American HMO AmericanHealthCare
Health Plan Illinois 2000 Providers Inc
A Health Maintenance Organization
For
changes in
benefits see
pages 3 4
Serving The Chicago and Downstate Illinois areas and Northwest Indiana
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
AC1 Self only
AC2 Self and family
Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United States
Office of Personnel
Management
Retirement and
Insurance Service
RI 73 427
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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 5 8
Section 4 What to do if we deny your claim or request for service 9 10
Section 5 Benefits 11 22
Section 6 General exclusions Things we don't cover 22
Section 7 Limitations Rules that affect your benefits 23 24
Section 8 FEHB FACTS 25 29
Inspector General Advisory Stop Healthcare Fraud 30
Summary of benefits 31
Premiums 32
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Introduction
American HMO
P O Box 7000
4601 Sauk Trail
Richton Park IL 60471 7000
This brochure describes the benefits you can receive from American Health Care Providers Inc d b a American HMO 4601 Sauk
Trail Richton Park Illinois 60471 under its contract CS2290 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 American HMO 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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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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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 or 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 changes 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 this Plan
Your share of the non postal premium will increase by 2 6 for Self Only or 38 6 for Self and Family See back cover page 32
The Plan has dropped the Point of Service POS Product option and is only offering the HMO option See Section 5
The Plan has increased its office visit copay from nothing to 10 See page 11
The emergency room copay has increased from 25 to 50 See page 16
The non hospital based urgent care visit copay has decreased from 25 to 10 See page 16
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Section 2 How We Change For 2000 continued
Changes to this Plan
continued
Durable Medical Equipment DME copay has increased from nothing to 20 See page 13
Under Prescription Drug Benefits brand name drugs have an increased copay when generic substitution is permissible See page 19
Coverage for cryosurgery to treat localized prostate cancer is shown in the brochure See page 13
Oral injectable and contraceptive devices including contraceptive diaphragms and Norplant are shown as covered in the brochure See page 19
The Plan's service and enrollment area is reduced See page 5
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Section 3 How to get benefits
What is this Plan's service To enroll with us you must live in our service area This is where our providers practice
area Our service area is In Illinois including all of Christian Cook DuPage Kane Kankakee Kendall Lake Logan Macon Macoupin Mason Menard McHenry Morgan Peoria
Sangamon Tazewell and Will Lake LaPorte and Porter counties in Indiana
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
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 I pay for
services You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance a set percentage of charges Please remember you must pay this
amount when you receive services except for in patient hospitalization
Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from
claims a provider 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
health care American HMO is a mixed model Health Maintenance Organization licensed in 1984 to provide comprehensive and quality health care services to its members
American HMO has contracted for the provision of services with Medical Groups IPA's
individual doctors hospitals and other auxiliary providers Each American HMO member
must select a Primary Care Doctor during the enrollment process
American HMO considers General Practitioners Family Practitioners Internists and
Pediatricians as Primary Care Doctors Women may select an OB GYN Doctor as a
Principal Health Care Provider This individual must be part of the Medical Group IPA or
must have a referral relationship with the Medical Group Pediatricians generally cover
children up to 16 years of age Currently American HMO contracts with approximately
2900 Primary Care Providers and 5000 specialty care providers in the Chicago metropolitan
area Other specialists and sub specialists may contract as consultants Consultant doctors
can provide medical care to American HMO members through a proper referral from an
American HMO Primary Care Doctor
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American HMO Health Plan 2000
Section 3 How to get benefits continued
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
to go into the hospital primary care physician or authorized specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm First call our customer service department at 800 242 7460
in the hospital when I 1 800 481 5819 Springfield and surrounding counties
join this plan TDD 800 774 2767 If 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 speciality care Your primary care physician will arrange your referral to a specialist Except in a medical emergency 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 doctor's
discretion if specialists or consultants are required beyond those participating in the Plan the
primary care doctor will make arrangements for appropriate referrals
When you receive a referral from your primary care doctor you must return to the primary care
doctor after the consultation All follow up care must be provided or arranged by the primary care
doctor On referrals the primary care doctor will give specific instructions to the consultant as to
what services are authorized If additional services or visits are suggested by the consultant you
must first check with your primary care doctor Do not go to the specialist unless your primary care
doctor has arranged for and the Plan has 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 get appropriate authorizations
beforehand
What do I do if I am seeing Your primary care physician will decide what treatment
a specialist when I enroll you need If they decide to refer you to a specialist ask if you can see your current specialist If your current specialist does not participate with us you must receive
treatment from a specialist who does Generally we will not pay for you to see a specialist who
does not participate with our Plan
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American HMO Health Plan 2000
Section 3 How to get benefits continued
What do I do if my Call your primary care physician who will arrange for you to see another
