Serving Rhode Island and portions of Southeastern Massachusetts
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
DA1 Self Only
DA2 Self and Family
This Plan has a commendable status
from the NCQA See the 2000 Guide
for more information on the NCQA
Visit the OPM website at http www opm gov insure
and
This Plan's website at http www bcbsri com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance service
BlueCHiP Coordinated Health Partners
Table of Contents
Page
Introduction
3
Plain language
3
How to use this brochure
3
Section 1 Health Maintenance Organizations
4
Section 2 How we change for 2000
4
Section 3 How to get benefits
5
Section 4 What to do if we deny your claim or request for service
7
Section 5 Benefits
9
Section 6 General exclusions Things we don't cover
19
Section 7 Limitations Rules that affect your benefits
19
Section 8 FEHB FACTS
20
Inspector General Advisory Stop Healthcare Fraud
24
Summary of benefits
27
Premiums
back cover
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BlueCHiP Coordinated Health Partners 2000
Introduction
BlueCHiP Coordinated Health Partners
15 LaSalle Square
Providence RI 02903
This brochure describes the benefits you can receive from Blue CHiP Coordinated Health Partners under its contract CS2328 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 4 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to BlueCHiP Coordinated Health Partners 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
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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BlueCHiP Coordinated Health Partners 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services or point of service benefits POS 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 or group of physicians hospital or other
provider will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing
any course of treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary
changes care 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 this Plan Your share of BlueCHiP Coordinated Health Partner's non postal premium will increase by 13.1 for Self Only or 21.3 for Self and Family
The copay for prescription drugs obtained at a Plan pharmacy is now 5 per prescription unit or
refill for generic drug 15 per prescription unit or refill for brand name drugs listed on the Plan's
drug formulary and 30 per prescription unit or refill for brand name drugs not listed on the
Plan's drug formulary unless you meet certain medical criteria for that prescription drug For
prescription drugs obtained at a non participating pharmacy you now pay a 30 copay plus 20
of the BlueCHiP Coordinated Health Partners allowance Previously you paid a 20 coinsurance
for all prescription drugs obtained at a Plan pharmacy and a 50 coinsurance for prescription
drugs obtained at a non Plan pharmacy
Home health services are no longer covered under the POS benefits All home health services
must be obtained from network providers Previously home health services were covered under
the POS benefit at 80 of the Plan's allowance
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BlueCHiP Coordinated Health Partners 2000
Durable Medical Equipment DME is no longer covered under the POS benefits All Durable
Medical equipment must be obtained from the network provider Previously DME was covered
under the POS benefit at 80 of the Plan's allowance
Diagnostic procedures such as laboratory tests and X rays are no longer covered under the POS
benefits Diagnostic procedures must be obtained from network providers Previously diagnostic
procedures were covered under the POS benefit at 80 of the Plan's allowance
Anesthesia consultations are no longer covered under the POS benefits All anesthesia consultations
must be obtained form network providers Previously anesthesia consultations were covered
under the POS benefit at 80 of the Plan's allowance
Infertility services are no longer covered under the POS benefits All infertility services must be
obtained from network providers Previously infertility services were covered under the POS
benefit at 80 of the Plan's allowance
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 The State of Rhode Island and the following cities and towns in the state of Massachusetts Acushnet Attleboro Bellingham Blackstone Dartmouth Dighton Fall River
Fairhaven Foxborough Franklin Mansfield Medway Mendon Millville New Bedford North
Attleboro Norton Plainville Raynham Rehoboth Seekonk Somerset Swansea Taunton
Uxbridge Westport Wrentham
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 or point of service benefits 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 BlueCHiP Coordinated Health Partners offers the HMO USA Away from Home
Care Guest Membership program To enroll in this program please contact Customer Service at
401 274 3500 or toll free at 1 800 564 0888 If you or a family member move you do not have
to wait until the 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
for services or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
After you pay 2,294 in copayments or coinsurance for one family member or 5,874 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 and dental services 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 submit You normally won't have to submit claims to us unless you receive emergency services from a
claims provider who doesn't contract with us or you use point of service benefits 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
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BlueCHiP Coordinated Health Partners 2000
Who provides my BlueCHiP Coordinated Health Partners is affiliated with Blue Cross Blue Shield of Rhode
health care Island BlueCHiP Coordinated Health Partners provides care through over 700 primary care doctors internists pediatricians and family practitioners and over 1,200 specialists along with a
full range of hospitals and other health care providers across the state When specialist services
are needed your primary care doctor will refer you to a BlueCHiP Coordinated Health Partners
specialist All participating primary care doctors practice out of offices in the community Each
member selects a primary care doctor who acts as a personal doctor working with you to coordinate
all of your health care needs
BlueCHiP Coordinated Health Partners has a POS product which offers members the flexibility
of obtaining services outside of the primary care doctor system and receiving an allowance for
services For more information regarding this benefit see pages 16 and 17
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 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 continue to supervise your care
