Serving Tallahassee Florida area
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
EA1 Self only
EA2 Self and family
This Plan has commendable
accreditation from NCQA See the
2000 Guide for more information on NCQA
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www capitalhealth com
Authorized for distribution by the
United States Office of
Personnel Management
retirement and insurance service
RI 73197
1
1
Page 2
3
Capital Health Plan 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 4
Section 3 How to get benefits 4 6
Section 4 What to do if we deny your claim or request for service 6 7
Section 5 Benefits 7 13
Section 6 General exclusions Things we don't cover 13
Section 7 Limitations Rules that affect your benefits 13 15
Section 8 FEHB FACTS 15 17
Inspector General Advisory Stop Healthcare Fraud 20
Summary of Benefits 21
Premiums 22
I
2
2
Page 3
4
Capital Health Plan 2000
Introduction
Capital Health Plan 2140 Centerville Place Tallahassee Florida 32308
This brochure describes the benefits you can receive from Capital Group Health Services of Florida Inc d b a Capital Health Plan 2140
Centerville Place Tallahassee Florida 32308 under its contract CS2034 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 pages
3 4 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 Capital Health Plan 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 rewritten the Benefits section of this brochure You will find new benefits language next year
1
3
3
Page 4
5
Capital Health Plan 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
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
2
4
4
Page 5
6
Capital Health Plan 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 To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes office visits
This year you have a right to more information about this Plan care management our networks 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 Your share of the non postal premium will increase by 12.9 for Self Only or 12.9 for Self and
this Plan Family
The cost to you for obtaining services from Plan doctors will change as follows in 2000 See page 7
Benefit In 1999 You Paid In 2000 You Will Pay
Primary Care Office Visit 5 10
After Hours Urgent Care 7 15
Specialist on Referral 0 10
The cost to you for obtaining Emergency Benefits will change as follows in 2000 See pages 10 11
Benefit In 1999 You Paid In 2000 You Will Pay
Emergency Services
Within the Service Area 25 50
Outside the Service Area 25 50
3
5
5
Page 6
7
Capital Health Plan 2000
The cost to you for obtaining short term rehabilitative therapy physical speech and occupational will change
as follows in 2000 See page 9
Benefit In 1999 You Paid In 2000 You Will Pay
Physical Speech
Occupational Therapy 5 10
The cost to you for obtaining Vision Care will change as follows in 2000 See page 13
Benefit In 1999 You Paid In 2000 You Will Pay
Annual Refractions to
determine the need for
Eyeglasses 5 10
The cost to you for obtaining Prescription Drugs will change as follows in 2000 See page 12
Benefit In 1999 You Paid In 2000 You Will Pay
Generic Drugs 5 7
Brand Drugs 12 20
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our service
Plan's service area is Tallahassee Florida including Gadsden Jefferson Leon and Wakulla counties
area 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 unless authorized
by the Plan
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 you should
consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas 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 You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance
I pay for a set percentage of charges Please remember you must pay this amount when you receive services
services
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider who
submit claims 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 Capital Health Plan as a mixed model prepaid direct service health plan provides primary medical care to its
my health members at many different locations in the greater Tallahassee area These medical offices offer care through
care internal medicine doctors family practice doctors and pediatricians The Centerville Road and Governors Square offices offer pediatric care family practice doctors and internal medicine doctors Members have
access to all Plan benefits at whatever location they choose Laboratory tests and X rays as well as referrals to
specialists and hospitalizations can be authorized and monitored by any member of CHP's primary care
network
4
6
6
Page 7
8
Capital Health Plan 2000
What do I do if Call us We will help you select a new one
my primary care
physician leaves
the Plan
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will
need to go into the make the necessary hospital arrangements and supervise your care
hospital
What do I do if First call our customer service department at 850 383 3311 If you are new to the FEHB Program we will
I'm in the hospital arrange for you to receive care If you are currently in the FEHB Program and are switching to us your former
when I join this plan will pay for the hospital stay until
Plan 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 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
What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a specialist
am seeing a ask if you can see your current specialist If your current specialist does not participate with us you must
specialist when I receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does
enroll not participate with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive services
my specialist from your current specialist until we can make arrangements for you to see someone else
leaves the 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 seeing
serious illness and your provider for up to 90 days after we notify you that we are terminating our contract with the provider
my provider leaves unless the termination is for cause If you are in the second or third trimester of pregnancy you may
the Plan or this Plan 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 and if it follows generally accepted medical practice
5
7
7
Page 8
9
Capital Health Plan 2000
How do you When CHP determines that an evaluation treatment therapy or device is experimental investigational it will
decide if a service not be covered by the Plan CHP makes such determinations based in part on information obtained from the
is experimental or United States Food and Drug Administration The Florida Department of Health and most recently published
investigational medical literature in the United States Canada or Great Britain A consensus of opinion among experts is sought showing that the evaluation treatment therapy or device is considered safe and effective as compared
with the standard means for treatment or diagnosis of the condition in question Additional information
regarding the process for determining and evaluating treatments that may be considered experimental investigational
may be obtained from this Plan
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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will
OPM to review a determine if we correctly applied the terms of our contract when we denied your claim or request for service
denial
What if I have a Call us at 850 383 3311 and we will expedite our review
serious or life
threatening 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 OPM so
denied my request that they can give your claim expedited treatment too Alternately you can call OPM's health benefits
for care and my Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are
condition is serious ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
or life threatening
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial
time limits or refusal of service You may also ask OPM to review your claim if
1 We do 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 did 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
6
8
8
Page 9
10
Capital Health Plan 2000
What do I Your request must be complete or OPM will return it to you You must send the following information