Specialist leaves the Plan specialist You may receive services from your current specialist until we can make arrangements for you to see someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling
serious illness and my You may be able to continue seeing your provider for up to 90 days
provider leaves the plan after we notify you that we are terminating our contract with the provider unless
or this Plan leaves the the termination is for cause If you are in the second or third trimester of
program pregnancy you may continue to see your OB GYN until the end of your postpartum care
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
medical services you to a specialist or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice The Plan will
provide benefits for covered services only when the services are medically necessary to prevent
diagnose or treat your illness or condition Your Plan doctor must obtain the Plan's determination
of medical necessity before you may be hospitalized referred for specialty care or obtain followup
care from a specialist
How do you decide if a The Plan bases its determination of whether or not a treatment service or supply is
service is experimental experimental or investigational in nature if there is no consensus in the medical
or investigational Community as to the safety or effectiveness of the technology or the treatment as applied to the patient's medical problem or there is insufficient evidence to determine its appropriateness in a
given situation or the technology is undergoing clinical trials or is largely confined to research
protocols or the physician or facility rendering the treatment classifies the treatment as
experimental or investigational for purposes of obtaining an informed consent
A prescription drug is believed to be experimental investigational until it has been approved by the
FDA for the approved indications Once FDA has approved the drugs the Plan determines its
efficacy through the Pharmacy and Therapeutics Committee P T or our Pharmacy
Management Co PBM
All drugs are evaluated based on clinical effectiveness safety side effects daily dosage
requirements and cost compared to other drugs in the same therapeutic class The committee
reviews the published literature of the drugs being evaluated and the presentations made by the
various P T members before voting on the drugs reviewed
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American HMO Health Plan 2000
Section 3 How to get benefits continued
How do you decide if a Members who have questions regarding covered drugs or prior authorization of
service is experimental or drugs can contact the American HMO Pharmacy Benefit Manager at
investigational 800 242 7460 continued
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American HMO Health Plan 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 in 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
to review a denial denial or refusal OPM 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 1 800 367 9597 and we will expedite our review
or life threatening
condition and you haven't
responded to my request
for service
What if you have denied If we expedite your review due to serious medical condition and deny your
my request for care claim we will inform OPM so that they can give your claim expedited treatment
and my condition is serious too Alternatively you may call OPM's health benefit Contracts Division III at
or life threatening 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after
time limits we uphold our initial denial 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
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American HMO Health Plan 2000
Section 4 What to do if we deny your claim or request for service continued
Are there other 2 You provided us with additional information we asked for and we did not
time limits Answer within 30 days In this case OPM must receive your request within continued 120 days of the date we asked you for additional information
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
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 mail Send your request for review to Office of Personnel Management Office of
my disputed claim Insurance Programs Contract Division III P O Box 436 Washington D C 20044
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees
the Plan's denial with our decision your only recourse is to sue
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 Federal law governs your lawsuit benefits and payment of benefits The Federal
I file a lawsuit court will base its 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 Chapter 89 of title 5 United States Code allows OPM to use the information it
the Privacy Act 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
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American HMO Health Plan 2000
Section 5 Benefits
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 copay and no
additional costs for laboratory tests and X rays Within the service area house calls will be
provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay
nothing for a doctor's house call and you pay nothing for home visits by nurses and health aides
The following services are included and are subject to the office visit copay 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 mother at her option may remain in the hospital up to 48
hours after a regular delivery and 96 hours after a cesarean 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
Diagnosis and treatment of infertility is covered The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI intrauterine
insemination IUI and all other non experimental assisted reproductive technology ART
procedures such as in vitro fertilization and embryo transfer are covered Cost of donor sperm
is not covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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American HMO Health Plan 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
What is covered continued
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints The cost of the devices is covered except for artificial knuckles and penile implants
Cornea heart heart lung kidney liver lung single or 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 Transplants
are covered 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
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces
Prosthetic devices such as artificial limbs breast prostheses surgical bras and their replacement and lenses following cataract removal
Chiropractic services
Home health services of nurses 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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American HMO Health Plan 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
