Bluegrass Family Health 2000 A Health Maintenance Organization
For changes
in benefits
see page 2
Serving Central and Eastern Kentucky Enrollment in this Plan is limited see page 4 for requirements
Enrollment Codes 2B1 Self only
2B2 Self and Family
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www bgfh com
Authorized for distribution by the
United States
Office of Personnel
Management
Table of Contents Page
Introduction
1
Plain language
1
How to use this brochure
1
Section 1 Health Maintenance Organizations
2
Section 2 How we change for 2000
2
Section 3 How to get benefits
4
Section 4 What to do if we deny your claim or request for service
8
Section 5 Benefits
10
Section 6 General exclusions Things we don't cover
24
Section 7 Limitations Rules that affect your benefits
24
Section 8 FEHB facts
26
Inspector General Advisory Stop Healthcare Fraud
31
Summary of benefits
32
Premiums
Back cover
2
2
Page 3
4
Bluegrass Family Health 2000
Introduction Bluegrass Family Health Inc 651 Perimeter Drive Lexington Kentucky 40517
This brochure describes the benefits you can receive from Bluegrass Family Health under its contract
CS 2728 with the Office of Personnel Management OPM as authorized by the Federal Employees
Health Benefits FEHB law This brochure is the official statement of benefits on which you can rely
A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled
for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January
1 2000 and are shown on page 2 Premiums are listed at the end of this brochure
Plain language The President and Vice President are making the Government's communication more responsive
accessible and understandable to the public by requiring agencies to use plain language Health plan
representatives and Office of Personnel Management staff have worked cooperatively to make portions
of this brochure clearer In it you will find common everyday words except for necessary technical
terms you and other personal pronouns active voice and short sentences
We refer to Bluegrass Family Health 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
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Bluegrass Family Health 2000
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 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
You should join an HMO because you prefer the plan s benefits not because a particular provider is
available You cannot change plans because a provider leaves our Plan We cannot guarantee that any
one physician hospital or other provider will be available and or remain under contract with us Our
providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000 Program wide To keep your premiums as low as possible OPM has set a minimum copay of
changes 10 for all primary care office visits
This year you have a right to more information about this Plan care
management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at
our request you may continue to see your specialist for up to 90 days If your
provider leaves the Plan and you are in the second or third trimester of
pregnancy you may be able to continue seeing your OB GYN until the end of
your postpartum care You have similar rights if this Plan leaves the FEHB
program See Section 3 How to get Benefits for more information
You may review and obtain copies of your medical records on request If you
want copies of your medical records ask your health care provider for them
You may ask that a physician amend a record that is not accurate not relevant
or incomplete If the physician does not amend your record you may add a brief
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Bluegrass Family Health 2000
Section 2 How we change for 2000 cont'd 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 Your share of the non postal premium will increase by 30.7 for Self only Plan
or 6.6 for Self and Family
The following Kentucky counties have been added to the service area Ballard Calloway Carlisle Hickman Livingston Lyon Marshall and
McCracken
The prescription drug copay has decreased to a 5 copay for up to a 31 day supply of generic drugs and a 10 copay for up to a 31 day supply of name
brand drugs If you request the name brand medication when your doctor
allows a generic drug you will pay your name brand copayment plus the
difference between the name brand drug and the generic
The Out of Pocket maximums have changed to None for in Plan network 2250 Self only and 4500 Family for in Plan self referral and 4500 Self
only and 9000 Family for Point of Service POS
The ambulatory hospital outpatient surgery copay has decreased to 50 per procedure for in Plan network 75 per procedure for in Plan self referral
and 30 of charges after Deductible for Point of Service
The maternity visit copay has changed to 10 per visit up to a max of 100 per pregnancy for in Plan network and 25 per visit up to a max of 250 per
pregnancy for in Plan self referral
Ambulance copays are waived if you are admitted The POS copay has decreased to 50 per trip
The Inpatient Substance Abuse copay has decreased to 100 per admission for in Plan network
Outpatient Substance Abuse visits have increased to 30 visits per calendar year for in Plan network in Plan self referral and POS
The outpatient copay for physical speech and occupational therapy has decreased to 10 per session for in Plan network and 25 per session for inPlan
self referral
Cardiac rehabilitation and chiropractic services are limited to 30 visits each per calendar year
Home health care services are covered in full if substituted for hospitalization except for POS which is 30 of charges
The copay has decreased and the number of covered days have increased for skilled nursing in an extended care facility to a 100 copay for up to 40 days
per calendar year for in Plan network and a 150 copay for up to 40 days per
calendar year for in Plan self referral
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Bluegrass Family Health 2000
Section 2 How we change for 2000 cont'd
The coinsurance for durable medical equipment prosthetic and orthotic devices has decreased to 10 of charges
The copay has decreased for tubal ligations and vasectomies to 50 for inPlan network and 75 for in Plan self referral
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
Plan's service providers practice Our service area is the following counties in Kentucky Adair area Anderson Ballard Bath Bell Bourbon Boyle Bracken Breathitt Calloway Carlisle
Casey Clark Clay Estill Fayette Fleming Floyd Franklin Garrard Grant Green
