Pages 1--39 from fehb2000

Blue Cross HMO CaliforniaCare 2000
A Health Maintenance Organization

For
changes in
benefits
see page 5

Enrollment in this Plan is limited see page 6 for requirements
Enrollment Code M51 Self Only
M52 Self and Family

This Plan has full accreditation from the NCQA See the
2000 Guide for more information on NCQA

Visit the OPM website at http www opm gov insure and
this Plan's website at http www bluecrossca com

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE

RI 73 517 1
1 Page 2 3

Table of Contents
Introduction 3

Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 11
Section 5 Benefits 14
Section 6 General exclusions Things we don't cover 26
Section 7 Limitations Rules that affect your benefits 27
Section 8 FEHB facts 29
Department of Defense FEHB Demonstration Project 34
Inspector General Advisory Stop Health Care Fraud 36
Non FEHB Benefits 37
Summary of benefits Inside Back Cover
2000 Rate Information Back Cover 2
2 Page 3 4
Blue Cross HMO CaliforniaCare 2000
Introduction
Blue Cross of California P O Box 4089 Woodland Hills Ca 91365
This brochure describes the benefits you can receive from Blue Cross HMO CaliforniaCare under its contract CS 2514
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 5 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 Blue Cross HMO CaliforniaCare 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

3 3
3 Page 4 5
Blue Cross HMO CaliforniaCare 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this
Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar
information to make comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO See Section 1 below 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

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 preventive care such as routine office visits physical exams well baby care and immunizations as well as
treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim
forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot
change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider
will be available and or remain under contract with us Our providers follow generally accepted medical practice when
prescribing any course of treatment

4 4
4 Page 5 6
Blue Cross HMO CaliforniaCare 2000
Section 2 How we change for 2000
Program wide This year you have a right to more information about this Plan care management our networks changes 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

The copayment for physician office and home visits has been increased from 5 to 10 This 10
copayment now applies to each physician home or office visit including visits for preventive
care specialists consultations family planning allergy testing and treatment acupuncture
services maternity visits etc

Changes to this Plan The prescription drug copayment for name brand drugs and non formulary generic drugs has been changed as follows
Name brand drugs and non formulary generic drugs filled at a Blue Cross
participating pharmacy will now require a 10 copayment
Name brand drugs filled at a non participating pharmacy will be reimbursed at 50
minus a 10 copayment
Name brand drugs and non formulary generic drugs received through the mail order
program will now require a 20 copayment
See Section 5 Benefits Prescription Drug Benefits

Your share of the premium will increase by 21.8 for Self Only and 21.8 for Self and Family

5 5
5 Page 6 7
Blue Cross HMO CaliforniaCare 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our Plan's service service area is
area Northern California
Amador Fresno Marin Nevada San Francisco Sonoma
Alameda Humboldt Mendocino Placer San Joaquin Stanislaus
Butte Kings Merced Plumas San Mateo Tehama
Contra Costa Lake Modoc Sacramento Santa Cruz Tulare
Del Norte Lassen Monterey San Benito Shasta Tuolumne
El Dorado Madera Napa Santa Clara Solano Yolo

Southern California Imperial Los Angeles Orange San Diego San Louis Obispo
Santa Barbara Ventura
You may also enroll with us if you live or work in the Zip Codes of the following counties

KERN 93203 93205 06 93215 17 93220 93222 93224 26 93238 93240 41 93243 93249 52
93255 93263 93276 93280 93283 93285 93287 93300 09 93311 13 93380 89 93399 93504 05
93516 93518 19 93523 24 93528 93531 93554 93555 93556 93560 61 93570 93581 82 93596

RIVERSIDE 91718 20 91752 91753 91760 92201 03 92210 92211 92220 92223 92230 92234
36 92240 92241 92253 55 92258 92260 64 92270 92276 92282 92292 92303 92320 92330 31
92343 44 92348 92353 92355 92360 62 92367 92370 92379 81 92383 92387 88 92390 92395
96 92500 09 92513 19 92521 23 92530 32 92542 46 92548 92550 92552 57 92562 64 92567
92570 72 92581 87 92589 93 92595 96 92599