What is covered continued
The medical aspects and pharmaceutical management of mental conditions are covered For detailed Mental Condition benefits see page 18
Cryosurgery for localized prostate cancer
Limited benefits Oral and maxillofacial surgery is provided for non dental 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
intra oral areas surrounding the teeth are not covered including any 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 covered 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
their attending physician will decide whether or not to have breast reconstruction surgery following
a mastectomy including whether or not to have surgery on the other breast in order to produce a
symmetrical appearance
Short term rehabilitative therapy physical speech cardiac and occupational is provided on an
outpatient basis for up to two months per condition if significant improvement can be expected
within two months Short term rehabilitative therapy is provided on an inpatient basis for up to
120 days per condition if significant improvement can be expected within 120 days you pay
nothing 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
Cardiac rehabilitation is covered and limited to services following a heart transplant bypass
surgery or a myocardial infarction The outpatient visits are inclusive of speech occupational
therapy and physical therapy
Durable medical equipment You pay a 20 copay for covered equipment Only standard
wheelchairs and standard hospital beds are covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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American HMO Health Plan 2000
Section 5 Benefits continued
Medical and Surgical 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 Infertility treatment after voluntary sterilization
Surgery primarily for cosmetic purposes Hearing Aids
Long term rehabilitative therapy Homemaker services
Transplants not listed as covered Blood and blood derivatives not replaced by the member
Non durable medical supplies and over the counter medical supplies Cost of organ acquisition in organ transplants including travel expenses
Foot orthotics including shoe inserts and shoes Cost of donor sperm
Stair lifts motorized scooters electric wheelchairs and home alterations of durable medical equipment
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 with no dollar limit for 30 days 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
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American HMO Health Plan 2000
Section 5 Benefits continued
Hospital Extended Care Benefits continued
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility up to a lifetime maximum of 7,500 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 Air ambulance must have prior authorization of the Plan
Limited benefits Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental
procedure the Plan will cover the hospitalization but not the cost of the 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 detoxification Hospitalization for medical treatment of substance abuse is
limited to emergency care diagnosis 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 18 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
Blood and blood derivatives not replaced by the member
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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American HMO Health Plan 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical emergency A medical emergency is the sudden and unexpected onset of a condition or an injury that you 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 the Plan may
determine are medical emergencies what they all have in common is the need for quick action
Emergencies within the If you are in an emergency situation please call your primary care doctor
service area If unable to reach your doctor please call the Medical Help Line which is available after hours on holidays and weekends In extreme emergencies if 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 the Plan You or a family member should notify the Plan within 48
hours 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 you pay 10 office visit co pay per urgent care center visit for emergency services that are covered benefits of this Plan If the hospital emergency room visit
results in an admission to a hospital the copay is waived
Emergencies outside the Benefits are available for any medically necessary health service that is immediately
service area required because of injury 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
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American HMO Health Plan 2000
Section 5 Benefits continued
Emergency Benefits continued 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 you pay 10 office visit co pay per urgent care center visit for emergency services that are covered benefits of this Plan If the hospital emergency room visit
results in admission to a hospital the copay is waived
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 non emergency 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 full term delivery of a baby outside the
service area
Filing claims for non Plan With your authorization the Plan will pay benefits directly to the providers of your
Providers emergency care upon 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 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 pages 9 10
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
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American HMO Health Plan 2000
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered Prior to receiving care for a mental health substance abuse condition please contact the Mental Health and Substance Abuse Provider at 1 800 327 5904 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
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 20 copay for each covered visit all charges thereafter At the option of AHCP
group outpatient may be substituted on a two to one basis for individual mental health care visits
as deemed medically necessary Intensive outpatient treatment may be substituted on a two to one
basis for inpatient hospital services as deemed medically necessary
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all
charges thereafter
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 when not medically necessary to determine the appropriate treatment of
a short term psychiatric condition
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric 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 Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for each covered visit all charges thereafter In addition outpatient Rehabilitation services are
covered for a maximum of twenty 20 individual outpatient care visits per member per calendar