Harlan Harrison Hickman Jackson Jessamine Johnson Knott Knox Laurel Lee
Leslie Letcher Lincoln Livingston Lyon Madison Magoffin Marion Marshall
Mason McCracken McCreary Menifee Mercer Montgomery Morgan Nicholas
Owen Owsley Pendleton Perry Pike Powell Pulaski Robertson Rockcastle
Rowan Scott Taylor Washington Whitley Wolfe and Woodford
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 ofservice
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 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 You must share the cost of some services This is called either a copayment a set I pay for dollar amount or coinsurance a set percentage of charges Please remember you
services must pay this amount when you receive services except for diagnostic testing such as lab and x ray which doesn't have a separate copay amount unless you use a non Plan
provider with the POS option and home health and hospice care which is covered in
full unless you use a non Plan provider with the POS option
After you pay the following amounts in copayments or coinsurance for one family
member or for two or more family members you do not have to make any further
payments for certain services for the rest of the calendar year 2,250 Self only 4,500
Family for in Plan self referral and 4,500 Self only 9,000 Family for Point ofService
This is called a catastrophic limit However copayments for
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Bluegrass Family Health 2000
Section 3 How to get benefits cont'd
your prescription drugs 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
submit services from a provider who doesn't contract with us or you use point of service claims benefits from a non Plan provider If you file a claim please send us all of the
documents for your claim as soon as possible You must submit claims by December
31 of the year after the year you received the service Either OPM or we can extend
this deadline if you show that circumstances beyond your control prevented you from
filing on time
Who provides We are an Individual Practice Prepayment IPP HMO located in Lexington
my health Kentucky Our provider network includes 52 participating hospitals and care approximately 561 primary care doctors and over 1600 specialists who practice out of
their own offices
What do I do Call us We will help you select a new one
if my primary care physician
leaves the Plan
What do I do Talk to your Plan physician If you need to be hospitalized your primary care physician if I need to go or specialist will make the necessary hospital arrangements and supervise your care If
into the hospitalization is necessary your Plan physician will make the arrangements and will hospital continue to provide or supervise your care in Plan affiliated hospitals This Plan contracts
with its affiliated hospitals on an independent contract basis Where you are hospitalized
will depend on several factors appropriateness for the particular treatment or procedure
required staff privileges of the physician and in some cases quickest availability of a
hospital bed
Should a medical emergency require you to be hospitalized in a non affiliated hospital
you must notify the Plan as soon as possible no later than 24 hours or the next business
day after your hospitalization to assure coordination of and payment for your care
Coverage in a non affiliated hospital will be provided only until your condition permits
you to be transferred to the care of a Plan physician at the nearest Plan affiliated hospital
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Bluegrass Family Health 2000
Section 3 How to get benefits cont'd
What do I do First call our customer service department at 606 269 4475 If you are new to the if I'm in the FEHB Program we will arrange for you to receive care If you are currently in the
hospital when FEHB Program and are switching to us your former plan will pay for the hospital stay I join this until
Plan
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist with the specialty care following exceptions women may receive an annual gynecological examination from
a participating gynecologist without a referral or when you choose to use the Plan's
POS benefits
Referrals HMO benefit level only Referrals will be covered if ALL of the following conditions are met
referral is for a covered services benefit
referral is made by your Primary Care Physician
referral is approved by the Plan
Referrals will not be covered if ANY of the following apply
referral is for non covered services benefit
referral is not made by your Primary Care Physician
referral is not approved by the Plan
referral is to a non participating provider unless prior approval with the Plan is obtained
If you need to see a specialist frequently because of a chronic complex or serious
medical condition your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals Your primary care physician will use our criteria when creating your
treatment plan
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Bluegrass Family Health 2000
Section 3 How to get benefits cont'd
What do I do Your primary care physician will decide what treatment you need If they decide to if I am seeing refer you to a specialist ask if you can see your current specialist If your current
a specialist specialist does not participate with us you must receive treatment from a specialist when who does Generally we will not pay for you to see a specialist who does not
I enroll participate with our Plan
What do I do Call your primary care physician who will arrange for you to see another specialist
if my specialist You may receive services from your current specialist until we can make arrangements leaves the for you to see someone else
Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be
have a serious able to continue seeing your provider for up to 90 days after we notify you that we are illness and my terminating our contract with the provider unless the termination is for cause If you
provider are in the second or third trimester of pregnancy you may continue to see your leaves the Plan OB GYN until the end of your postpartum care
or this Plan leaves the
Program You may also be able to continue seeing your provider if your plan drops out of the
FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain
that you have a serious or chronic condition or are in your second or third trimester
Your new plan will pay for or provide your care for up to 90 days after you receive
