A Health Maintenance Organization
For changesin benefitssee
page
3
Serving
Sioux City Area in Iowa Nebraska and South Dakota
Enrollment in this Plan is limited see page 4 for requirements
Enrollment Code
FA1 Self Only
FA2 Self and Family
Visit the OPM website at http www opm gov insure and
this Plan's website at http www carechoices com
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE Federal Employees Health Benefits Program
RI 73 444
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Care Choices 2000
Table of Contents
Page
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 6
Section 5 Benefits 8
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 17
Section 8 FEHB FACTS 18
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits 23
Premiums 24
Introduction
Care Choices 522 4th St Suite 250 Sioux City Iowa 51101
This brochure describes the benefits you can receive from Care Choices under its contract CS2305 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of
benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 3 Premiums are listed at the end of this brochure
Plain Language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked
cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences
We refer to Care Choices 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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Care Choices 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
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 10.00 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 decrease by 0.3 for Self Only or 20.0 for Self and Family this Plan
The primary care office visit copay will increase from 5 to 10 See page 8
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Care Choices 2000
Section 3 How To Get Benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is
Sioux City Area in Iowa Nebraska and South Dakota
Iowa Buena Vista Calhoun Carroll Cherokee Clay Crawford Dickinson Emmet Ida Lyon Monona O'Brien Osceola Palo Alto Plymouth Pocahontas Sac Sioux and Woodbury Counties
Nebraska Burt Cedar Cuming Dakota Dixon Madison Pierce Stanton Thurston and Wayne Counties South Dakota Clay and Union Couties
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 You must share the cost of some services This is called either a copayment a set dollar amount or for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive
services
After you pay 10.00 in copayments or coinsurance per office visit for each family member the rest is covered at 100 However copayments or coinsurance for your prescription drugs do not count toward
these limits and you must continue to make these payments
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as
soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time
Who provides Care Choices is an Individual Practice Association IPA Model Health Maintenance Organization HMO my health care which covers your medical bills and also arranges for the delivery of services through participating
physicians hospitals and other health professionals Care Choices contracts with more than 420 private practice physicians representing a wide range of primary and specialty care services These physicians
practice in their own offices Participating outpatient centers may also have physicians offices as well as urgent care and laboratory facilities The Plan contracts with hospitals as well As a subscriber to
Care Choices you select your primary care physician who will arrange for your health care He she will either provide your care directly or refer you to a specialist if necessary However a woman may see her
gynecologist without having to obtain a referral Only those services approved by your doctor will be paid for by Care Choices
What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
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Care Choices 2000
Section 3 How To Get Benefits continued
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist need to go into the will make the necessary hospital arrangements and supervise your care
hospital
What do I do if I'm First call our customer service department at 800 535 6252 or 712 252 2344 If you are new to the in the hospital when FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and
I join this Plan are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist specialty care
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 The physician may have to get an authorization or approval
beforehand
What do I do if I am If you are already under the care of a specialist who is a Plan participant you must still obtain a referral seeing a specialist from a Plan primary care physician for the care to be covered by the Plan If the physician who originally
when I enroll referred you prior to your joining this Plan is now your Plan primary care physician you must contact your physician to explain that you now belong to this Plan and discuss any needs for further
specialty care In the event such a need continues your primary care physician must issue a written referral prior to your next visit to the specialist for the service to be a covered benefit
Your primary care physician will decide what treatment 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
What do I do if Call your primary care physician who will arrange for you to see another specialist You may my specialist leaves receive limited services from your current specialist until we can make arrangements for you to
the Plan see someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
provider leaves the provider unless the termination is for cause If you are in the second or third trimester of pregnancy Plan or this Plan you may continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for
up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your
current provider until the end of your postpartum care
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Care Choices 2000
Section 3 How To Get Benefits continued
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
How do you decide if a Experimental procedures are defined as services supplies or devices which Care Choices determines to service is experimental be experimental unproven research in nature or not recognized as acceptable medical practice by an
or investigational appropriate medical specialty organization The process for review of experimental procedures include gathering current medical literature of outcome data and the requesting members medical history and
records A review is conducted by Care Choices Medical Directors and specialists as appropriate determinations are made on an individual case by case basis
Section 4 What To Do If We Deny Your Claim Or Request For Service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond
your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive
the requested information within 60 days we will make our decision based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a denial will determine if we correctly applied the terms of our contract when we denied your claim or request
for service
What if I have a Call us at 800 535 6252 and we will expedite our review serious or life
threatening condition and you haven't
responded to my request for service
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Section 4 What To Do If We Deny Your Claim Or Request For Service continued
What if you have If we expedite our review due to a serious medical condition and deny your claim we will inform OPM denied my request so that they can give your claim expedited treatment too Alternatively you can call OPM's health
for care and my benefits Division 3 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
or life threatening possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial time limits denial or refusal of service You may also ask OPM to review your claim if