SAN BERNARDINO 91701 91708 10 91729 30 91737 91739 91743 91758 91761 64 91784 86
91798 92337 92252 92256 92268 92277 78 92284 86 92301 92305 92307 08 92311 13 92314
18 92321 22 92324 27 92329 92333 37 92339 42 92345 47 92350 92352 92354 92356 59
92365 92368 69 92371 78 92382 92385 86 92391 94 92397 92398 92399 92400 18 92420
92423 24 92427

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 or urgent care services

If you or a covered family member move outside of our service area you can enroll in another plan If
you or a family member move you do not have to wait until Open Season to change plans Contact
your employing or retirement office

How much do I You must share the cost of some services This is called either a copayment a set dollar amount or pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services

After you pay 1,000 in copayments or coinsurance for one family member or 3,000 for three 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 or infertility treatment 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 or urgent case services submit claims from a provider who doesn't contract with us If you file a claim please send us all of the documents
for your claim as soon as possible You must submit claims by December 31 of the year after the year
6 6
6 Page 7 8
Blue Cross HMO CaliforniaCare 2000
you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides When you enroll you should choose a primary care physician Your primary care physician will be the my health care first doctor you see for all your health care needs If you need special kinds of care this physician will
refer you to other kinds of health care providers
Your primary care physician will be part of a CaliforniaCare contracting medical group There are two
types of CaliforniaCare medical groups

A primary medical group PMG is a group practice staffed by a team of doctors nurses and other health care providers

An independent practice association IPA is group of doctors in private offices who usually have ties to the same hospital
You and your family members can enroll in whatever medical group is best for you
You must live or work within 30 miles of the medical group
You and your family members do not have to enroll in the same medical group

What do I do if Call us We will help you select a new one my primary
care physician leaves the Plan

What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist need to go into will make the necessary hospital arrangements and supervise your care
the hospital

What do I do if First call our customer service department at 800 235 8631 If you are new to the FEHB Program we I'm in the will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
hospital when I your former plan will pay for the hospital stay until join this 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

7 7
7 Page 8 9
Blue Cross HMO CaliforniaCare 2000
How do I get Your primary care physician may refer you to another doctor if you need special care Your primary specialty care
care physician must OK all the care you get except when you have an emergency or need urgent care

Your physician's medical group has to agree that the service or care you will be getting from the other
health care provider is medically necessary Otherwise it won't be covered

You will need to make the appointment at the other physician's office

Your primary care physician will give you a referral form to take with you to your appointment This form gives you the OK to get this care If you don't get this form ask for it or talk to your
CaliforniaCare coordinator
You may have to pay a copay You shouldn't get a bill unless for a copay for this service If you do send it to your CaliforniaCare coordinator right away The medical group will see that the bill is
paid
Your primary care physician may be able to send you to some health care providers without getting the OK from the medical group first

Ask your CaliforniaCare coordinator if your medical group takes part in a program called Speedy Referral

Standing Referrals If you have a condition or disease that
Requires continuing care from a specialist or is
Life threatening
Degenerative or
Disabling
your primary care physician may give you a standing referral to a specialist or specialty care center
The referral will be made if your primary care physician in consultation with you and a specialist or
specialty care center if any determine that continuing specialized care is medically necessary for your
condition or disease

If it is determined that you need a standing referral for your condition or disease a treatment plan will
be set up for you The treatment plan

Will describe the specialized care you will receive
May limit the number of visits to the specialist and
May limit the period of time that visits may be made to the specialist

8 8
8 Page 9 10
Blue Cross HMO CaliforniaCare 2000
How do I get If a standing referral is authorized your primary care physician will determine which specialist or specialty care
specialty care center to send you to in the following order
continued First a CaliforniaCare contracting specialist or specialty care center which is associated with your

medical group
Second any CaliforniaCare contracting specialist or specialty care center and
Last any specialist or specialty care center
That has the expertise to provide the care you need for your condition or disease
After the referral is made the specialist or specialty care center will be authorized to provide you health
care services that are within the specialist's area of expertise and training in the same manner as your
primary care physician subject to the terms of the treatment plan

Remember We only pay for the number of visits and the type of special care that your primary care physician OK's Call your doctor if you need more care If your care isn't approved ahead of time
you will have to pay for it except for emergencies or urgent care

If You Are A Woman
You can get OB GYN services from a physician who specializes in caring for women OB GYN or
family practice doctor who does OB GYN and works with your medical group

You can get these services without an OK from your primary care physician
Ask your CaliforniaCare coordinator for the list of OB GYN health care providers you must choose from