notice that your prior plan is leaving the FEHB Program If you are in your second or
third trimester your new plan will pay for the OB GYN care you receive from your
current provider until the end of your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you
authorize to a specialist or recommending follow up care Before giving approval we consider medical if the service is medically necessary and if it follows generally accepted medical
services practice
How do you The Plan's Chief Medical Officer and the Director of Quality Improvement and
decide if Utilization determine what procedures and services are experimental investigational a service is using FDA guidelines and Hayes Technology an outside consultant
experimental or
investigational
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Bluegrass Family Health 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
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial OPM to review a denial or refusal OPM will determine if we correctly applied the terms of our
denial contract when we denied your claim or request for service
What if I have a Call us at either 606 269 5044 or 800 787 2680 and we will expedite our serious or life review
threatening condition and you
haven't responded to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your denied my request claim we will inform OPM so that they can give your claim expedited treatment
for care and my too Alternatively you can call OPM's health benefits Contract Division IV at condition is serious 202 606 0737 between 8 a m and 5 p m Serious or life threatening conditions
or life threatening are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days time limits after we uphold our initial denial or refusal of service You may also ask OPM
to review your claim if
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Section 4 What to do if we deny your claim or request for service cont'd
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 OPM 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
What address Send your request for review to Office of Personnel Management Office of should I send my Insurance Programs Contract Division IV P O Box 436 Washington D C
disputed claim to 20044
What if OPM OPM's decision is final There are no other administrative appeals If OPM upholds the Plan's agrees with our 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
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Section 4 What to do if we deny your claim or request for service cont'd What laws apply if Federal law governs your lawsuit benefits and payment of benefits The
I file a lawsuit Federal court will base its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits
in dispute
You or a person acting on your behalf may not sue to recover benefits on a
claim for treatment services supplies or drugs covered by us until you have
completed the OPM review procedure described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it
the Privacy Act collects from you and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part
of your disputed claims file and is subject to the provisions of the Freedom of
Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will
become part of the court record
Section 5 BENEFITS Medical and Surgical Benefits in Network 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 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 nothing for
home visits by nurses and health aides
The following services are included and are subject to the office visit copay
unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one
mammogram every year for women age 50 through 64 one mammogram
every year and for women age 65 and above one mammogram every two
years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your
illness
Routine immunizations and boosters Consultations by specialists
Diagnostic procedures such as laboratory tests and x rays you pay 10 per testing session
Ambulatory hospital outpatient surgery you pay a 50 copay per procedure
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Section 5 BENEFITS Medical and Surgical Benefits in Network cont'd Complete obstetrical maternity care for all covered females including
prenatal delivery and postnatal care by a Plan doctor The office visit copay
is waived after the 10 th visit The mother at her option may remain n the
hospital up to 48 hours after a regular delivery and 96 hours after a cesarean
delivery Inpatient stays will be extended if medically necessary If
enrollment in the Plan is terminated during pregnancy benefits will not be
provided after coverage under the Plan has ended Ordinary nursery care of
the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self only or Self
and Family enrollment other care of an infant who requires definitive
treatment will be covered only if the infant is covered under a Self and
Family enrollment
Voluntary sterilization and family planning services including Norplant implantations You pay 50 for a tubal ligation or vasectomy
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum you pay a 5 copay per allergy injection given in the
physician's office
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung pancreas kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic on non lymphocytic leukemia advanced
Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced
neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer
and testicular mediastinal retroperitoneal and ovarian germ cell tumors
Transplants are covered when approved by the 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
Durable medical equipment including but not limited to wheelchairs hospital beds and apnea monitors The rental purchase of the equipment
includes any necessary fittings adjustments and delivery installation of the
Durable Medical Equipment Items that are not considered Durable Medical
Equipment include but are not limited to adjustments made to vehicles air
purifiers ramps stair glides and whirlpool baths You pay 10 of charges
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Section 5 BENEFITS Medical and Surgical Benefits in Network cont'd Home health services of nurses and health aides including intravenous fluids
and medications and when prescribed by your plan doctor who will
periodically review the program for continuing appropriateness and need
When home health care is substituted for hospitalization you pay nothing