hospital
What do I do if I'm First call our customer service department at 401 274 3500 or toll free at 1 800 564 0888 If you
in the hospital when I are new to the FEHB Program we will arrange for you to receive care If you are currently in
join this Plan the FEHB Program and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
Your primary care physician will arrange your referral to a specialist
How do I get specialty If you need to see a specialist frequently because of a chronic complex or serious medical condition
care 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 When you receive a referral from your
primary care doctor you must return to the primary care doctor after the consultation unless your
doctor authorizes additional visits All follow up care must be provided or authorized by the primary
care doctor Do not go to the specialist unless your primary care doctor has arranged for
the referral in advance
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to
seeing a specialist a 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 my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see someone else
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to continue
illness and my provider seeing your provider for up to 90 days after we notify you that we are terminating our contract
leaves the Plan or this Plan with the provider unless the termination is for cause If you are in the second or third trimester
leaves the Program of pregnancy you may continue to see your OB GYN until the end of your postpartum care
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BlueCHiP Coordinated Health Partners 2000
You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services or 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 or investigational services include any treatment procedure facility equipment
service is experimental drug device supply or service hereinafter referred to collectively as service when the service
or investigational has progressed to limited human application but has not been recognized as proven effective in clinical medicine A service is considered experimental or investigational if the plan determines
that one or more of the following circumstances are true 1 the service is the subject of an
ongoing clinical trial or is under study to determine the maximum tolerated dose toxicity safety
efficacy or efficacy as compared with a standard means of treatment or diagnosis or 2 the prevailing
opinion among experts regarding the service is that further studies or clinical trials are
necessary or 3 the current belief in the pertinent specialty of the medical profession in the
United States is that the service or supply should not be used for the diagnosis or indications
being requested outside of clinical trials or other research settings because it requires further
evaluation for that diagnosis or indications
BlueCHiP will determine the applicability of this criterion based on Published reports in authoritative
peer reviewed medical literature and reports publications evaluations and other sources
published by government agencies or the service has FDA approval but the indication for the
drug device or dosage is not an accepted off label use
To the extent that BlueCHiP's definition of experimental or demonstrated reliable evidence conflicts
with Rhode Island General Laws Section 27.41 41,41.1 and 41.2 relating to new cancer
therapies and Rhode Island General Laws Chapter 27 55 relating to off label uses of prescription
drugs those statutory provisions will control
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
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When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a serious or Call us at 401 274 3500 or 1 800 564 0888 and we will expedite our review
life threatening condition
and you haven't responded
to my request for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will
my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is serious or OPM's health benefits Contract Division 3 at 202 606 0755 between 8 am and 5 pm Eastern
life threatening Time Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with
the review request
Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance
disputed claim to OPM Programs Contract Division 3 P O Box 436 Washington DC 20044
What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our
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
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What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
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
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 and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit
copay for primary care and specialist office visits but no additional copay for laboratory tests or
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 and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 through age 49 one mammogram every one or two
years for women age 50 64 one mammogram every year for women age 65 and above one
mammogram every two years In addition to routine screenings 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
Hearing exams when referred by the primary care doctor
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor Copays are waived for maternity care after the initial visit
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 in addition coverage of injury or sickness
including necessary care and treatment of medically diagnosed congenital defects and birth
abnormalities will be covered for the first 31 days of the newborn's life all care after the first
31 days will be covered only if the infant is covered under a Self and Family enrollment
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE STANDARD HMO BENEFITS
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BlueCHiP Coordinated Health Partners 2000
Voluntary sterilization and family planning services
Infertility services diagnosis and treatment including artificial insemination and injectable
fertility drugs you pay 20 of BlueCHiP Coordinated Health Partners fee allowance
The following types of artificial insemination are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI cost of donor sperm is
not covered Non injectable fertility drugs are covered under the prescription drug benefit
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient
or outpatient basis if significant improvement can be expected On an inpatient basis you
pay nothing On an outpatient basis you pay 10 per session
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 also breast
