Serving Oklahoma City and Tulsa areas
Enrollment in this Plan is limited see page 6 for requirements
Enrollment code
7C1 Self only
7C2 Self and family
This Plan has accreditation with
Commendation from the JCAHO
See the 2000 Guide for more
Information on JCAHO
Visit the OPM website at http www opm gov insure
and
our Plan's website at http www ccmhp com
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI73 746
1
1
Page 2
3
Table of Contents Page
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 9
Section 4 What to do if we deny your claim or request for service 10 12
Section 5 Benefits 13 23
Section 6 General exclusions Things we don't cover 24
Section 7 Limitations Rules that affect your benefits 24 25
Section 8 FEHB FACTS 26 29
Inspector General Advisory Stop Healthcare Fraud 30
Summary of benefits Inside back cover
Premiums Back cover
2
2
Page 3
4
CommunityCare HMO 2000
Introduction
CommunityCare HMO 218 West 6 th Street Tulsa Oklahoma 74119
This brochure describes the benefits you can receive from CommunityCare HMO under its contract CS2812 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 CommunityCare HMO 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
CommunityCare HMO 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs
and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our
decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations 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 When you receive emergency or urgent care services from non network
providers it may be necessary for you or the provider to file a claim with CommunityCare HMO in order for these providers to
receive payment If payment is required at the time of service please submit an itemized bill to CommunityCare HMO for
reimbursement
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
CommunityCare HMO 2000
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes office visits
This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you
may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until
the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record
you may add a brief statement to it If they do not provide you your records call us and we will assist
you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Plan Your share of the non postal premium will increase by 13.2 for Self Only or 13.2 for Self and Family
Our doctor office short term rehabilitative therapy cardiac rehabilitation accidental injury and
vision care visits increased from 5 per visit to 10 per visit
Our Inpatient Mental Health benefit has changed from an 80 copay per day to no copay Our
Outpatient Mental Health benefit has changed from 25 per visit to 10 per visit
5
5
5
Page 6
7
CommunityCare HMO 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 Entire Oklahoma counties of Cleveland Creek Kingfisher Logan Nowata Oklahoma Okmulgee
Pottawatomie Rogers Tulsa and Wagoner
Portions of Canadian Grady Lincoln McClain Osage Pawnee and Washington counties are also in the
service area as indicated by zip codes shown below
County Zip
Canadian 73014 73022 73036 73064 73078 73085 73090 73099
Grady 73002 73004 73011 73018 73059 73067 73079 73082 73089 73092
Lincoln 74026 74079 74824 74832 74834 74855 74864 74869 74875 74881
McClain 73010 73031 73065 73080 73093 73095 74831
Osage 74070 74127 74003 74001 74002 74009 74035 74054 74056 74060 74084
74633 74637 74652
Pawnee 74020 74034 74045 74058 74081 74650
Washington 74004 74005 74006 74022 74029 74051 74061 74082
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 services or urgent care services with prior authorization
from your primary care physician We will not pay for any other health care services unless you receive
prior authorization from your primary care physician and or the patient care committee
If you or a covered family member move outside of our service area you can enroll in another plan If your
dependents live out of the area for example if your child goes to college in another state you should
consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If
you or a family member move you do not have to wait until Open Season to change plans Contact your
employing or retirement office
How much do I 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 but no additional copayment for laboratory tests and x rays
After you pay 400 in copayments or coinsurance for one family member or 1,200 for two or more family
members you do not have to make any further payments for certain services for the rest of the year This is
called a catastrophic limit However copayments or coinsurance for your prescription drugs and durable
medical equipment 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
6
6
6
Page 7
8
CommunityCare HMO 2000
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service
Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented
you from filing on time
Who provides CommunityCare HMO is locally owned and operated by four of the premier hospitals in Oklahoma We
my health care are an Independent Practice Association Physician Hospital Organization model Health Maintenance Organization We have 476 Primary Care Physicians General Practice Internal Medicine Pediatrics 24
Hospitals 379 Pharmacy locations and 1,608 Specialists to serve all of our members health care needs
You will need to let us know which physician you selected for each member of the family If you need help
choosing a doctor contact Member Services at 1 800 777 4890
If you are unable to establish a satisfactory patient physician relationship with your primary care physician
you may choose another within the same hospital network by contacting CommunityCare HMO Member
Services in writing or by phone Changes are subject to physician availability and are coordinated by
CommunityCare HMO Requests made by the fifteenth of the month will be effective the first of the
following month Requests made after the fifteenth will be effective on the first day of the month following
the expiration of the 30 day notice All existing referrals or precertifications made by your former primary