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Prosthetic and orthotic devices and supplies which replace all or part of an absent body part including contiguous tissue or replace all or part of the
function of a permanently inoperative or malfunctioning body part This
includes coverage for the purchase fitting and any necessary adjustments
and repairs breast prostheses and surgical bras as well as their replacement
you pay 10 of charges
Diabetic equipment supplies outpatient self management training and education including medical nutrition therapy and all medications for he
treatment of insulin dependent diabetics insulin using diabetics gestational
diabetics and noninsulin using diabetics This includes blood glucose
monitors and testing strips insulin syringes injection aids insulin infusion
devices oral agents for controlling sugar and medically necessary insulin
pumps and appurtenances
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 Surgical treatment for Temporomandibular Joint
Disorder TMJ is provided for services included in a treatment plan authorized
by the Plan prior to surgery All other procedures involving the teeth or intraoral
areas surrounding the teeth are not covered
Reconstructive surgery will be provided to correct a condition resulting from a
functional defect or from an injury or surgery that has produced a major effect
on the member's appearance and if the condition can reasonably be expected to
be corrected by such surgery A patient and her attending physician may decide
whether to have breast 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 for up to two consecutive months per
condition if significant improvement can be expected within two months you
pay a 10 copay per outpatient session 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
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Section 5 BENEFITS Medical and Surgical Benefits in Network cont'd Cardiac rehabilitation and chiropractic services are covered for up to 30
visits per calendar year You pay 10 per visit
Diagnosis and treatment of infertility is covered you pay a 10 copay The following types of artificial insemination are covered intravaginal insemination
IVI and intracervical insemination ICI you pay 50 of charges Cost of
donor sperm is not covered Fertility drugs are not covered under the
Prescription Drug Benefit 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
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
Transplants not listed as covered
Blood and blood derivatives not replaced by the member
Hearing aids
Long term rehabilitative therapy
Homemaker services
Foot orthotics
Acupuncture
Radial keratotomy
Hospital Extended Care Benefits In Network 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 a 100
copay per 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 limited to 40 days per
calendar year when full time skilled nursing care is necessary and confinement
in a skilled nursing facility is medically appropriate as determined by a Plan
doctor and approved by the Plan You pay a 100 copay per admission 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
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Hospital Extended Care Benefits In Network cont'd
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 Benefits are provided for ground ambulance transportation ordered or authorized by a Plan doctor You pay a 50 copay per trip waived if admitted
Limited Benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor
procedures 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 heart disease the need for anesthesia by itself is
not such condition
Acute inpatient 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 19 for nonmedical
substance abuse benefits
What is not covered Personal comfort items such as telephones and television
Blood and blood derivatives not replaced by the member
Custodial care rest cures Domiciliary or convalescent care
Emergency Benefits What is a medical A medical emergency is the sudden and unexpected onset of a condition or an
emergency injury you believe endangers your life or could result in serious injury or disability and that 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 the service area extreme emergencies if you are unable to contact your doctor contact the local
emergency system e g the 911 telephone system or go to the nearest hospital
emergency room
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Bluegrass Family Health 2000
Emergency Benefits cont'd
Be sure to tell the emergency room personnel that you are a Plan member so
they can notify the Plan Or a family member should notify the Plan within 48
hours unless it was 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
Benefits are available for care from non Plan providers in a medical emergency
only if delay in reaching a Plan provider would result in death disability or
significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan
providers must be approved by the Plan or provided by Plan providers 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 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness
Emergencies If you need to be hospitalized the Plan must be notified within 48 hours or on outside the service the first working day following your admission unless it was not reasonably
area 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 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
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Bluegrass Family Health 2000
Emergency Benefits cont'd
You pay 50 per hospital emergency room visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
What is Covered Emergency care at a doctor's office
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service if approved by the Plan
What is not Elective care or nonemergency care except as covered under POS benefits
Covered Emergency care provided outside the service area if the need for care could
have been foreseen before departing the service area except as covered under
POS benefits
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area except as covered under POS benefits
Filing Claims for With your authorization the plan will pay benefits directly to the providers of non Plan providers 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 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 26
Mental Condition Substance Abuse Mental
Conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the
treatment of mental illness or disorders
Diagnostic evaluation