prostheses and surgical bras including their replacements
Cornea heart heart lung kidney liver lung single or double and pancreas transplants allogenic
donor bone marrow transplants autologous bone marrow transplants autologous stem
cell and peripheral stem cell support for the following conditions acute lymphocytic or nonlymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma and testicular mediastinal retroperitoneal and ovarian germ cell
tumors and breast cancer multiple myeloma and epithelial ovarian cancer 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 Additionally such
trials must be delivered at a facility that is a National Cancer Institute NCI funded National
Cooperative Cancer study group institution that has been approved by the Cooperative Groups
to conduct clinical research on HDC ABMT treatment or an institution that has an NCI funded
peer reviewed grant to study HDC ABMT In the absence of an available clinical trial the
Plan will provide the same level of coverage for these transplants as any other transplant
covered by the Plan 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
Podiatric services
Initial orthopedic devices such as braces initial prosthetic devices such as artificial limbs and
durable medical equipment such as wheelchairs and hospital beds you pay a 20 copay per
item The Plan will determine whether an item is to be rented or purchased
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE STANDARD HMO BENEFITS
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BlueCHiP Coordinated Health Partners 2000
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 you pay a 10 copay for office visits All other procedures
involving the teeth or intra oral areas surrounding the teeth are not covered including any
dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by surgery you pay nothing A patient and
her attending physician may decide whether to have breast reconstruction surgery following a mastectomy
and whether surgery on the other breast is needed to produce a symmetrical appearance
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided at a Plan facility for up to 32 visits you pay nothing
Chiropractic services when received from an in network chiropractor are covered for up to six
self referred visits per calendar year You pay 10 per visit
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment insurance or attending school or camp or travel
Blood and blood derivatives not replaced by the member
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Homemaker services or custodial care
Replacement orthopedic and prosthetic devices
Foot orthotics
Hospital Extended Care Benefits
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
Hospital care Semiprivate room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu of hospitalization
as determined by a Plan doctor and approved by the Plan You pay nothing All necessary
services are covered including
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE STANDARD HMO BENEFITS
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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 for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are
provided under the direction of a Plan doctor who certifies that the patient is in the terminal
stages of illness with a life expectancy of approximately six months or less You pay nothing
Ambulance service Benefits are provided for medically necessary ambulance services for emergency care Nonemergent
situations require a BlueCHiP authorization
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
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 Mental Health Administrator determines that outpatient management is not
medically appropriate See page 14 for non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE STANDARD HMO BENEFITS
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 serous injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan
may determine are medical emergencies what they all have in common is the need for quick
action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies
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 is not reasonably possible to do so It is your
responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility 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
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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
except as shown on page 16
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by Plan providers except as covered under POS benefits
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 hospital emergency room visit for emergency services or 20 per urgent care visit at a Plan participating urgent care center for benefits covered under this Plan If the emergency
results in an admission to a hospital within 24 hours the emergency care copay is waived
Emergencies outside the Benefits are available for any medically necessary health service that is immediately required
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
day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred
when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by Plan providers except as covered under POS benefits
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 hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital within 24 hours the emergency care
copay is waived
What is covered Emergency care at a doctor's office
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 except as covered under the POS Benefits
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 except as covered under the POS benefits
Filing claims for non Plan With your authorization the Plan will pay benefits directly to the providers of your emergency
providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan
along with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the
denial and the provisions of the contract on which denial was based If you disagree with the
Plan's decision you may request reconsideration in accordance with the disputed claims procedure
described on pages 7 9
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BlueCHiP Coordinated Health Partners 2000
Reciprocity BlueCHiP Coordinated Health Partners offers the HMO USA Away From Home Urgent Care program When you or a covered member are traveling throughout the United States and need
medical care before you return home call the Away From Home Coordinator at 1 800 4 HMOUSA
1 800 446 6872 The Away From Home Care Coordinator will assist you with scheduling
an appointment with a qualified doctor during normal business hours and give you directions to
