CIGNA HealthCare HealthCare of New York Inc 2000
A Health Maintenance Organization
Serving Metropolitan New York City area For benefits changes
in page 2
Enrollment in this Plan is limited see page 2 for requirements see
Enrollment code
HU1 Self Only
HU2 Self and Family
The National Committee for Quality
Assurance NCQA awarded CIGNA HealthCare of New York Inc a
Commendable accreditation
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www cigna com healthcare
Authorized for distribution by the
LOGO United States Office of Federal Employees
Personnel Health Benefits Program Management
CIGNA HealthCare of New York 2000
Table of Contents
Page
Introduction 1
Plain Language 1
How to Use This Brochure 1
Section 1 Health Maintenance Organizations 2
Section 2 How We Change for 2000 2
Section 3 How to Get Benefits 2 4
Section 4 What to Do If We Deny Your Claim or Request for Service 4 5
Section 5 Benefits 6 12
Section 6 General Exclusions Things We Don t Cover 13
Section 7 Limitations Rules That Affect Your Benefits 13 14
Section 8 FEHB Facts 14 17
Inspector General Advisory Stop Healthcare Fraud 18
Summary of Benefits Inside back cover
Premiums Back cover
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CIGNA HealthCare of New York 2000
Introduction
CIGNA HealthCare of New York Inc
Member Services
5700 Bigelow Commons
Enfield Connecticut 06082
This brochure describes the benefits you can receive from CIGNA HealthCare of New York Inc under its contract CS 2388 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 2 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 efer to CIGNA HealthCare of New York Inc 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 ewritten the Benefits section of this brochure You will find new benefits language next year
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 compari
sons 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 ead 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 equest 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 informa
tion 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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CIGNA HealthCare of New York 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that equire 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 p eventative
care such as outine 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 premiums as low as possible OPM has set a minimum copay of 10 for all primarcare
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 equest 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 ecords on request If you want copies of your
medical ecords ask your health care provider for them You may ask that a physician amend a
record that is not accurate not elevant 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 ecords call us and we
will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to Your share of the non postal premium will increase by 6.6 for Self Only and decreases by1.8 for
this Plan Self and Family
Prescription Drug Benefits copays change to 7 for generic drugs and 14 for name brand drugs
Section 3 How to Get Benefits
What is this Plan s To enroll with us you must live in our service area This is where our providers practice Our
service area service area is The counties of Bronx Kings Nassau New York Manhattan Orange Putnam Queens Richmond Rockland Suffolk and Westchester
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 etirement office
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CIGNA HealthCare of New York 2000
Section 3 How to Get Benefits continued
How much do You must share the cost of some services This is called either a copayment a set dollar amount or
I pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services except for certain benefits
After you pay 1,500 in copayments or coinsurance for one family member or 3,000 for two or
more family members you do not have to make any further payments for certain services for the
rest of the year This is called a catastrophic limit However copayments or coinsurance for your
prescription drugs dental services mental health substance abuse services durable medical
equipment and external prosthetic appliances do not count toward these limits and you must
continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to You normally won t have to submit claims to us unless you receive emergency services from a
submit claims 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 circum
stances beyond your control prevented you from filing on time
Who provides The Plan contracts with associations of physicians and with individual physicians to provide health
my health care care services to you and your family There are more than 3,000 physicians and other healthcare
providers participating all from their private offices in the community Each family member machoose
a different primary care doctor located anywhere in the service area A woman may see her
Plan gynecologist for her annual outine examination without a eferral
What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or
to go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if First call our customer service department at 800 345 9458 If you are new to the FEHB Program
I m in the hospital we will arrange for you to eceive care If you are currently in the FEHB Program and are switching
when I join this to us your former plan will pay for the hospital stay until
Plan You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your eferral to a specialist
specialty care If you need to see a specialist frequently because of a chronic complex or serious medical condi
tion your primary care physician will develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional eferrals Your primary care physician in consulta
tion with the Plan will use our criteria when creating your treatment plan
What do I do if I Your primary care physician will decide what treatment you need If they decide to efer you to a
am seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll 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 mareceive
my specialist leaves services from your current specialist until we can make arrangements for you to see
the Plan someone else
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CIGNA HealthCare of New York 2000
Section 3 How to Get Benefits continued
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue
a serious illness and seeing your provider for up to 90 days after we notify you that we are terminating our contract with
my provider leaves the provider unless the termination is for cause If you are in the second or third trimester of
the Plan or this Plan pregnancy 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 o
chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services or ecommending follow up care Before giving approval we consider if the service is medicallnecessary
and if it follows generally accepted medical practice
How do you decide if a The Plan evaluates equests for new and emerging treatments experimental and investigational
service is experimental treatments on a case by case basis The Plan uses a Medical Technology Assessment Council
or investigational peer reviewed medical literature and independent medical experts to assist the medical director in
reaching determinations
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 easons beyond your control
We have 30 days from the date we receive your econsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service o