1 We did not answer your request within 30 days In this case OPM must receive your request within 120 days of the last 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 that we asked you for
additional information
What do I send Your request must be complete or OPM will return it to you You must send the following information 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 mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contracts Division 3 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 with our decision the Plan's denial 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
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Section 4 What To Do If We Deny Your Claim Or Request For Service continued
What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure described
above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us the Privacy Act 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 Benefits
Medical 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 but no
additional copay for laboratory tests and 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 a 10 copay for a
doctor's house call You pay nothing for 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 up
Mammograms are covered as follows for women age 35 through 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 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
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Section 5 Benefits continued
Medical Surgical Benefits
continued
What is covered Voluntary family planning services continued
Diagnosis and treatment of diseases of the eye
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
Cornea heart heart lung kidney liver lung single or double and pancreas kidney 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 Treatment for breast cancer multiple
myeloma and epithelial ovarian cancer may be provided in a non randomized clinical trial subject to approval by the Plan's 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 and lenses following cataract removal and breast protheses including the surgical bra for external prothesis following a mastectomy and including
the necessary protheses and bra
Durable medical equipment such as wheelchairs and hospital beds
Inpatient rehabilitative therapy physical speech occupational and respiratory
Diabetic supplies including glucose test tablets and test tape Benedict's solution or equivalent and acetone tablets
Home health services of nurses and health aides including intravenous fluids and medications when medically necessary and 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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Care Choices 2000
Section 5 Benefits continued
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 extraction of impacted teeth partially or totally covered by bone 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 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 mascetomy including whether
or not to have surgery on the other breast in order to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 60 visits per condition if significant improvement can be expected within two
months 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
Diagnosis and treatment of infertility is covered for non experimental procedures you pay a 10 copay per office visit Fertility drugs are not covered Artificial insemination is not covered Other
assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for up to two months per year you pay nothing
What is Physical examinations that are not necessary for medical reasons such as those required for not covered obtaining or continuing employment or insurance attending school or camp or travel
Sterilization or insertion of IUDs
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Refractions including lens prescriptions
Corrective eyeglasses and frames or contact lenses including the fitting of the lenses except immediately following cataract surgery
Long term rehabilitative therapy
Hearing aids
Foot orthotics
Homemaker services
Dental benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Hospital Extended Care
Benefits
Hospital Care
What is covered 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 or when a private room is all that is available 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 730 days per confinement 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
Hospice Care Supportive and palliative care including pain relief and symptom management for members who are terminally ill and who elect to receive hospice care rather than curative treatment of the illness in the
home or hospice facility Services include physician services nursing services provided by or under the supervision of a registered nurse licensed social worker services and medical appliances and
supplies including drugs and biologicals These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of six
months or less Services are limited to 90 days per member renewable after 90 days when certified and approved by the Plan
What is covered The following services are covered only when an integral part of the basic hospice care but not separately reimbursable as a covered benefit
Home Health Aides under supervision of a registered nurse
Physical occupational therapy and speech language pathology services for symptom control and maintenance of daily living and basic functional skills and
Bereavement dietary and spiritual counseling
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Section 5 Benefits continued
Extended Care continued
What is not covered All services not specifically listed as covered in this section including but not limited to
Services provided by volunteers or services provided by a Member's family or persons who do not regularly charge for their services
Financial or legal counseling services and
Housekeeping meal services or custodial care
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor service
Limited Benefits
Inpatient Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a dental procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate See page 15 for nonmedical substance abuse benefits
What is not Personal comfort items such as telephone and television covered
Custodial care rest cures homemaking services domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or
surgical attention 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
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Care Choices 2000
Section 5 Benefits continued
Emergency Benefits
continued
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies the service area 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 and 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 25 per visit at a hospital emergency facility 10 at an urgent care center for emergency services which are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforseen illness
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan and 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 25 per hospital emergency room visit 10 at an urgent care center for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care
copay is waived
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Care Choices 2000
Section 5 Benefits continued
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not Elective care or nonemergency care covered
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers 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 page 6
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 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay per visit for each covered visit all charges thereafter
Inpatient care Up to 45 days of hospitalization each calendar year you pay nothing for first 45 days all charges thereafter
The 45 days of inpatient hospitalization for mental conditions can be exchanged on a two for one basis for up to 90 days of partial hospitalization Partial hospitalization session shall not be less than four 4
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Care Choices 2000