Psychological Testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient Care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 20 copay 10 per group session for
each covered visit all charges thereafter
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Mental Condition Substance Abuse cont'd
Inpatient Care Up to 30 days of hospitalization each calendar year you pay a 100 copay per admission all charges thereafter Inpatient days may be exchanged for
outpatient day treatment at the rate of two treatment days for each inpatient day
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively shortterm
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 Up to 30 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay 10 per group session for each covered visit all charges
thereafter
Inpatient Care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan
you pay a 100 copay per admission Benefits are limited to one admission per 6 month period
What is not covered Treatment that is not authorized by the Plan
Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan
pharmacy will be dispensed for up to a 31 day supply You pay 5 per generic
prescription unit or refill and 10 per name brand prescription unit or refill If
you request the name brand drug when your physician has ordered or approved a
generic you will pay the name brand copayment plus the cost difference
between the name brand drug and the generic drug
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Prescription Drug Benefits cont'd
Covered medications and accessories include
Cancer drugs if the drug prescribed is recognized as safe and effective in the official compendium or in medical literature
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs contraceptive devices diaphragms and IUDs
Insulin a copay charge applies to each vial
Disposable needles and syringes and other diabetic supplies necessary for the treatment of diabetes
Additional Benefits Implanted time release medications such as Norplant are covered under the Medical and Surgical Benefits on page 10 For Norplant and other internally
implanted time release medication you pay a 10 office visit copy There is no
charge when the device is implanted during a covered hospitalization
There will be no refund of any portion of these copays if the implanted timerelease
medication is removed before the end of its expected life
Intravenous fluids and medications for home use implantable drugs such as
Norplant and some injectable drugs such as Depo Provera are covered under the
Medical and Surgical Benefits
Limited Benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose
limits at 1 800 787 2680 You pay 50 of charges up to the dosage limits
and all charges above that
What is not covered Drugs available without a prescription or for which there is a nonprescription
equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes and to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Fertility drugs
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Other Benefits In Network
Dental Care
What is covered Accidental injury Restorative services and supplies necessary to promptly repair but not replace
benefit sound natural teeth The need for these services must result from an accidental injury and must occur on or after your effective date You pay nothing
Vision care In addition to the medical and surgical benefits provided for diagnosis and What is covered treatment of diseases of the eye this Plan provides eye refractions including
written lens prescriptions from Plan providers every 12 month period for
members up to age 17 and every 24 month period for members ages 18 and over
You pay a 10 copay per visit
What is not Eye exercises covered
Corrective glasses frames or contact lenses
Point of Service POS Benefits
Facts about this At your option you may choose to obtain benefits covered by this Plan from
Plan's POS Option non Plan doctors and hospital whenever you need care except for the benefits listed below under What is not covered Benefits 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 deductibles
coinsurance and maximum benefit stated below
As a member of a POS plan you have benefits for both Plan and non Plan
doctors except for the benefits listed below under What is not covered You
pay a higher copayment or coinsurance amount if you self refer to Plan doctors for covered services You pay deductibles and higher coinsurance when you
obtain covered services from non Plan doctors except life threatening
emergencies
You will always pay higher copayments and coinsurance when you see non Plan
or Plan providers without Primary Care Physician referral
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Point of Service POS Benefits cont'd
What is covered The following is a Schedule of Benefits for the POS Plan
Service InPlan Self Referral Non Plan Member Pays Member Pays
Provider office visits primary care and specialists 25 copay per visit 30 of charges after Deductible
Diagnostic tests No separate copay 30 of charges after Deductible
Obstetrical care 25 copay per visit to a maximum of 30 of charges after Deductible
250 per pregnancy
Allergy serum and injections 7 copay per injection 30 of charges after Deductible
Prosthetic devices 25 of charges 30 of charges after Deductible
Ambulatory hospital outpatient surgery 75 copay 30 of charges after Deductible
Tubal ligation and vasectomy 75 copay 30 of charges after Deductible
Durable medical equipment 25 of charges 30 of charges after Deductible
Short term rehabilitative therapy speech physical 25 copay 30 of charges after Deductible
occupation chiropractic and cardiac rehab visit limits apply
Inpatient hospital care 200 copay per admission 30 of charges after Deductible
Extended care limits apply 150 copay per admission 30 of charges after Deductible
Ambulance 50 copay per trip waived if admitted 30 of charges after Deductible
Hospital emergency room true emergencies are always 50 copay waived if admitted 30 of charges after Deductible
payable as in Plan benefits
Mental health inpatient limits apply 200 copay per admission 30 of charges after Deductible
Mental health outpatient limits apply 30 copay per visit 30 of charges after Deductible
Substance abuse inpatient limits apply 200 copay per admission 30 of charges after Deductible
Substance abuse outpatient limits apply 30 copay per visit 30 of charges after Deductible
Prescription drugs 5 copay generic 30 of charges after Deductible