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our equest We must make a decision within 30 days
after we receive the additional information If we do not eceive the requested information within 60 days we will make our decision
based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
OPM to review OPM will determine if we correctly applied the terms of our contract when we denied your claim o
a denial request for service
What if I have a serious Call us at 1 800 832 8211 and we will expedite our eview
or life threatening
condition and you have
not responded to my
request for service
What if you have If we expedite your eview due to a serious medical condition and deny your claim we will inform
denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM s
for care and my health benefits Contracts Division IV at 202 606 0737 between 8 am and 5 pm Serious or life
condition is serious threatening conditions are ones that may cause permanent loss of bodily functions or death if theare
or life threatening not treated as soon as possible
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CIGNA HealthCare of New York 2000
Section 4 What to Do If We Deny Your Claim or Request for Service continued
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time limits initial denial or refusal of service You may also ask OPM to eview your claim if
1 We do not answer your equest within 30 days In this case OPM must receive your equest
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your equest within 120 days of the date we asked you
for additional information
What do I send Your equest must be complete or OPM will return it to you You must send the following
to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical ecords 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 eview 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
What address should Send your equest for review to Office of Personnel Management Office of Insurance Programs
I send my disputed Contracts Division IV P O Box 436 Washington D C 20044
claim to
What if OPM upholds OPM s decision is final There are no other administrative appeals If OPM agrees with our
the Plan s denial 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 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 marecover
only the amount of benefits in dispute
You or a person acting on your behalf may not sue to ecover 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
the Privacy Act 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 provi
sions 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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CIGNA HealthCare of New York 2000
Section 5 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 for office
visits or 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 a 10 copay for a
doctor s house call 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 periodic check ups adult physical exams and well woman exams 2 self referral exams per year
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 outine 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 mammography based on age Complete obstetrical maternity care for all covered females 10 copay for office visit to
determine pregnancy no copay per visit thereafter 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
Voluntary sterilization and family planning services Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver 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 leuke
mia advanced Hodgkin s lymphoma advanced non Hodgkin s lymphoma advanced neuro
blastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediasti
nal retroperitoneal and ovarian germ cell tumors T ansplants are covered when approved bthe
Medical Director Related medical and hospital expenses of the donor are covered when the
recipient is covered by this Plan
Dialysis Women who undergo mastectomy may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure
Chemotherapy radiation therapy and inhalation therap Surgical treatment of morbid obesit
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
Diabetic self management courses to include courses outside the home courses at home are covered as part of an approved home health care program
Chiropractic services by Plan doctors when approved by Plan Medical Director or your primary care doctor
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures
for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of
fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral
areas surrounding the teeth are not covered including any dental care involved in treatment of
temporomandibular joint TMJ pain dysfunction syndrome
6 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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CIGNA HealthCare of New York 2000
Section 5 Benefits continued
Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery that has produced a major effect on the member s appearance and if
the condition can reasonably be expected to be corrected by such surgery A patient and her
attending physician may decide whether to have breast reconstructive surgery following a mastec
tomy and whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an outpa
tient basis for 60 consecutive days per condition if significant improvement can be expected within
60 consecutive days you pay a 10 copay per outpatient session Speech therapy is limited to
treatment of certain speech impairments of o ganic 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 you pay 10 The following types of artificial
insemination are covered intravaginal insemination IVI intracervical insemination ICI and
intrauterine insemination IUI you pay 200 per procedure cost of donor sperm is not covered
Injectable fertility drugs are not covered under the Prescription Drug benefit Oral fertility drugs are
covered under the Prescription Drug benefit Injectable infertility drugs are covered as part of a
Plan approved infertility treatment program under the Medical Benefit Other assisted reproductive
technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Durable medical equipment such as wheelchairs and hospital beds is covered you pay nothing
External prosthetic devices such as artificial limbs limited to initial purchase and subsequent
purchase due to physical growth and breast prostheses and bras including their replacement are
covered up to a maximum Plan payment of 1,000 per member per contract year you pay a 200
deductible per contract year
What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterilit Surgery primarily for cosmetic purposes
Hearing aids Long term ehabilitative therap
Homemaker services Orthopedic devices such as braces
Foot orthotics T ansplants not listed as covered
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 60 days per 365 day period when
full time skilled nursing care is necessary and confinement in a skilled nursing facility is medicallappropriate
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 7
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Section 5 Benefits continued
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facilitfor
up to 210 days per lifetime Services include inpatient and outpatient care and family counseling
up to 5 visits for bereavement counseling these services are provided under the direction of a Plan
doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of
approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
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 detoxifi
cation if the Plan doctor determines that outpatient management is not medically appropriate See
pages 9 10 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care est cures domiciliary or convalescent care
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency 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 themight
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 madetermine
are medical emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies
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 unless it was not easonable to do so It is your esponsibility 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 dafollowing
your admission unless it was not easonably possible to notify the Plan within that time
If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in
a Plan hospital you will be transferred when medically feasible with any ambulance charges
covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay 50 per hospital emergency room visit or 10 per u gent care center visit 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
Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the service area 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 dafollowing
your admission unless it was not easonably 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
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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CIGNA HealthCare of New York 2000
Section 5 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 services to the extent the services would have been covered if
received from Plan providers
You pay 50 per hospital emergency room visit or 10 per u gent care center visit 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
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 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 eceipts 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 4 5
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 30 outpatient sessions to Plan doctors consultants or other psychiatric personnel each 365
day period You pay 10 per session
Inpatient care Up to 30 days of hospitalization each 365 day period you pay nothing for 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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Section 5 Benefits continued
Outpatient care Up to 60 sessions or one structured program per member per 365 day period to Plan providers for
treatment You pay 10 per session for first 60 sessions all charges thereafter
Inpatient care Up to 30 days per 365 day period in an alcohol detoxification or rehabilitation center You pay
nothing for 30 days all charges thereafter
What is not covered T eatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be
dispensed for up to a 30 day supply not to exceed one hundred 100 units You pay a 7 copay per
prescription unit or efill of generic drugs or a 14 copay per prescription unit or efill for name
brand drugs When generic substitution is permissible i e generic drug is available and the
prescribing doctor does not equire the use of a name brand drug but you request the name brand
drug you pay the price difference between the generic and name brand drug as well as the 14
name brand copay per prescription unit or efill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan s drug formulary
Medically necessary non formulary drugs will be covered when prescribed by a Plan doctor and
approved by Plan s medical director
The Plan s drug formulary is updated regularly by the Pharmacy and Therapeutics Committee The
Committee consists of providers pharmacists medical directors and pharmacy directors Thereview
medications for safety therapeutic value and cost effectiveness Based on this review
medications are added or deleted from the formulary
Covered medications and accessories include
Drugs for which a prescription is required by Federal law Oral and injectable contraceptive drugs contraceptive devices and diaphragms
Insulin Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use implantable drugs including Norplant and some
injectable drugs are covered under Medical and Surgical Benefits
Limited benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay a 7
copayment for generic or a 14 copayment for name brand up to the dosage limits and all charges
after that
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 Drugs for cosmetic purposes
Drugs to enhance athletic performance Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics Injectable fertility drugs see Infertility benefit under Medical and Surgical Benefits for limited
coverage
Smoking cessation drugs and medication including nicotine patches
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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CIGNA HealthCare of New York 2000
Section 5 Benefits continued
Other Benefits
Dental care
Accidental Restorative services and supplies necessary to promptly epair but not eplace sound natural
injury benefit teeth The need for these services must result from an accidental injury occurring while the member
is covered under the FEHB Program you pay nothing
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 which include the written lens prescription may be obtained from
Plan providers You pay nothing
Limited benefits Eyeglasses or one set of contact lenses including external lenses following cataract surgery are
available once per 365 day period from Plan providers You pay 80 of charges
What is not covered Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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CIGNA HealthCare of New York 2000
Section 5 Benefits continued
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 avail
able to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not included in
the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure
Guest Privileges If you or a covered family member temporarily moves outside of the service area for at least 90
days you may be eligible for the Plan s guest privileges program The guest privileges program
allows participants to enroll as guests in another CIGNA HealthCare site This program is onlavailable
when you or your covered family member is temporarily elocating to an approved
CIGNA guest site Guest privileges is an ideal way to arrange for benefits in situations such as a
temporary job transfer work assignments college child attending school away from home etc You
should be aware that your FEHBP benefits will NOT follow you to the guest site You will be
covered by the CIGNA HealthCare guest privileges program plan of benefits Contact member
services at 1 800 832 3211 for more information
Medicare prepaid This plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As
plan enrollment indicated on page 13 annuitants and former spouses with FEHB coverage and Medicare Part B
may elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available
in their area They may then later re enroll in the FEHB Program Most Federal annuitants have
Medicare Part A Those without Medicare Part A may join this Medicare prepaid plan but will
probably have to pay for hospital coverage in addition to the Part B premium Before you join the
plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact
your etirement system for information on dropping your FEHB enrollment and changing to a
Medicare prepaid plan Contact us at 1 800 547 5843