Section 5 Benefits continued
What is Inpatient care for psychiatric conditions that in the professional judgment of Plan doctors are not not covered 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 35 outpatient visits per year up to a lifetime maximum of 140 visits You pay 50 of charges for each visit
Inpatient care 30 days per year up to a lifetime maximum of 120 days You pay nothing during the benefit periodall charges thereafter
After the lifetime limits are reached services are provided up to a dollar level that is adjusted each year based on changes in the Consumer Price Index This dollar limit for 1999 was 2,922
What is not covered Treatment that is not authorized by a Plan doctor
Care for conditions which in the professional judgement of Plan doctors are not subject to significant improvement through relatively short term treatment
Treatment on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply or 100 unit supply whichever is less or one commercially
prepared unit i e one inhaler one vial ophthalmic medication or insulin You pay a 5 copay per prescription unit or refill
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin
Insulin syringes and needles if prescribed and purchased at the same time as the insulin and in a days supply corresponding to the amount of insulin dispensed see page 12 for coverage of diabetic supplies
Disposable needles and syringes needed to inject covered prescribed medication
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Care Choices 2000
Section 5 Benefits continued
Prescription Drug Benefits
What is covered Compounded preparations of which at least one ingredient is a prescription drug continued
Smoking cessation drugs and medication including nicotine patches coverage limitations apply
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits
Drugs to treat sexual dysfunction
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available covered
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Contraceptive drugs and devices
Implanted contraceptive devices such as Norplant
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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
16 Expenses you incurred while you were not enrolled in this Plan
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Care Choices 2000
Section 7 Limitations Rules That Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our control them In that case we will make all reasonable efforts to provide you with necessary care
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the cost
for injuries 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
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Section 7 Limitations Rules That Affect Your Benefits continued
Workers We do not cover services that Compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for
Section 8 FEHB FACTS
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to to information information about your health plan its networks providers and facilities You can also find out about
about your HMO 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 800 535 6252 or 712 252 2344 or write to Care Choices 522 4th St Suite 250 Sioux City Iowa 51101 You may also contact us by fax at
712 294 7018 or visit our website at www carechoices com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums effective premiums begin January 1
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Care Choices 2000
Section 8 FEHB FACTS continued
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in when I retire 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for my retirement office authorizes coverage for Under certain circumstances you may also get coverage for a family and me disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days after you
give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an eligible family
member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
Are my medical We will keep your medical and claims information confidential Only the following will have access to it and claims records
confidential 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 Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you Conditions enrolled in this Plan solely because you had the condition before you enrolled
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Care Choices 2000
Section 8 FEHB FACTS continued
When You Lose Benefits
What happens You will receive an additional 31 days of coverage for no additional premium when if 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 spouse coverage If you are divorced from a Federal employee or annuitant you may not continue to 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 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in 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
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Care Choices 2000
Section 8 FEHB FACTS continued
How do I enroll Former spouses You or your former spouse must notify your employing or retirement office within in TCC 60 days of one of these qualifying events
continued 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 pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of Plan Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for
health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well
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Care Choices 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 800 535 6252 or 712 252 2344 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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Care Choices 2000
Summary of Benefits for Care Choices 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change
your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan Pays Provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day Care 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 11
Extended Care All necessary services for up to 730 days per confinement You pay nothing 11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 45 days Conditions of care per year You pay nothing 14
Substance Abuse Up to 30 days per year you pay nothing Lifetime maximum of 120 days 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness Care 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 a 10 copay per office visit or house call
by a doctor 8 9
Home Health Care All necessary visits by nurses and health aides You pay nothing 9
Mental Conditions Up to 20 outpatient visits per year You pay a 10 copay per visit 14
Substance Abuse Up to 35 outpatient visits per year You pay 50 of charges for each visit Lifetime of 140 visits 15
Emergency Reasonable charges for services and supplies required because of a medical Care emergency You pay a 25 copay at hospital emergency room a 10 copay at
urgent care center 13
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy Drugs You pay a 5 copay per prescription unit or refill 16
Dental Care No current benefit
Vision Care No current benefit
Out of Pocket Your out of pocket expenses for benefits covered under this Plan are limited to the stated maximum copayments which are required for a few benefits
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Care Choices 2000
2000 Rate Information for Care Choices
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 but do not apply to non career Postal employees Postal retirees certain special Postal employment categories or associate members of any Postal employee organization If you are in a special Postal
employment category refer to the FEHB Guide for that category
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Gov't Your Gov't Your USPS Your USPS Your Enrollment Code Share Share Share Share Share Share Share Share
Self Only FA1 66.94 22.31 145.04 48.34 79.21 10.04 79.21 10.04
Self and Family FA2 175.97 64.27 381.27 139.25 207.74 32.50 201.02 39.22
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