10 copay name brand If you request
name brand you must pay the
difference
Precertification The plan will provide benefits for covered services only when the services are medically necessary to prevent diagnose or treat your illness or condition You
Plan doctor must obtain the Plan's determination of medical necessity before
you may be hospitalized referred for specialty care or obtain follow up care
from a specialist If your Plan provider pre authorizes services with non Plan
doctors benefits may be paid at the HMO benefit level If you are using your
POS benefits or seeing non Plan providers and receiving services that require
authorization you are responsible for verifying pre certification requirements
To verify Precertification you may call 1 800 787 2680 If you receive covered
services that require authorization but have not been authorized you pay a
Precertification penalty of 500 SERVICES THAT ARE NOT
MEDICALLY NECESSARY ARE NOT COVERED
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Bluegrass Family Health 2000
Point of Service POS Benefits cont'd
Deductible The Deductible applies to all covered services received from non Plan providers except for hospital emergency treatment The Deductible must be satisfied each
Plan Year before benefits are paid The Deductible does not apply to the out ofpocket
maximum The Family Deductible is satisfied when one covered person
satisfies an Individual Deductible in a Plan Year and the remaining covered
persons together satisfy an amount equal to one Individual Deductible in a Plan
Year You pay no Deductible for services received from a Plan doctor You
pay a 400 Deductible for Self only enrollment and you pay 800 for Self and Family Enrollment for services received from non Plan doctors
Coinsurance Coinsurance is calculated based on eligible expenses for services provided You pay 30 of charges for most services received from non Plan doctors
Coinsurance is subject to reasonable and customary limits You are responsible
for all charges that exceed the reasonable and customary limit
Maximum Lifetime There is no maximum lifetime benefit Benefit
Annual out ofpocket The annual out of pocket is the maximum eligible expense that may be incurred
limit by an individual or a family in a Plan Year After the out of pocket limit is satisfied the Plan pays 100 of eligible expenses for covered services
Expenses that apply to the out of pocket limit are copayments and coinsurance
for covered services Expenses that do not apply to the out of pocket limit
include the Deductible charges exceeding eligible expenses all expenses for
non covered services non FEHB benefits and penalties for failure to obtain
required pre certification and compliance with Plan delivery system rules There
in no out of pocket maximum for HMO benefits For In Plan Self Referral
Benefits you pay a maximum of 2,250 out of pocket for Self only Enrollment
and you pay 4,500 out of pocket for Self and Family Enrollment if you receive
care from a Plan doctor If care is not received from a Plan doctor you pay
4,500 for Self only Enrollment and you pay 9,000 for Self and Family
Enrollment
Hospital extended The Plan provides a comprehensive range of benefits with no dollar limit when care you are hospitalized under the care of a Plan doctor You pay a 150 copay per
admission for hospitalizations or extended care not arranged by your primary
care doctor You pay 30 of charges after any applicable Deductible when you
are hospitalized in a non Plan facility This does not include any copayment or
coinsurance that applies to doctor's services
Emergency Benefits Emergencies are always paid as an In Plan benefit
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Bluegrass Family Health 2000
Other Benefits
Mental conditions Inpatient Mental conditions and substance abuse benefits are covered You pay substance abuse a 200 copay per admission for each benefit for plan doctors and you pay 30
benefits of charges after any applicable deductible for non Plan doctors This condition is limited to 30 days per Plan year and 1 admission per 6 months for each
benefit
Outpatient Mental conditions are a covered benefit You pay a 30 copay per
visit limited to 40 visits per year for Plan doctors and you pay 30 of charges
after any applicable Deductible limited to 40 visits per year for non Plan
doctors
Outpatient substance abuse benefits are covered You pay a 30 copay per visit
limited to 30 visits per Plan year for Plan doctors and you pay 30 of charges
after any applicable Deductible limited to 30 visits per Plan year for non Plan
doctors
What is not In addition to the above not covered services preventive care and transplant covered benefits are not covered when received from non Plan providers
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Bluegrass Family Health 2000
Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles POS maximum benefits opt out
maximum benefits or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure
Concordia PLUS Dental Plan At Bluegrass Family health we know that dental health is an important part of your family's wellness Therefore Bluegrass
Family Health is pleased to offer its members the opportunity to receive dental benefits through United Concordia It is a
comprehensive plan that emphasizes preventive and diagnostic care generally by covering such services in full or with only a
nominal copayment
To enroll in this dental plan you must be enrolled in Bluegrass Family Health and complete and sign the ConcordiaPLUS
enrollment form ConcordiaPLUS premiums are payable to United Concordia on an annual basis by check Visa or
MasterCard
ConcordiaPLUS IIC covered services include preventive and diagnostic services such as but not limited to oral exams and
bitewing x rays Restorative services include but are not limited to routine fillings simple extraction and crowns
This optional plan is available to Federal employees during the scheduled Federal open enrollment period for coverage
effective January 1 2000 Federal employees who do not enroll at this time will not be eligible for these dental benefits until
the next open enrollment period For more information regarding the ConcordiaPLUS dental health plan please contact
United Concordia at 800 822 3368
This is not a contract For a complete schedule of benefits please see your ConcordiaPLUS Certificate of Coverage
Bluegrass Family Health AHealth A Helpers As a Bluegrass Family Health member you are eligible for Health Helper discounts of 10 to 25 on Optical Wellness and