the doctor's office
Mental Conditions Substance Abuse Benefits
Mental conditions Treatment for mental health conditions and substance abuse may be obtained directly from Continuum Behavioral Care or other mental health administrator as determined by the Plan the
member must call 800 544 5977 or 401 276 4052 prior to services being rendered Continuum
Behavorial Care will determine and authorize the appropriate number of visits and determine the
appropriate specialist A referral from your PCP is not required
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
Biological disorders of the brain that substantially limit the life activities of an individual
including but not limited to schizophrenia schizoaffective disorder delusional disorder bipolar
affective disorders major depression and obsessive compulsive disorder
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay for each covered visit all charges thereafter
Inpatient care Up to 90 days of hospitalization each calendar year you pay nothing for the first 90 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 that is 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 Alcohol abuse Up to 30 visits for each individual under treatment and 20 visits for other family members per calendar year for counseling you pay a 10 per visit copay
Other substance abuse Up to 20 visits per calendar year for rehabilitation you pay a 10 per
visit copay
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE STANDARD HMO BENEFITS
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BlueCHiP Coordinated Health Partners 2000
These substance abuse benefits may be combined with the outpatient mental conditions benefits
shown above provided such treatment is necessary as a mental health service and is approved by
the Plan to permit an additional 20 outpatient visits per calendar year with the applicable mental
conditions benefits coinsurance
Inpatient care Alcohol abuse Up to 30 days per calendar year for rehabilitation lifetime maximum of 90 days on all substance abuse care you pay nothing
Other substance abuse Up to 30 days per calendar year for rehabilitation lifetime maximum of
90 days on all inpatient substance abuse care you pay nothing
What is not covered Treatment that is not authorized by the Plan Mental Health Administrator
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor will be dispensed for up to a 34 day supply for non maintenance drugs or the greater of a 34 day supply or 100 units for maintenance
drugs For prescription drugs obtained at a Plan participating pharmacy you pay a 5 copay per
prescription unit or refill for generic drugs a 15 copay per prescription unit or refill for brand
name drugs listed on the Plan's drug formulary or a 30 copay per prescription unit or refill for
brand name drugs not listed on the Plan's drug formulary unless you meet certain medical criteria
for the prescription drug see note below
Note There is a two month grace period for non formulary drugs during which the member
will only be charged only the 5 generic or 15 brand name copay whichever applies If you
meet the pre established medical criteria for the non formulary drug you will only be required to
pay the applicable 5 generic or 15 brand name copay If they do not meet the pre established
medical criteria or your physician does not submit the necessary information for medical necessity
to be determined you will be responsible for the 30 copay amount after the two month grace
period has ended
Plan pharmacies include pharmacies from the Preferred Rx network which is composed of CVS
Brooks and additional independent pharmacies For prescription drugs obtained at a non participating
pharmacy you are responsible for paying the non participating pharmacy directly and the
Plan will reimburse you once you have submitted the receipt your name and identification number
to BlueCHiP 15 Lasalle Square Providence RI 02903
Covered medications and accessories include
Diabetic supplies are covered under Medical and Surgical Benefits you pay 20 of BlueCHiP
Coordinated Health Partner's fee allowance
Drugs for which a prescription is required by Federal law
Fertility drugs non injectables
All FDA approved contraceptive drugs and devices
Implanted time release medications such as Norplant included with office visit copay covered
under Medical Surgical benefits
Insulin
Intravenous fluids and medication for home use implantable drugs and injectible drugs
excluding insulin are covered under Medical and Surgical Benefits
Needles and syringes when dispensed with insulin
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE STANDARD HMO BENEFITS
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BlueCHiP Coordinated Health Partners 2000
Nicotine substitute prescriptions the patch and gum you pay all charges at the time of purchase
keep your receipts you are reimbursed after you are smoke free for 12 months You
are reimbursed at 80 of BlueCHiP Coordinated Health Partners fee allowance after submitting
to the Plan a sales receipt and physician's documentation that you are smoke free This
coverage is limited to a three month treatment one per lifetime maximum
Prenatal and other prescribed vitamins
Limited benefits Drugs to treat sexual dysfunction are subject to dosage limitations Contact the Plan for specific dosage limitations
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Injectable fertility drugs
Medical supplies such as dressings and antiseptics
Vitamins and nutritional substances that can be purchased without a prescription
Other Covered Benefits
Dental care
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered The need for these services must result from an accidental injury you pay nothing
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 a 10 copay for office visits
What is not covered Corrective lenses or frames
Eye exercises
Facts about BlueCHiP Coordinated Health Partners POS
BlueCHiP Coordinated At your option you may choose to obtain benefits covered by this Plan from non Plan doctors Health Partners POS and hospitals or from Plan doctors without a referral whenever you need care except for the benefits
listed below under What is not covered Medical services and supplies not covered under
Point of Service must either be received from or arranged by Plan doctors to be covered When
you obtain covered non emergency medical treatment from a non Plan doctor without a referral
from a Plan doctor you are subject to the annual deductible and coinsurance stated below An
annual out of pocket maximum is also stated below