Direct Access You may be able to get some special care without an OK from your primary care physician We have a
program called Direct Access which lets you get special care without an OK from your primary care
physician for

Allergy
Dermatology
Ear Nose Throat
Ask your CaliforniaCare coordinator if your medical group takes part in the Direct Access program
If your medical group participates in the Direct Access program you must still get your care from a
doctor who works with your medical group The CaliforniaCare coordinator will give you a list of
those doctors

What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with
specialist when us you must receive treatment from a specialist who does Generally we will not pay for you to see a I enroll specialist who does not participate with our Plan

What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan

9 9
9 Page 10 11
Blue Cross HMO CaliforniaCare 2000
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy provider leaves you may continue to see your OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and Plan leaves the
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic Program
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 Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize recommending follow up care Before giving approval we consider if the service is medically
medical necessary and if it follows generally accepted medical practice services

How do you Experimental procedures are those that are mainly limited to laboratory and or animal research decide if a Investigative procedures or medications are those that have progressed to limited use on humans but
service is which are not generally accepted as proven and effective within the organized medical community Any experimental or experimental or investigative procedures or medications are not covered under this Plan Your medical
investigational group or we will determine whether a service is considered experimental or investigative

10 10
10 Page 11 12
Blue Cross HMO CaliforniaCare 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording 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

Review of Denials of Experimental or Investigative Treatment
If coverage for a proposed treatment is denied because we or your medical group determine that the treatment is experimental
or investigative you may ask that the denial be reviewed by an external independent medical review organization with which
we contract To request this review please call us at the telephone number listed on your identification card or write to us at
Blue Cross of California P O Box 4089 Woodland Hills Ca 91365 To receive this review all of the following conditions
must be met

You have a terminal condition that has a high probability of causing death within two years
The proposed treatment must be recommended by either a a participating provider or b a board certified or board eligible doctor qualified to treat you who certifies in writing that the proposed treatment is more likely to be beneficial

than standard treatment This certification must include a statement of the evidence relied upon
If this review is requested either by you or by a qualified non participating provider as described above the requestor must supply two items of acceptable medical and scientific evidence This evidence consists of the following sources

Peer reviewed scientific studies published in medical journals with nationally recognized standards
Medical literature meeting the criteria of the National Institute of Health's National Library of
Medicine for indexing in Index Medicus Excerpta Medicus Medline and MEDLARS database
Health Services Technology Assessment Research
Medical journals recognized by the Secretary of Health and Human Services under Section
1861 t 2 of the Social Security Act
The American Hospital Formulary Service Drug Information the American Medical
Association Drug Evaluation the American Dental Association Accepted Dental Therapeutics and the
United States Pharmacopoeia Drug Information
Findings studies or research conducted by or under the auspices of federal governmental
agencies and nationally recognized federal research institutes and
Peer reviewed abstracts accepted for presentation at major medical association meetings

Within five days of receiving your request for review we will send the reviewing panel all relevant medical records and documents in
our possession as well as any additional information submitted by you or your doctor Information we receive subsequently will be
sent to the review panel within five business days The external independent review organization will complete its review and render
its opinion within 30 days of its receipt of request for review or within seven days in the case of an expedited review This
timeframe may be extended by up to three days for any delay in receiving necessary records

11 11
11 Page 12 13
Blue Cross HMO CaliforniaCare 2000
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied
denial your claim or request for service

What if I have a Call us at 800 235 8631 and we will expedite your review serious of life
threatening condition and you haven't
responded to my request for service

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We did not answer your request within 30 days In this case OPM must receive your
request within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we do 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 Your request must be complete or OPM will return it to you You must send the following 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 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

12 12
12 Page 13 14
Blue Cross HMO CaliforniaCare 2000
What if you have If we expedite your review due to a serious medical condition and deny your claim we will denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can call
for care and my OPM's health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious condition is serious or life threatening conditions are ones that may cause permanent loss of bodily functions or
or life threatening death if they are not treated as soon as possible

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies

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

13 13
13 Page 14 15
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Medical and surgical benefits
What is covered
A comprehensive range of preventive diagnostic and treatment services are provided by Plan doctors and other Plan providers This
includes all necessary office visits you pay a 10 office visit copay unless otherwise noted below but no additional copay for
laboratory tests and X rays by Participating providers The 10 office visit copay is not charged for well baby well child care Within
the Service Area house calls will be provided if in the judgment of the Plan such care is necessary and appropriate you pay a 10
copay for a doctor's house call and nothing for visits by nurses and health aides