Dental needs from the providers listed on the Health Helper page of the Plan s provider director
Optical Discounts Optical services are not a covered benefit under the FEHB benefits program offered by Bluegrass Family health To
accommodate those Members who need optical services BFH Members may obtain services such as vision exams glasses
and contact lenses at a discounted fee from the providers listed on the Health Helper page of the Plan s provider directory
Wellness Discounts Bluegrass Family Health has made arrangements with businesses to give HMO Members a substantial discount on their fitness
services Wellness is a big part of our plan and Bluegrass Family Health has decided to do all we can to assist our Members in
that area All you need to do is show your ID Card and these discounts can be yours at the establishments listed on the Health
Helper page of the Plan s provider directory
Dental Discounts Bluegrass Family Health Members can enjoy discounts on Dental services from certain dentists Many dentists have agreed to
supply preventive dental services at a discounted rate for orthodontic restorative surgical and other dental needs We at
Bluegrass Family Health wish to assist our Members in any way we can to have the best possible treatment in all areas of
your health and Health Helpers is how we are able to do this Please refer to the list of dentists on the Health Helper page of
the Plan s provider directory
Benefits on this page are not part of the FEHB contract
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Bluegrass Family Health 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit
we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or
treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits 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
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 reenroll
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
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Bluegrass Family Health 2000
Section 7 Limitations Rules that affect your benefits cont'd Other group When anyone has coverage with us and with another group health plan it is called
insurance double coverage You must tell us if you or a family member has double coverage coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first
The other plan is secondary it pays benefits next We decide which insurance is
primary according to the National Association of Insurance Commissioners
Guidelines
If we pay second we will determine what the reasonable charge for the benefit should
be After the first plan pays we will pay either what is left of the reasonable charge or
our regular benefit whichever is less We will not pay more than the reasonable
charge If we are the secondary payer we may be entitled to receive payment from
your primary plan
We will always provide you with the benefits described in this brochure Remember
even if you do not file a claim with your other plan you must still tell us that you have
double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be beyond our unable to provide them In that case we will make all reasonable efforts to provide
control you with necessary care
When others When you receive money to compensate you for medical or hospital care for injuries are or illness that another person caused you must reimburse us for whatever services we
responsible for paid for We will cover the cost of treatment that exceeds the amount you received in injuries 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 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
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Bluegrass Family Health 2000
Section 7 Limitations Rules that affect your benefits cont'd
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
Government agency directly or indirectly pays for Agencies
If you have a If you have a malpractice claim because of services you did or did not receive from a
malpractice plan provider it must go to binding arbitration Contact us about how to begin our claim binding arbitration process
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights information about which gives you the right to information about your health plan its networks
your HMO providers and facilities You can also find out about care management which includes medical practice guidelines disease management programs and how we
determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 606 269 4475 or write to 651
Perimeter Drive Lexington Kentucky 40517 You may also contact us by fax
at 606 269 5044 or visit our website at www bgfh com
Where do I get Your employing or retirement office can answer your questions and give you a
information about Guide to Federal Employees Health Benefits Plans brochures for other plans enrolling in the and other materials you need to 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
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Bluegrass Family Health 2000
Section 8 FEHB FACTS cont'd When are my The benefits in this brochure are effective on January 1 If you are new to this
benefits and plan your coverage and premiums begin on the first day of your first pay period premiums that starts on or after January 1 Annuitants premiums begin January 1
effective
What happens When you retire you can usually stay in the FEHB Program Generally you when I retire must have been enrolled in the FEHB Program for the last five years of your
Federal service If you do not meet this requirement you may be eligible for
other forms of coverage such as Temporary Continuation of Coverage which is
described later in this section
What happens When you retire you can usually stay in the FEHB Program Generally you when I retire must have been enrolled in the FEHB Program for the last five years of your
Federal service If you do not meet this requirement you may be eligible for
other forms of coverage such as Temporary Continuation of Coverage which is
described later in this section
What types of Self only coverage is for you alone Self and Family coverage is for you your coverage are spouse and your unmarried dependent children under age 22 including any
available for me foster or step children your employing or retirement office authorizes coverage and my family for Under certain circumstances you may also get coverage for a disabled child
22 years of age or older who is incapable of self support
If you have a Self only enrollment you may change to a Self and Family