What is covered Members may use providers who do not participate in the program or may self refer to participating providers but are strongly encouraged to obtain care through the primary care doctor system
Members may receive eligible services from any doctor hospital or other provider without referral
from their primary care doctor Some of the services are covered ONLY under the Plan's
Standard HMO Benefits See What is not covered below However members may choose to
receive benefits using the POS benefit i e receive medical services from providers without a
PCP referral and receive a lower allowance than when the standard HMO benefit is utilized
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BlueCHiP Coordinated Health Partners 2000
Deductible When the POS benefit is utilized you pay a 250 deductible per member per calendar year or a 500 deductible per family per calendar year for doctors visits other outpatient services and for
hospital services The deductible is not reimbursable by the Plan If you decide to use non participating
providers or self refer to a participant provider this deductible applies to all covered
benefits Copays under the BlueCHiP Coordinated Health Partners POS benefits cannot be used
to meet the calendar year deductible
Coinsurance for When you self refer to Plan participating providers the Plan pays 80 of its fee allowance after participating providers the deductible is met you pay 20 of the fee allowance
Coinsurance for nonparticipating When you self refer to non Plan participating providers the Plan pays 80 of its fee allowance providers after the deductible is met you pay 20 of the fee allowance and all charges over and above the
fee allowance
Plan authorization Services requiring Plan authorization under the Plan's Standard HMO benefits continue to require authorization under the POS benefit When utilizing non Plan participating providers you are
responsible for assuring that Plan Authorization is obtained in advance for such services
Out of pocket maximum Members are protected by an out of pocket maximum of 3,000 per person per calendar year and 6,000 per family per calendar year This includes deductibles and copayments Charges
over the usual and customary allowance cannot be applied to the out of pocket maximum
Prescription drugs You may have prescriptions filled when utilizing the POS benefit The benefits and requirements are the same as those for the standard HMO Prescription Drug Benefit see page 15
What is not covered Anesthesia consultations services are covered under the prepaid plan see page 9
Chiropractic care services are covered under the prepaid plan see page 11
Diagnostic procedures such as laboratory tests and x rays services are covered under the
prepaid plan see page 9
Durable Medical Equipment DME and medical supplies services are covered under the
prepaid plan see page 10
Emergency room visits emergency services are covered under the prepaid plan see page 12
Home health services services are covered under the prepaid plan see page 10
Infertility services services are covered under the prepaid plan see page 10
Mental conditions substance abuse benefits services are covered under the prepaid plan see
page 14
Outpatient physical speech and occupational therapies cardiac rehabilitation services are
covered under the prepaid plan see pages 10 and 11
Rehabilitation hospitalizations services are covered under the prepaid plan see page 11
Skilled nursing facility care services are covered under the prepaid plan see page 11
Transplant coverage services are covered under the prepaid plan see page 10
Vision care benefits services are covered under the prepaid plan see page 16
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Non FEHB Benefits Available to Plan Members
neither offered or guaranteed under the contract with FEHB Program The benefits described on this page are The cost of the benefits described on
are made available to all enrollees and family members of this Plan any but premium and any charges for these services do not count toward
this page is not included in the FEHB maximums These benefits are not subject to
FEHB deductibles POS maximum benefits or out of pocket
the FEHB disputed claims procedure
prepaid plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare This Plan annuitants and former spouses with FEHB
enrollment Medicare As indicated on page 19 enroll in a coverage and Medicare B may elect to drop their FEHB coverage and
prepaid plan when one is available in their area They may then later Medicare Federal annuitants have Medicare Part A
re enroll in the FEHB Program Most but will
Those without Medicare Part A may join this Medicare prepaid plan have to pay for hospital coverage in addition to the Part B premium
probably the plan covers hospital benefits and
Before you join the plan ask whether for information
if so what you will have to pay Contact your retirement system your FEHB enrollment and changing to a Medicare prepaid plan
on dropping on the Medicare prepaid plan and
Contact us at 800 505 2583 for information
the cost of that enrollment
Medicare eligible and are interested in enrolling in a Medicare HMO If you are enrollment in this Plan's FEHB
sponsored by this Plan without dropping your 800 505 2583 for information on the benefits available under the
plan call
Medicare HMO
BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
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BlueCHiP Coordinated Health Partners 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 Services drugs or supplies that are not medically necessary following
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits or eligible self referred services see Point of Service benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program
and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the
Medicare Choice plan offered by this Plan see page 18
Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage You must tell us if you or a family member has double coverage You must also send us
documents about other insurance if we ask for them
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BlueCHiP Coordinated Health Partners 2000
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances beyond our Under certain extraordinary circumstances we may have to delay your services or be unable to provide
control them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will
cover the cost of treatment that exceeds the amount you received in the settlement If you do not
seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage
Workers compensation