send to
OPM 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
Who can make Those who have a legal right to file a disputed claim with OPM are
the 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 Send your request for review to Office of Personnel Management Office of Insurance Programs
mail my disputed Contract Division III P O Box 436 Washington D C 20044
claim
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your
upholds the 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review on
if I file a lawsuit 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 Privacy Act
Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and 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
Section 5 Medical and Surgical Benefits
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 a 10 office visit copay and a 15 copay for
after hour visits but no additional copay for laboratory tests X rays Within the Service Area house calls will
be provided if in the judgement of the Plan doctor such care is necessary and appropriate you pay nothing for
a doctor's visit or for visits by nurses and health aides
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
7
9
9
Page 10
11
Capital Health Plan 2000
The following services are included and are subject to the office copay unless stated otherwise
Preventive care including well baby care and periodic checkups
Mammograms are covered as follows for women age 35 through 39 one mammogram during these five years for women 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 Copays are waived for maternity care The mother at her option may remain in the
hospital up to 48 hours after 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 and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum you pay nothing for allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver lung single and double 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 and testicular mediastinal retroperitoneal and
ovarian germ cell tumors when approved by the Medical Director Related medical and hospital expenses
of the donor are covered when the recipient is covered by this Plan
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
Chiropractic services acute and diagnostic care only
The medical treatment of temporomandibular joint TMJ disease
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
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 All other procedures involving the teeth or intraoral areas surrounding the teeth are not covered
including dental care involved in the 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 8
10
10
Page 11
12
Capital Health Plan 2000
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient
basis for up to two consecutive months per condition if significant improvement can be expected within two
months you pay a 10 copay per outpatient session Speech therapy is limited to treatment of certain speech
impairments of organic origin Occupational therapy is limited to services that assist the member to achieve
and maintain self care and improved functioning in other activities of daily living
Durable medical equipment and prosthetic appliances coverage is limited to the following crutches canes
braces only braces required to correct a medical condition and for the purposes of every day living are
covered wheelchairs cardiac pacemakers lenses following cataract removal and artificial limbs and eyes to
replace natural limbs and eyes lost and breast protheses and surgical bras following mastectomies as well as
their replacement Braces and covered prosthetic devices except cardiac pacemaker breast protheses and
surgical bras following mastectomies are limited to the first such item prescribed for each specific medical
condition All other prosthetic devices including braces used during athletic activities are excluded Oxygen
for home use including equipment is covered CHP reserves the right to rent or purchase durable medical
equipment and members are entitled to use but not own such equipment Maximum payment for the appliances
equipment and services outlined herein will be for up to 2500 per member per contract year
Diagnosis and treatment of infertility is covered you pay nothing The following type of artificial insemination
is covered intravaginal insemination IVI you pay nothing The cost of donor sperm is not covered
Fertility drugs are not covered Other assisted reproductive technology ART procedures such as in vitro
fertilization and embryo transfer are not covered
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
Plastic surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not specifically listed as covered
Long term rehabilitative therapy
Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction
Foot orthotics
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing 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 The Plan provides a comprehensive range of benefits for up to 60 days per admission with subsequent
admission available 180 days from discharge date of previous admission 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 the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
9
11
11
Page 12
13
Capital Health Plan 2000
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
approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
procedures 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 treatment of
detoxification medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 12 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
Emergency benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers
emergency 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 the Plan 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 you are
the service area 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 the Plan You or a family member should notify the Plan within 48 hours unless it was not
reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following
your admission unless it was not reasonably possible to notify the Plan 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
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the
Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been
covered if received from Plan providers
You pay 50 per hospital emergency room visit or 15 per urgent care center visit for emergency
services that are covered benefits of this Plan
10
12
12
Page 13
14
Capital Health Plan 2000
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because of injury
the service area or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following
your admission unless it was not reasonably possible to notify the Plan 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
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the
Plan or provided by Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers
You pay 50 per hospital emergency room visit or 15 per urgent care center visit for emergency
services that are covered benefits of this Plan
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 the Plan
What is not covered Elective care or nonemergency care
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 fullterm delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon
non Plan receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are
providers required to pay for the services submit itemized bills and your receipts to the Plan 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 the Plan's decision you may request reconsideration
in accordance with the disputed claims procedure described on page 6 7
Mental Conditions Substance Abuse Benefits
Mental Conditions
What is covered To the extent shown below the Plan provides 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 Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay for each covered visit all charges thereafter
Inpatient care Up to 31 days of hospitalization each calendar year you pay nothing for the first 31 days all charges thereafter
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
11
13
13
Page 14
15
Capital Health Plan 2000
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 shortterm psychiatric condition