12 BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
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CIGNA HealthCare of New York 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
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 emain
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 etirement 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 mare
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 equire you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our egular benefit
whichever is less
We will not pay more than the reasonable charge If we are the secondary payer we may be entitled
to eceive payment from your primary plan We will always provide you with the benefits de
scribed 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
beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care
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CIGNA HealthCare of New York 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 or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek
damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military
TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are
the primary payer See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage
Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compen sation 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 o
Agencies indirectly pays for
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also find
your HMO 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 800 832 3211 or write to Member Services
5700 Bigelow Commons Enfield Connecticut 06082 You may also visit our website at
www cigna com healthcare
Where do I get Your employing or etirement 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
enrolling in the an 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 etirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums effective Annuitants premiums begin January 1
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CIGNA HealthCare of New York 2000
Section 8 FEHB Facts continued
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I retire 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for me unmarried dependent children under age 22 including any foster or step children your employing or
and my family retirement office authorizes coverage for Under certain circumstances you may also get coverage
for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member
Your employing or etirement office will not notify you when a family member is no longer eligible
to eceive health benefits nor will we Please tell us immediately when you add or emove familmembers
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
and claims records access to it
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
Preexisting conditions We will not efuse to cover the treatment of a condition that you or a family member had before you
enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in
this Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
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CIGNA HealthCare of New York 2000
Section 8 FEHB Facts continued
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
spouse coverage 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 etirement 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 etirement 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
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under
in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or etirement 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 etirement 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 etirement 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 notifies
your employing or etirement 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 avail
able 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 etirement office will not notify you
You must apply in writing to us within 31 days after you are no longer eligible for coverage
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CIGNA HealthCare of New York 2000
Section 8 FEHB Facts continued
Your benefits and rates will differ from those under the FEHB Program however you will not have
to answer questions about your health and we will not impose a waiting period or limit your
coverage due to preexisting conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health lan Coverage insurance or other health care coverage You must 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 elated 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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CIGNA HealthCare of New York 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 eceive 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 800 832 3211 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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CIGNA HealthCare of New York 2000
Summary of Benefits for CIGNA HealthCare of New York 2000
Do not ely 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 lan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit
Includes in hospital doctor care oom 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 7
Extended All necessary services for up to 100 days per contract year You pay nothing 7
care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of
conditions inpatient care per year You pay nothing 9
Substance Up to 30 days ehabilitation in substance abuse programs per 365 day period
abuse You pay nothing 10
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 checkups
and routine immunizations laboratory tests and X rays complete maternity care
You pay a 10 copay per office visit a 10 copay per house call by a doctor 6
Home health All necessary visits by nurses and health aides You pay nothing 6
care
Mental Up to 30 outpatient visits per 365 day period You pay a 10 copay per session 9
conditions
Substance Up to 60 sessions or one structured program per member per 365 day period You pay a
abuse 10 copay per session 10
Emergency care Reasonable charges for services and supplies required because of a medical emergency
You pay a 50 copay to the hospital 10 copay to Urgent Care Center for each
emergency room visit and any charges for services that are not covered by this Plan 8 9
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 7
copay per prescription unit or refill for generic and a 14 copay per prescription unit or
refill of name brand 10
Dental care Accidental injury benefit you pay nothing 11
Vision care One refraction annually you pay nothing 11
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses
reach a maximum of 1,500 per Self Only or 3,000 per Self and Family enrollment
per contract year covered benefits will be provided at 100 This copay maximum
does not include the cost of prescription drugs or dental services 3
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CIGNA HealthCare of New York 2000
2000 Rate Information for
CIGNA HealthCare of New York
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category efer 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 noncareer 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 Gov t Your Gov t Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
New York City area
Self only HU1 73.01 24.33 158.18 52.72 86.39 10.95 86.39 10.95
Self and Family HU2 175.97 81.99 381.27 177.64 207.74 50.22 201.02 56.94
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