The following services are included and the copayments indicated below will apply
Physician office visits 10 copay
Physician home visits if within the Medical
Group's area and medically necessary 10 copay

Preventive care and periodic check ups for the
employee or annuitant and enrolled spouse 10 copay

Well baby care child care
for all enrolled dependent children regardless of age No copay

Routine mammograms as recommended by your
Plan doctor and medically necessary mammograms
to diagnose or treat an illness No copay

Routine immunizations and boosters No copay
Routine vision exams No copay
Routine hearing exams No copay
Consultations by specialists 10 copay
Diagnostic procedures such as laboratory tests and X rays No copay
Family planning services 10 copay
Voluntary sterilization 150 copay
for tubal ligations
50 copay
for vasectomies

14 14
14 Page 15 16
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Medical and surgical benefits
Diagnosis and treatment of diseases of the eye 10 copay
Allergy testing and treatment which includes 10 copay
the cost of the testing and treatment materials
such as allergy serum

The insertion of internal prosthetic devices such as pacemakers
artificial joints and breast prostheses following a mastectomy No copay

Mastectomy and lymph node dissection
complications from a mastectomy
including lymphedema No copay
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 Benefits for inpatient stays will be
extended if medically necessary

Reconstructive surgery performed to
restore symmetry following a mastectomy No copay

Dialysis No copay
Chemotherapy radiation therapy
and inhalation therapy No copay

Surgical treatment of morbid obesity No copay
Orthopedic devices such as braces No copay
Prosthetic devices such as artificial limbs and lenses
following cataract removal No copay

Home health services of nurses and health aides No copay
up to 3 two hour visits each day 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 No copay

Acupuncture services
Benefits are only covered if referred by the PCP and approved
by the medical group for the treatment of chronic pain 10 copay

If referred by the PCP and approved by the medical group
for the treatment of substance abuse see page 22
covered under the Mental Conditions benefit for copayment

15 15
15 Page 16 17
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Medical and surgical benefits
Complete obstetrical maternity care for 10 copay
all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her
option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery Benefits for 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

Cornea heart lung kidney and pancreas 10 copay
transplants and liver 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 non lymphatic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkins lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal multiple
myeoloma epithelial ovarian cancer and ovarian germ cell tumors and breast cancer when approved by the
Plan medical director Related medical and hospital expenses of the donor are covered when the recipient
is covered by this Plan

Limited benefits
Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including but
not limited to the removal of impacted teeth the treatment of fractures and the 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

Reconstructive surgery will be provided to correct deformities caused by congenital or developmental abnormalities illness or injury for the purpose of improving bodily function or symptomatology or creating a normal appearance 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

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis you pay nothing Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to
services that assist the member to achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 50 of charges The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI Other assisted
reproductive technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant through
other artificial conception procedures such as in vitro fertilization and embryo transfer are not covered Cost of donor sperm is not
covered Drugs used primarily for the purpose of treating infertility are not covered under your Medical and Surgical Benefits

Cardiac rehabilitation following a heart transplant by pass surgery or a myocardial infarction is provided for up to 60 days you pay nothing

16 16
16 Page 17 18
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Medical and surgical benefits
Durable medical equipment is covered up to 2,000 per calendar year you pay nothing Examples of covered durable medical equipment include standard wheelchairs hospital beds and surgical bras

Chiropractic services are covered up to 20 visits per calendar year you pay a 10 copay per visit when services are provided by the
American Specialty Health Network ASHN

In addition the Plan will also provide up to 50 in rental or purchase charges for medical equipment and supplies which are ordered
by an ASHN chiropractor and pre certified as medically necessary by ASHN Such medical equipment includes 1 elbow back
thoracic lumbar rib or wrist supports 2 cervical collars or pillows 3 ankle knee lumbar or wrist braces 4 heel lifts 5 hot or
cold packs 6 lumbar cushions 7 orthotics and 8 home traction units for treatment of the cervical or lumbar regions