care physician are canceled as of the effective date of the change to you new primary care physician Your
new primary care physician is responsible for your care as of the effective date CommunityCare HMO will
advise you in writing of the effective date of any approved change in PCP You may also change primary
care physician or hospital networks during Open Season
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 will
need to go into make the necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our customer service department at 1 800 777 4890 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 your
hospital when I 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
CommunityCare HMO 2000
How do I get Your primary care physician will arrange your referral to a specialist Except in a medical emergency or
specialty care when a primary care doctor has designated another doctor to see his or her patients you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services
Referral to a participating specialist is given at the primary care doctor's discretion and will be to
specialists within the same medical network as your primary care doctor When you receive a referral from
your primary care doctor you must return to the primary care doctor after the consultation unless your
doctor authorizes additional visits All follow up care must be provided or authorized by the primary care
doctor Do not go to the specialist for a second visit unless your primary care doctor has arranged for and
the Patient Care Committee has issued an authorization for the referral in advance If non Plan specialists
or consultants are required the primary care doctor will arrange appropriate referrals
You may self refer to an OB GYN within the same medical network as your primary care physician for
your annual well woman exam Other self referral options include an annual vision screening by calling
1 800 831 8930 and mental health services by contacting the Plan at 1 800 774 2677
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 which may include prior authorization from the Patient Care Committee
What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a specialist
am seeing a ask if you can see your current specialist Your specialist will need to be in the same medical network as
specialist when your primary care physician If your current specialist is unavailable to you under our plan you must
I enroll receive treatment from a specialist who is Generally we will not pay for you to see unauthorized specialists
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
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
have a serious your provider for up to 90 days after we notify you that we are terminating our contract with the provider
illness and my unless the termination is for cause If you are in the second or third trimester of pregnancy you may
provider leaves 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 you
Plan leaves the enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition
Program 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
8
8
8
Page 9
10
CommunityCare HMO 2000
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 necessary
medical and if it follows generally accepted medical practice The Plan will provide benefits for covered services
services only when the services are medically necessary to prevent diagnose or treat your illness or condition When your primary care doctor determines you need special tests or the services of a specialist your
primary care doctor will submit a referral request to the Patient Care Committee for their recommendations
regarding your medical care The Patient Care Committee consists of both primary care doctors and
specialists Within two working days following the weekly meeting your primary care doctor and
specialist when appropriate will be notified of the committee's recommendations If the committee denies
a referral request you will also be notified in writing within two working days following the Patient Care
Committee meeting stating why the request was denied If additional tests or treatment is recommended
instructions will be sent to the appropriate medical department You will need to contact your primary care
doctor or specialist to arrange your treatment and to verify they have received your authorization Referrals
are made to specialists in the same medical network as your primary care doctor All reports or results of
any testing you have done will be sent to your primary care doctor If your primary care doctor determines
that your referral needs to be handled urgently your primary care doctor will contact the Patient Care
Committee without delay to arrange services
How do you A drug device or service will not be considered investigational if it meets any of the following criteria
decide if a 1 It has received approval from the Food and Drug Administration
service is 2 It is considered to be a part of the treatment or diagnosis process by any responsible agency of the
experimental or federal or state government
investigational 3 It is considered standard or optional by a recognized specialty society 4 It is not viewed as investigational by the Medical Director and the Quality Assurance or Patient Care
Committees of at least two of CommunityCare's owner networks
In each of these instances the service will be covered if it is not otherwise outside the scope of the
remainder of the schedule of benefits and exclusions If you need more information contact us for more
details
9
9
9
Page 10
11
CommunityCare HMO 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 OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a Call us at 1 800 777 4890 and we will expedite your review
serious or life
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 claim we will inform
denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
care and my condition health benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or life
is serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they