Substance Abuse
What is covered This Plan provides 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 Services for the psychiatric aspects are provided in conjunction with the mental conditions
benefits shown above Outpatient visits to Plan providers for treatment are covered as well as inpatient
services necessary for diagnosis and treatment The mental conditions benefits visit day limitations and copays
apply to any covered substance abuse care
What is not covered Treatment that is not authorized by a Plan doctor
All charges if the member does not complete the program
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 30 day supply or one commercially prepared unit i e one inhaler one vial ophthalmic medication
or insulin you pay a 20 copay per prescription unit or refill for name brand drugs when generic substitution
is not available and a 7 copay per prescription unit or refill for generic drugs If a generic drug is available
and at the request of the member or the prescribing physician a brand name prescription is dispensed you pay
the price difference between the generic and the name brand drug as well as the 20 copay for the brand name
drug per prescription unit or refill
Prescription refills will not be covered until at least 75 of the previous prescription has been used by the
member based on the dosage schedule prescribed by the physician
Covered medications and accessories include
Drugs for which a prescription is required by law
All FDA approved contraceptive drugs and devices
Insulin with a 7 copay charge applied to each vial
Vitamins
Disposable needles and syringes needed to inject covered prescribed medication
Allergy serum you pay nothing
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
Diabetic supplies including test strips and glucometers at the CHP Pharmacy only
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 dressing and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Injectable and oral medications to treat infertility
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
14
14
Page 15
16
Capital Health Plan 2000
Dental care
Accidental Restorative services and supplies necessary to promptly repair but not replace sound natural teeth recovered
injury benefit The need for these services must result from an accidental injury occurring while the member is covered under the FEHB program You pay nothing
Vision Care
In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual refraction to determine
the need for eyeglasses which includes a written prescription for eyeglasses may be obtained from Plan providers you pay a 10 copay
per visit
What is covered Initial eyeglasses following cataract surgery or an accidental injury which would necessitate corrective lenses initial pair of eyeglasses is limited to the cost of the lens and up to 25 for the frame and obtained only at
CHP's eye care centers
What is not covered Eyeglasses except initial pair following cataract surgery or an accidental injury which requires corrective lenses
An examination and fitting for contact lenses CHP Eye Care offers this service on a fee for service basis
Contact lenses
Replacements for any lenses provided during the same calendar year
Eye exercises
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 the following
Services drugs or supplies that are not medically necessary
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
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 or when the pregnancy is the result of an act of rape or incest
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
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
reenroll in the FEHB Program generally you may do so only at the next Open Season
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
13
15
15
Page 16
17
Capital Health Plan 2000
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll 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 You must
insurance coverage 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 them
beyond our control 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 another
responsible for person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment
injuries 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
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
14
16
16
Page 17
18
Capital Health Plan 2000
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 indirectly
Agencies pays for
If you have a malpractice claim
If you have a malpractice claim because of services you did or did not receive from a plan provider it must go to binding arbitration
Contact us about how to begin our binding arbitration process
Section 8 FEHB FACTS
You have a right to information about your HMO OPM requires that all FEHB plans comply with the Patients Bill of Rights which
gives you the right to information about your health plan its networks providers and facilities You can also find out 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 850 383 3311 or write to Capital Health Plan P O Box 15349 Tallahassee Florida 32317 5349 You
may also contact us by fax at 850 383 3590 or visit our website at www capitalhealth com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees
information about Health Benefits Plans brochures for other plans and other materials you need to make an informed decision
enrolling in the 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 premiums
effective begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the
when I retire 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried
coverage are dependent children under age 22 including any foster or step children your employing or retirement office
available for my authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years
family and me 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
15
17
17
Page 18
19
Capital Health Plan 2000
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan
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 payments 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 We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809
cards 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
Preexisting We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled
conditions in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in
this Plan ends Your enrollment ends unless you cancel your enrollment or
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 your
spouse coverage 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
Key points about TCC
You can pick a new plan
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
16
18
18
Page 19
20
Capital Health Plan 2000
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 If you leave Federal service your employing office will notify you of your right to enroll under TCC You must
in TCC 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 You may convert to an individual policy if
to 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 preexisting
conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates
Certificate of how long you have been enrolled with us You can use this certificate when getting health insurance or other
Group Health health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new
Plan Coverage plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate
If you have beeCould not acquire words on page 23
n 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
17
19
19
Page 20
21
Capital Health Plan 2000
Notes
18
20
20
Page 21
22
Capital Health Plan 2000
Notes
19
21
21
Page 22
23
Capital Health Plan 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 850 383 3311 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
20
22
22
Page 23
24
23
Page 24
Capital Health Plan 2000
2000 Rate Information for
Capital Health Plan
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 Service
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
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Tallahassee area
Self Only EA1 63.68 21.23 137.98 45.99 75.36 9.55 75.36 9.55
Self and
Family EA2 170.04 56.68 368.42 122.81 201.21 25.51 201.02 25.70
22 24