What is not covered
Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment
or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
This exclusion does not apply to reconstructive surgery that is surgery performed to correct deformities caused by congenital or
developmental abnormalities illness or injury for the purpose of improving bodily function or symptomatology or to create a
normal appearance including surgery performed to restore symmetry following mastectomy

Transplants not listed as covered
Hearing aids
Long term rehabilitative therapy
Homemaker services
Shoe insole

17 17
17 Page 18 19
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS 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 per inpatient admission 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 up to 100 days each calendar year when full time skilled nursing care is
necessary and confinement in a skilled nursing facility is in lieu of hospitalization You pay nothing All necessary services are
covered including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor

Hospice care
Supportive and palliative care for terminally ill members is covered in the home or hospice facility up to 180 days Services include
inpatient and outpatient care and family counseling these services are provided under the direction of a Plan doctor who certifies that
the patient is in the terminal stages of illness with a life expectancy of approximately six months or less

Ambulance service The following ambulance services
1 Base charge mileage and non reusable supplies of a licensed ambulance company for ground service to transport you to and
from a hospital

2 Emergency services or transportation services provided by a licensed ambulance company for ground service that is provided to
you as a result of a 911 emergency response system request for assistance if you have an emergency medical condition
requiring ambulance transport

If you have an emergency medical condition that requires ambulance transport services please call the 911 emergency
response system if you are in an area where the system is established and operating

3 Base charge mileage and non reusable supplies of a licensed air ambulance company to transport you from the area where you
are first disabled to the nearest hospital where appropriate treatment is provided if and only if such services are medically
necessary and ground ambulance service is inadequate

4 Monitoring electrocardiograms EKGs ECGs cardiac defibrillation cardiopulmonary resuscitation CPR and administration
of oxygen and intravenous IV solutions in connection with ambulance service An appropriately licensed person must render
the services

18 18
18 Page 19 20
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Hospital extended care benefits
Limited Benefits
Inpatient dental procedures
Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons
totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the 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 detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of medical conditions
and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is
not medically appropriate See Page 22 for non medical substance abuse benefits

What is not covered
Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care

19 19
19 Page 20 21
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Emergency benefits
What is a medical emergency
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could
result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not
treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because
they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There
are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for
quick action

What is urgent care
We provide coverage for medically necessary care provided by non Plan providers to prevent serious deterioration of your health
resulting from an unforeseen illness or injury when you are more than 20 miles from your Medical Group or your Medical Group's
enrollment area hospital if you are enrolled in an independent practice association and seeking health services cannot be delayed
until you return

If you need urgent care you should seek medical attention immediately If you are admitted to a hospital for urgently needed care
you should contact your primary care doctor or Medical Group within 48 hours unless extraordinary circumstances prevent such
notification Follow up care will be covered when the care required continues to meet our definition of Urgent Care Urgent care
is defined as services received for a sudden serious or unexpected illness injury or condition which is not an emergency but which
requires immediate care for the relief of pain or diagnosis and treatment of such condition

Emergencies within the area
If you are in an emergency or urgent situation and you are within 20 miles of your Medical Group or 20 miles of your Medical Group's assigned hospital please call your primary care doctor 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 reasonably possible to notify the Plan within that time If you are hospitalized in nonPlan
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

Your primary care doctor will provide the necessary care refer you to other Plan provider or make arrangements with other
providers Benefits are available for care from non Plan providers in a medical emergency or for urgent care 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 25 per hospital emergency room visit or urgent care center visit for emergency services which are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care copay is waived

20 20
20 Page 21 22
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Emergency benefits
Emergencies outside of area
If you need emergency treatment and you are more than 20 miles from your Medical Group or your Medical Group's assigned
hospital benefits are available for medically necessary health services that are immediately required because of injury or unforeseen
illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless
it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan
hospital you will be transferred when medically feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by
Plan providers

Plan pays reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers

You pay 25 per hospital emergency room visit or urgent care center visit for emergency services which are covered benefits of this Plan If the emergency results in admission to a hospital the emergency care copay is waived
What is covered Emergency care or urgent care at a doctor's office or an urgent care center
Emergency care or urgent 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 urgent care
Emergency care or urgent care provided outside the service area if the need for care could have
been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area

Filing claims for non Plan providers
With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims
Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills
and your receipts to the Plan along with an explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based If you
disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on
page 11