year as appropriate for evaluation short term treatment or crisis intervention services At the
option of AHCP group outpatient care visits may be substituted on a two to one basis for
individual outpatient visits as deemed medically necessary
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the benefit
period all charges thereafter The Substance Abuse benefit may be combined with the inpatient
mental conditions benefit shown above provided such treatment is necessary and is approved by
the Plan to permit an additional 30 inpatient days
What is not covered Treatment that is not authorized by the Mental Health and Substance Abuse Provider The telephone number is 1 800 327 5904
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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American HMO Health Plan 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 with one copay for up to a 34 day supply or 100 unit supply whichever is less or one
commercially prepared unit i e one inhaler one vial ophthalmic medication insulin or per unit
of injectable vial
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
Non formulary drugs will be covered when prescribed by a Plan doctor You pay a 5 copay per
prescription unit or refill for generic drugs and a 10 copay per prescription unit or refill for brand
name drugs When generic substitution is permissible i e a generic drug is available and can be
safely substituted by law or you request the brand name drug you pay the price difference
between the generic and brand name drug as well as the 10 copay per prescription unit or refill
At no time will the copay exceed 50 of the retail pharmacy cost per prescription unit or refill
60 Day Mail Order Members can receive their maintenance prescription drugs through the mail A 60Maintenance
Prescription day supply per prescription unit or refill you pay a 5 copay for generic drugs you
Drug Program pay a 10 copay for brand name drugs For additional information contact Member Services at
800 242 7460 When generic substitution is permissible i e a generic drug is available and can
be safely substituted by law or the prescribing doctor does not require the use of a brand name
drug but you request the brand name drug you pay the price difference between the generic and
brand name drug as well as the 10 copay per prescription unit or refill At no time will the copay
exceed 50 of the retail pharmacy cost per prescription unit or refill
Limited Benefits Sexual dysfunction drugs have dispensing limitations Contact the plan for
details
Covered medications and
accessories include Drugs for which a prescription is required by Federal law
Fertility drugs with a copay charge applied to each vial
Insulin a brand name copay applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic insulin syringes and needles a brand name copay applies
Contraceptive devices including contraceptive diaphragms
Oral and injectable contraceptive drugs
Norplant
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are
covered under Medical and Surgical Benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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American HMO Health Plan 2000
Section 5 Benefits continued
Prescription Drug 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
Experimental and investigational drugs
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Drugs for weight reduction
Other Benefits
Dental Care
What is covered Accidental Injury Benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result from an accidental injury you pay
nothing Members must initiate treatment within 30 days and be completed in 6 months Orthodontic
supplies will not be covered
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 for children through age 17 to provide a written
lens prescription may be obtained from Plan providers you pay nothing
What is not covered Corrective lenses or frames
Eye exercises
Contact lenses
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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American HMO Health Plan 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 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 or out of pocket maximums These benefits are not subject to the FEHB
disputed claims procedure
Expanded dental benefits American Health Care Providers Inc American HMO as part of its commitment to preventive care is pleased to make the following benefits available to our members
Comp Dent This plan provides benefits when services are performed in a dentist's office by a Plan Family Dentist Here are some examples of covered services
DIAGNOSTIC MEMBER PREVENTIVE MEMBER
DENTISTRY PAYS DENTISTRY PAYS
Routine office visit No Charge Prophylaxis Semi Annually No Charge
Bitewing X rays No Charge Fluoride Application child No Charge
Emergency office visit exam 15.00
RESTORATIVE PERIODONTICS
DENTISTRY
Periodontal Scaling and Root Planning 45.00
Amalgam One Surface Primary 9 00 Per Quadrant
Amalgam One Surface Permanent 10.00
Amalgam Four Surfaces Permanent 20.00 ORAL SURGERY
Resin One Surface Anterior 25.00 Extraction Single Tooth 9.00
Extraction Each Additional Tooth 9.00
For a complete description of covered services and a list of participating dentists contact the Customer Service Department at 1 800 242 7460 or
800 481 5819 Springfield and surrounding counties TDD 800 774 2767 Or contact Comp Dent member services directly at 800 837 2341
Expanded vision care benefits
A supplemental benefit of Vision Care reimbursement is available to all members Under this Vision Care benefit eye exams for individuals over 17
years of age eye glasses contact lenses excluding tinted lens and sun glasses are covered once in any 24 month period Vision benefits may be
provided by any duly licensed Ophthalmologist Optometrist or Optician without referral from any American HMO physician The member will be
reimbursed by American HMO for the costs of such benefits up to an aggregate limitation of one hundred dollars 100.00 Please contact the Plan
office for claim submission procedure
In addition to the above American HMO members receive access to the Cole Vision network which gives a variety of discounts on lenses and
accessories Please contact the Plan office for details
Comp Dent and Cole Vision are separate companies from American HMO However American HMO's member services department will serve as
our contact point for any question you have regarding these benefits American HMO members will receive a separate I D card for both the dental
and vision plans in addition to their HMO I D card Your vision and dental plan I D cards will be under the Federal employee's name but can be
used by the employee's spouse and children
BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