We do not cover You need because of a workplace related disease or injury that the Office of Workers Compensation services that 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 Agencies or 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 your right to information about your health plan its networks providers and facilities You can also
HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's
website www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 401 274 3500 or toll free at 1 800 564 0888 or
write to Customer Service 15 LaSalle Square Providence RI 02903 You may also contact us
by fax at 401 459 5089 or visit our website at www bcbsri com
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BlueCHiP Coordinated Health Partners 2000
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal
about enrolling in the Employees Health Benefits Plans brochures for other plans and other materials you need to make
FEHB Program an informed decision about
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been
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 my unmarried dependent children under age 22 including any foster or step children your employing
family and me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support which is also
authorized by your employing or retirement office
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 No new enrollment form
is necessary
If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan
Are my medical and claims We will keep your medical and claims information confidential Only the following will have
records confidential access to it
OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensations 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
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BlueCHiP Coordinated Health Partners 2000
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
What if I paid a deductible Your old plan's deductible continues until our coverage begins under my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits You will receive an additional 31 days of coverage for no additional premium when
What happens if my Your enrollment ends unless you cancel your enrollment or enrollment in this Plan You are a family member no longer eligible for coverage
ends You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits 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 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
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
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BlueCHiP Coordinated Health Partners 2000
Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline
How can I convert to You may convert to an individual policy if individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if
you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions
How can I get a Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage of Group Health Plan that indicates how long you have been enrolled with us You can use this certificate when getting
Coverage health 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 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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BlueCHiP Coordinated Health Partners 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 401 459 5500 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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Notes
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Notes
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Summary of Benefits for Blue CHiP Coordinated Health Partners 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 AND SERVICES
AVAILABLE AS POS BENEFITS ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care private room and private
nursing care if medically necessary diagnostic tests drugs and medical supplies use of
operating room intensive care and complete maternity care You pay nothing 11
Extended care All necessary services You pay nothing 11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 90 days of inpatient
conditions care per calendar year You pay nothing 14
Substance Abuse Up to 30 days for lifetime maximum of 90 days for alcohol abuse and up to 30
days lifetime maximum of 90 days for other drug abuse programs per calendar
year You pay nothing 14
Outpatient care Comprehensive range of services such as preventive care including well baby care periodic checkups office visits for routine immunizations primary care and specialist
office visits or house calls by a doctor You pay a 10 copay laboratory tests x rays
complete maternity care you pay nothing 9
Home health care All necessary visits by nurses and home health aides You pay nothing 10
Mental conditions Up to 20 outpatient visits per calendar year You pay 10 per visit 14
Substance abuse Up to 30 outpatient visits for alcoholism and up to 20 visits for other substance
abuse per calendar year You pay 10 per visit 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each emergency room visit
inside and outside the service area and any charges for services that are not
covered benefits of this Plan 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at Plan pharmacy You pay 5 generic 15 brand name per prescription unit or refill for formulary drugs for a 34 day
supply Non formulary drugs have a 30 copay unless medically necessary 15
Dental care Accidental injury benefit You pay nothing 16
Vision care One refraction every year You pay a 10 copay for office visits 16
Point of Service Benefits Services of non Plan doctors and hospitals Not all benefits are covered You pay the annual deductible then coinsurance thereafter An annual
out of pocket maximum also applies 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 2,294 per Self Only or 5,874 per Self or
Family enrollment per calendar year covered benefits will be provided at 100
This maximum does not include costs of prescription drugs or dental services 5
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Authorized for distribution by the
United States Office of Federal Employee
Personnel Management
2000 Rate Information for
BlueCHiP Coordinated Health Partners Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A
rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member of a special
postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States
Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members
of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal Employees
Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Self Only DA1 75.20 25.06 162.92 54.31 88.98 11.28 88.98 11.28
Self and Family DA2 175.97 80.72 381.27 174.89 207.74 48.95 201.02 55.67
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