21 21
21 Page 22 23
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS 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 or group therapy
Hospitalization including inpatient professional services
Visits for rehabilitative care such as physical therapy occupational therapy or speech therapy when appropriate and
medically necessary to treat conditions such as mental retardation and autism

Outpatient care
Up to 40 outpatient visits to Plan doctors consultant or other psychiatric personnel each calendar year you pay a 20 copay for each
covered visit all charges thereafter

Inpatient Care
Inpatient hospital care if determined by a Plan doctor to be necessary and appropriate you pay nothing
What is not Covered
Care for psychiatric conditions which 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 Outpatient visits to Plan
providers for treatment are covered as well as inpatient services necessary for diagnosis and treatment The Outpatient Mental
conditions benefits visit limitations apply to any covered substance abuse care You pay a 20 copay for each covered visit all
charges thereafter Inpatient mental condition benefit associated with substance abuse is limited to 30 days except for
detoxification You pay nothing

What is not covered
Treatment that is not authorized by a Plan doctor

22 22
22 Page 23 24
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Prescription drug benefits
What is covered
Prescription drugs prescribed by a Plan or referral doctor and obtained at a pharmacy will be dispensed for up to a 30 day supply or
100 unit supply whichever is less or one commercially prepared unit i e one inhaler one vial ophthalmic medication or insulin
For prescription drugs used in the treatment of attention deficit disorder the prescription must not exceed a 60 day supply Drugs are
prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Under the terms of your Plan only formulary
drugs are covered at participating pharmacies and through the mail order program unless the prescriber has specified dispense as
written If you are prescribed a non formulary drug without dispense as written you will pay the participating pharmacy's or mail
order program's full cost of the drug You pay the following copays per prescription unit or refill

For Blue Cross participating pharmacies Formulary generic drugs You pay a 5 copay per
prescription or refill
Name brand drugs and generic non formulary drugs
if the prescriber has specified dispense as written You pay a 10 copay per
prescription or refill

For non participating pharmacies Generic drugs Reimbursement is at 50 of the Drug Limited Fee
Schedule minus your 5 copay
Name brand drugs Reimbursement is at 50 of the Drug Limited Fee
Schedule minus your 10 copay

For designated mail order pharmacies Formulary generic You pay a 5 copay for up
to a 90 day supply
Name brand drugs and generic non formulary drugs
if the prescriber has specified dispense as written You pay a 20 copay for up
to a 90 day supply

Regarding formulary drugs Blue Cross of California uses a preferred list of drugs sometimes called a formulary to help your doctor make prescribing decisions
This list of drugs is updated quarterly by a committee consisting of doctors and pharmacists so that the list includes drugs that are safe
and effective in the treatment of disease If you have a question regarding whether a drug is on the Blue Cross Preferred Drug List
please call 1 800 700 2541

23 23
23 Page 24 25
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Prescription drug benefits
Covered medication and accessories include
Drugs for which a prescription is required by law Oral and injectable contraceptive drugs up to a three cycle supply may be obtained for a single copay charge
Prescribed birth control devices which are approved by the Food and Drug Administration
Insulin with a copay charge applied to each vial Diabetic supplies including insulin syringes needles glucose test tablets and test tape

Benedict's solution or equivalent and acetone test tablets
Disposable needles and syringes needed for injecting covered prescribed medication
Drugs used primarily for the purpose of treating infertility Smoking cessation drugs and medications only if a prescription is required by law

Intravenous fluids and medications for home use implanted time release medications such as Norplant and some
injectable drugs such as Depo Provera are not covered under your Prescription Drug Benefits but are covered
under Medical and Surgical benefits with no additional copay

What is not covered
Drugs available without a prescription or for which there is a non prescription equivalent available
Vitamins and nutritional substances which an be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Select classes of drugs where non formulary medications which have therapeutic alternatives have shown no benefit regarding
efficacy or side effect over formulary drugs However this will not apply to non participating pharmacies or if the prescriber
denotes dispense as written or do not substitute

24 24
24 Page 25 26
Blue Cross HMO CaliforniaCare 2000
Section 5 BENEFITS Other benefits
Accidental injury benefit
What is covered Restorative services and supplies necessary for the initial repair but not replacement of sound natural teeth
You pay nothing
What is not covered Restoration of the damaged tooth when defined as cosmetic
Damage to teeth resulting from eating food

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
What is not covered Corrective lenses or frames
Eye exercises