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American HMO Health Plan 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 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
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American HMO Health Plan 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 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 For information on the Medicare Choice
plan offered by this Plan see page 23
Other group insurance When anyone has coverage with us and with another group health plan it is called
Coverage double 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 beyond Under certain extraordinary circumstances we may have to delay your services or
our control be unable to provide them In that case we will make all reasonable efforts to provide you with necessary care
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American HMO Health Plan 2000
Section 7 Limitations Rules that affect your benefits continued
When others are When you receive money to compensate you for medical or hospital care for injuries
responsible for injuries or illness that another person caused you must reimburse us for whatever services we paid for We will cover the 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
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 Agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
American HMO Health Plan 2000
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 800 242 7460 800 481 5819 Springfield and
surrounding counties 800 774 2767 TDD or write to
American HMO 4601 Sauk Trail Richton Park IL 60471 You may also contact us by fax at
708 503 5001
Where do I get information Your employing or retirement office can answer your questions and give you a
about enrolling in the Guide to Federal Employees Health Benefits Plans brochures for other plans and
FEHB Program other materials you need to make an informed decision about
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 and The benefits in this brochure are effective on January 1 If you are new to this plan
premiums effective your coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
What happens when I When you retire you can usually stay in the FEHB Program Generally you must
retire have been enrolled 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 are Self Only coverage is for you alone Self and Family coverage is for you your
available for my family spouse and your unmarried dependent children under age 22 including any
and me foster or step children your employing or 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
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American HMO Health Plan 2000
Section 8 FEHB FACTS continued
What types of coverage are If you have a Self Only enrollment you may change to a Self and Family enrollment
Available for my family if you marry give birth or add a child to your family You may change your
and me enrollment 31 days before to 60 days after you give birth or add the child to your continued 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
Are my medical and claims We will keep your medical and claims information confidential Only the following
records confidential will have access to it
OPM this Plan and subcontractors when they administer this contract 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 cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 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 deductible Your old plan's deductible continues until our coverage begins
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
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American HMO Health Plan 2000
Section 8 FEHB FACTS continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium
enrollment in this Plan ends When
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 spouse If you are divorced from a Federal employee or annuitant you may not continue to
coverage get benefits under 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
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
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd 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
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American HMO Health Plan 2000
Section 8 FEHB FACTS continued
When you lose benefits continued
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under 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
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American HMO Health Plan 2000
Section 8 FEHB FACTS continued
When you lose benefits continued
How can I get a Certificate Coverage that indicates how long you have been enrolled with us You can use this
of Group Health Plan certificate when getting health insurance or other health care coverage You must
Coverage arrange for the other coverage within 63 days of 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
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American HMO 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 800 242 7460 800 481 5819 Springfield and surrounding counties or
800 774 2767 TDD 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
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American HMO Health Plan 2000
Summary of Benefits for American HMO Illinois 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 care
Hospital Comprehensive range of medical and surgical services without dollar
or day limit 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 nothing 14
Extended care All necessary services for up to 30 days You pay nothing 14
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for 30 days
of inpatient care per year You pay nothing 18
Substance abuse All necessary services for up to 30 days per year in a substance abuse
treatment program You pay nothing 18
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury 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 10 per office visit nothing per house
call by a doctor 11
Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions Up to 20 outpatient visits per year You pay a 20 copay per visit 18
Substance abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room
visit and any charges for services that are not covered by this Plan 16 17
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for generic drugs
a 10 copay per prescription unit or refill for brand name drugs 19 20
Dental care Accidental injury benefit you pay nothing 20
Vision care One refraction annually for children through age 17 You pay nothing 20
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American HMO Health Plan 2000
2000 Rate Information for
American HMO Health Plan Illinois
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
Self Only AC1 66.32 22.11 143.70 47.90 78.48 9.95 78.48 9.95
Self and Family AC2 175.97 71.66 381.27 155.26 207.74 39.89 201.02 46.61
32 34