Insurance Corporation 2000
2000 Rate Information for Compcare Health Services

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A
rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member of a special
postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States
Postal Services Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members
of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal Employees
Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Gov't Your Gov't Your USPS Your USPS Your Type of Enrollment Code Share Share Share Share Share Share Share Share

Southeastern Wisconsin
Self Only 691 78.22 26.07 169.47 56.49 92.56 11.73 92.56 11.73
Self and Family 692 175.97 93.97 381.27 203.60 207.74 62.20 201.02 68.92
Northcentral Northwest Wisconsin
Self Only 6X1 78.83 29.08 170.80 63.01 93.06 14.85 93.26 14.65
Self and Family 6X2 175.97 103.42 381.27 224.08 207.74 71.65 201.02 78.37

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