Health Education and Wellness Programs
As part of our continuous effort to support the health and well being of our members CaliforniaCare offers a wide range of Health
Education and Wellness Programs at discounted rates Separate copays may apply to some programs

25 25
25 Page 26 27
Blue Cross HMO CaliforniaCare 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 urgent care or eligible self referred services
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

26 26
26 Page 27 28
Blue Cross HMO CaliforniaCare 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want
to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan
offered by this Plan see page 37

Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever
is less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control

When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for 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

27 27
27 Page 28 29
Blue Cross HMO CaliforniaCare 2000
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 We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly or Government indirectly pays for
Agencies

28 28
28 Page 29 30
Blue Cross HMO CaliforniaCare 2000
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
your 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 800 235 8631 or write to P O Box 4089
Woodland Hills CA 91365 You may also contact us by fax at 818 712 6401 or visit our
website at www bluecrossca com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the make 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 retirement office

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been 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

29 29
29 Page 30 31
Blue Cross HMO CaliforniaCare 2000
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your
available for me and employing or retirement office authorizes coverage for Under certain circumstances you may my family 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 retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
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

30 30
30 Page 31 32
Blue Cross HMO CaliforniaCare 2000
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions 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
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 retirement office to get more information about your coverage
choices

31 31
31 Page 32 33
Blue Cross HMO CaliforniaCare 2000
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have

passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your
child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after they become eligible for
TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60 day deadline

32 32
32 Page 33 34
Blue Cross HMO CaliforniaCare 2000
How can I convert You may convert to an individual policy if to individual
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or coverage did not pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office
will not notify you You must apply in writing to us within 31 days after you are no longer
eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of that indicates how long you have been enrolled with us You can use this certificate when
Group Health getting health insurance or other health care coverage You must arrange for the other coverage Plan 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

33 33
33 Page 34 35
Blue Cross HMO CaliforniaCare 2000
Department of Defense FEHB Demonstration Project
What Is the The National Defense Authorization Act for 1999 Public law 105 261 established the DoD FEHBP Department of Demonstration Project It allows some active and retired uniformed service members and their
Defense DoD dependents to enroll in the FEHB Program The demonstration will last for three years beginning with and FHHB the 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000
Program DoD and OPM have set up some special procedures to successfully implement the Demonstration Demonstration Project noted below Otherwise the provisions described in this brochure apply
Project

Who is Eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and eligible for Medicare You are a qualified former spouse of an active or retired uniformed service member and you have

not remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas

If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits program you
are not eligible to enroll under the DoD FEHBP Demonstration Project

What are the Dover AFB Delaware Demonstration Commonwealth of Puerto Rico
Areas Fort Knox Kentucky Greensboro Winston Salem High Point North Carolina
Dallas Texas
Humboldt County California area Naval Hospital Camp Pendelton California

New Orleans Louisiana

When Can I Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through Join December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information
Processing Center IPC in Iowa to provide you with FEHB Program information plan brochures
enrollment instructions and forms The toll free phone number for the IPC is 1 877 DOD FEHB 1
877 363 3342

You may select coverage for yourself self only or for you and your family self and family during the
1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following the
Open Season that you enrolled

If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact the
IPC to find out how to enroll and when your coverage will begin

DoD has a web site devoted to the Demonstration Project You can view information such as their
Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area locations and
zip codes at www tricare osd mil fehbp You can also view information about the demonstration
project including The 2000 Guide to Federal Employees Health Benefits Plans Participating in the
DoD FEHBP Demonstration Project on the OPM web site at www opm gov

Am I Eligible See Section 8 FEHB Facts for information about TCC Under this Demonstration Project the only for Temporary individual eligible for TCC is one who ceases to be eligible as a member of family under your self
Continuation of and family enrollment This occurs when a child turns 22 for example or if you divorce and your Coverage spouse does not qualify to enroll as an unmarried former spouse under title 10 United States Code For

34 34
34 Page 35 36
Blue Cross HMO CaliforniaCare 2000
TCC these individuals TCC begins the day after their enrollment in the DoD FEHBP Demonstration Project ends TCC enrolment terminates after 36 months or the end of the Demonstration Project whichever
occurs first You your child or another person must notify the IPC when a family member loses
eligibility for coverage under the DoD FEHBP Demonstration Project

TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your
coverage or your coverage is terminated for any reason TCC is not available when the demonstration
project ends

Do I have the These provisions do not apply to the DoD FEHBP Demonstration Project 31 Day
Extension and Right to
Convert

35 35
35 Page 36 37
Blue Cross HMO CaliforniaCare 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you
for services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 235 8631 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

36 36
36 Page 37 38
Blue Cross HMO CaliforniaCare 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB but are made available 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 any charges or these services do not count toward any FEHB deductibles out of pocket maximum copay charges
etc These benefits are not subject to the FEHB disputed claims procedure

Optional Dental Benefits Separate benefit package that requires an additional premium
HERE'S AN OPPORTUNITY TO ENHANCE YOUR TOTAL HEALTH CARE PACKAGE BY ADDING COMPREHENSIVE DENTAL BENEFITS

Dental SelectHMO Dental Maintenance Organization Option A plan that offers members a broad range of dental coverage at a lower cost Members choose their own dentist from a network of providers and may change their dentist at any time Once you have
enrolled in Dental SelectHMO your provider will perform preventive and diagnostic services and other dental services free of charge
or at a greatly reduced rate

Key Dental SelectHMO Advantages
Diagnostic and Preventive Services are FREE
No Deductibles and No Claim Forms
Benefits include Orthodontic Coverage

Eyewear Savings Program for Blue Cross CaliforniaCare Members at no extra premium
Instant savings on eyewear As a Federal Employee and a member of the CaliforniaCare HMO you are now entitled to special savings on frames lenses
including contact lenses as well as other important eye care accessories These savings are available through optical
departments located in selected Sears Montgomery Ward and J C Penney stores
No Claim Forms There are currently more than 135 participating optical departments located throughout California To receive your eyewear

discount just present your CaliforniaCare ID card to the optical department of the stores listed above

Blue Cross Senior Secure Medicare prepaid plan HMO provides complete coverage for medically necessary hospital and doctor services with no monthly premium no deductibles and a prescription drug benefit
Coverage includes
Prescription Drug Chiropractic Care
Vision Hearing
Dental Podiatry

Blue Cross Senior Secure features all of the health coverage services offered by Medicare plus some extra services Medicare does not
offer Contact Customer Service toll free 1 888 230 7338 to obtain detailed benefits and a list of providers in your area As indicated
on page 27 you may remain enrolled in FEHBP when you enroll in a Medicare Prepaid Plan

Benefits on this page are not part of the FEHB contract

37 37
37 Page 38 39
Blue Cross HMO CaliforniaCare 2000
Summary of Benefits for Blue Cross HMO CaliforniaCare 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 OR URGENT
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Care Hospital Comprehensive range of medical 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 18
You pay nothing

Extended Care 18 All necessary services Up to 100 days per year You pay nothing

Mental Conditions Diagnosis and treatment of acute psychiatric conditions You pay nothing 22
Substance Abuse 22 Up to 30 days per year You pay nothing

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 no copay periodic
check ups 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 14

Home Health Care
All necessary visits by nurses and health aides up to 3 two hour visits each day You
pay nothing 15

Mental Conditions Up to 40 outpatient visits per year You pay a 20 copay per visit
22

Substance Abuse Covered under Mental conditions
22

Emergency Care You pay a 25 copay to the hospital for each emergency room visit or urgent care center 20 visit and any charges for services which are not covered benefits of this plan
Prescription You pay a 5 copay for formulary generic and a 10 copay for name brand drugs when 23 Drugs
prescribed by a Plan doctor and obtained at Plan pharmacy You pay a 5 copay for
formulary generic and a 20 copay for name brand drugs when prescribed by a Plan
doctor and provided through the mail order program

Out of Pocket After your out of pocket expenses reach a maximum of 1,000 per Self Only or 3,000 6 Maximum
per Self and Family enrollment per calendar year covered benefits will be provided at
100 This copay maximum does not include prescription drug or infertility treatment
services

38 38
38 Page 39
Blue Cross HMO CaliforniaCare 2000
2000 Rate Information for
Blue Cross HMO CaliforniaCare

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 is 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

Most of California
Self Only M51 67.71 22.57 146.71 48.90 80.12 10.16 80.12 10.16
Self and Family M52 172.76 57.59 374.32 124.77 204.44 25.91 201.02 29.33

39 39

Page Navigation Panel