enrollment if you marry give birth or add a child to your family You may
change your enrollment 31 days before to 60 days after you give birth or add the
child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member
Your employing or 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
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Bluegrass Family Health 2000
Section 8 FEHB FACTS cont'd
Are my medical We will keep your medical and claims information confidential Only the and claims records following will have access to it
confidential
OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating
benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health
cards Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation
letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family conditions member had before you enrolled in this Plan solely because you had the
condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium my enrollment in when
this Plan ends
Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of
Coverage
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Bluegrass Family Health 2000
Section 8 FEHB FACTS cont'd
What is former If you are divorced from a Federal employee or annuitant you may not continue spouse to get benefits under your former spouse's enrollment But you may be eligible
coverage for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or
retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you
may be eligible for TCC For example you can receive TCC if you are not able
to continue your FEHB enrollment after you retire You may not elect TCC if
you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees from your employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if
several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right TCC to enroll under TCC You must enroll within 60 days of leaving or receiving
this notice whichever is later
Children You must notify your employing or retirement office within 60 days
after your child is no longer an eligible family member That office will send
you information about enrolling in TCC You must enroll your child within
60 days after they become eligible for TCC or receive this notice whichever
is later
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Bluegrass Family Health 2000
Section 8 FEHB FACTS cont'd
Former spouses You or your former spouse must notify your employing or
retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce Your employing or retirement office will then send your former spouse
information about enrolling in TCC Your former spouse must enroll within 60
days after the event which qualifies them for coverage or receiving the
information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your
former spouse notify your employing or retirement office within the 60 day
deadline
How can I You may convert to an individual policy if convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled coverage
your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual
coverage is available You must apply in writing to us within 31 days after you
receive this notice However if you are a family member who is losing
coverage the employing or retirement office will not notify you You must
apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program
however you will not have to answer questions about your health and we will
not impose a waiting period or limit your coverage due to pre existing
conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health
Certificate of Plan Coverage that indicates how long you have been enrolled with us You can Group Health use this certificate when getting health insurance or other health care coverage
Plan 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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Bluegrass Family Health 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 606 269 4475 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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Bluegrass Family Health 2000
Summary of HMO Benefits for Bluegrass Family Health 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 a 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 a 100
copay per admission 13
Extended care All necessary services up to 40 days per calendar year You pay a 100 copay per admission
13
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay a 100 copay per admission
17
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay a 100 copay per admission
17
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist care preventive care well baby care periodic check ups and routine
immunizations laboratory tests and x rays complete maternity care You pay a 10
copay per office visit and for a house call by a doctor 10
Home health All necessary visits by nurses and health aides You pay nothing 12
care
Mental conditions Up to 40 outpatient visits per year You pay a 20 copay 10 per group session per visit
16
Substance abuse Up to 30 outpatient visits per year You pay a 20 copay 10 per group session per visit
17
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room visit
and any charges for services that are not covered by this Plan 14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay 5 copay per generic prescription unit or refill 10 per name brand prescription unit or
refill 17
Dental Care Accidental injury benefit you pay nothing 19
Vision Care One refraction every 12 month period for members up through 17 and every 24 months period for members age 18 and over You pay a 10 copay per visit 19
Out of Pocket Copayments are required for a few benefits however after your out of pocket expenses reach a meaximum of 2,250 per Self only or 4,500 per Self and Family enrollment for inPlan
referrals and 4,500 per Self only or 9.000 per Self and Family enrollment per
calendar year covered benefits will be provided at 100 This copy maximum does not
include charges for prescription drugs There is no out of pocket maximum for care
received in Plan Network 21
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Bluegrass Family Health 2000
2000 Rate Information for
Bluegrass Family Health
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 Postal Premium B Premium A
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
Central Eastern Kentucky
Self Only 2B1 78.83 28.12 170.80 60.93 93.06 13.89 93.26 13.69
Self and 2B2 163.55 54.52 354.37 118.12 193.54 24.53 193.54 24.53
Family
33 35