threatening are not treated as soon as possible
10
10
10
Page 11
12
CommunityCare HMO 2000
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 do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you for
additional information
What do I send to 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
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim to Contract Division III P O Box 436 Washington D C 20044
OPM
11
11
11
Page 12
13
CommunityCare HMO 2000
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our
the Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
Privacy Act 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
12
12
12
Page 13
14
CommunityCare HMO 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a
10 office visit copay but no additional copay for laboratory tests and X rays Within the
service area house calls will be provided if in the judgment of the Plan doctor such care
is necessary and appropriate you pay a 10 copay for a doctor's house call and nothing for
home visits by contracted home health care professionals
The following services are included and are subject to the office visit copay unless stated
otherwise
Preventive care including vision and hearing screenings well baby care and periodic check ups
Sigmoidoscopy screening for colorectal cancer every five years for those age 50 and above
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram
every one or two years for women age 50 through 64 one mammogram every year
and for women age 65 and above one mammogram every two years In addition to
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 no additional copay applies
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copay applies to initial visit only The
mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if
medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary
nursery care of the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self and Family
enrollment other care of an infant who requires definitive treatment will be covered
only if the infant is covered under a Self and Family enrollment
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
13
13
13
Page 14
15
CommunityCare HMO 2000
Medical and Surgical Benefits continued
What is covered Voluntary sterilization and family planning services continued
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung single and double kidney pancreas 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 or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast
cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal
retroperitoneal and ovarian germ cell tumors Transplants are covered when approved
by the Patient Care Committee Related medical and hospital expenses of the donor
are covered when the recipient is covered by this Plan
Patients 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
Prosthetic devices such as artificial limbs and lenses following cataract removal and breast prostheses surgical bras and replacements following a mastectomy You pay
20 of the total costs
Chiropractic services
Home health services by contracted home health care professionals including intravenous fluids and medications when prescribed by your Plan doctor who will
periodically review the program for continuing appropriateness and need you pay
nothing
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
14
14
14
Page 15
16
CommunityCare HMO 2000
Medical and Surgical Benefits continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including but
not limited to treatment of fractures and excision of tumors and cysts All other
procedures involving the teeth or intra oral areas surrounding the teeth are not covered
including any dental care involved in the treatment of temporomandibular joint TMJ pain
dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a
functional defect or from an injury or surgery that has produced a major effect on the
member's appearance and if the condition can reasonably be expected to be corrected by
such surgery A patient and 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 10 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
Diagnosis and treatment of infertility is covered you pay 50 of the total costs
including fertility drugs The following types of artificial insemination are covered
intravaginal insemination IVI intracervical insemination ICI and intrauterine
insemination IUI you pay 50 of the total costs cost of donor sperm is not covered
Other assisted reproductive technology ART procedures such as in vitro fertilization and
embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial
infarction is provided for up to 60 consecutive days you pay 10 per outpatient treatment
and nothing for inpatient treatment
Durable Medical Equipment such as hospital beds and wheelchairs and Orthopedic
Devices such as braces You pay 20 of costs Combined annual maximum benefit of
3,000
Foot Orthotics are covered up to a Plan benefit maximum of 500 for inflammatory
conditions of the foot
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
15
15
15
Page 16
17
CommunityCare HMO 2000
Medical and Surgical Benefits continued
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
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and blurring astigmatism
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you
are hospitalized under the care of a Plan doctor You pay nothing All necessary services
are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing
care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits up to 60 consecutive days when fulltime nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing
All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
16
16
16
Page 17
18
CommunityCare HMO 2000
Hospital Extended Care Benefits continued
What is covered continued
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a
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
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines
procedures 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 Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification 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 21 for nonmedical substance abuse benefits
What is not Personal comfort items such as telephone and television
covered
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
17
17
17
Page 18
19
CommunityCare HMO 2000
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that
emergency 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
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme
the service area 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 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 must 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 your primary care doctor must be notified within 48 hours
or on the first working day following your admission unless it was not reasonably possible
to notify your primary care doctor within that time If you are hospitalized in non Plan
facilities and your primary care 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
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 your primary care doctor
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 15 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital the copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately
the service area required because of injury or unforeseen illness
If you need to be hospitalized your primary care doctor must be notified within 48 hours
or on the first working day following your admission unless it was not reasonably possible
to notify your primary care doctor within that time If your primary care 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 managed and coordinated by your primary care doctor
18
18
18
Page 19
20
CommunityCare HMO 2000
Emergency Benefits continued
Emergencies outside
the service area continued
Plan pays Reasonable charges for emergency services to the extent the services would have been
covered if received from Plan providers
You pay 50 per hospital emergency room visit or 15 per urgent care center visit for emergency
services that are covered benefits of this Plan If the emergency results in admission to a
hospital the copay is waived
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have
been foreseen before leaving the service area
Nonemergency medical and hospital costs resulting from a normal full term delivery
of a baby outside the service area
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your
providers 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
19
19
19
Page 20
21
CommunityCare HMO 2000
Mental Conditions Substance Abuse Benefits
Mental conditions For services call the Plan at 1 800 774 2677
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 Unlimited visits to Plan doctors or other psychiatric personnel each calendar year You pay a 10 copay for each covered visit
Inpatient care Unlimited number of days in a participating facility authorized by CommunityCare HMO behavioral health case manager you pay nothing
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Treatment that is not authorized by a CommunityCare behavioral health case manager
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 care Unlimited visits to Plan providers for treatment each calendar year you pay a 25 copay
for each covered visit
Inpatient care Unlimited number of 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 80 copay per day
What is not covered Treatment that is not authorized by a CommunityCare behavioral health case manager
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
20
20
20
Page 21
22
CommunityCare HMO 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a participating pharmacy will be dispensed for up to a 30 day supply You pay a 5 copay for a
prescription in accordance with the plan's drug formulary or a 10 copay per prescription
for a non formulary drug In no event will the copay exceed the cost of the prescription
drug
When generic substitution is permissible i e a generic drug is available and the
prescribing doctor does not require the use of a name brand drug but you request the
name brand drug you pay the price difference between the generic and name brand drug as
well as the required copayment per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug
formulary Nonformulary drugs will be covered when prescribed by a Plan doctor
Formulary Development CommunityCare HMO's Pharmacy Therapeutics Committee
comprised of network physicians pharmacists and administrative personnel is responsible
for the development and maintenance of the drug formulary Drugs are evaluated on clinical
efficacy side effects therapeutic value and cost of therapy Formulary changes are made
quarterly
Because CommunityCare utilizes an open drug formulary non formulary drugs are available
to our patients for the non formulary copayment without intervention by the physician
Certain drugs including but not limited to Viagra Imitrex etc are available but have
dispensing limits or step therapy guidelines and require documentation of medical
necessity length of therapy from the prescribing physician
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral contraceptive drugs
Diaphragms with a prescription
Insulin with a copay charge applied prescription must show a correct one month supply
Disposable needles and syringes needed to inject covered prescribed medication
Diabetic supplies including insulin syringes needles and glucose monitoring strips
Fertility drugs you pay 50 contraceptive devices other than diaphragms 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 Certain drugs such as those for migraine therapies acne treatment and sexual dysfunction drugs have dosage limitations or step therapy guidelines Contact the Plan for details
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
21
21
21
Page 22
23
CommunityCare HMO 2000
Prescription Drug Benefits continued
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 or medications for cosmetic purposes
Drugs to enhance athletic performance
Contraceptive devices without FDA approval
Drugs or medication used for smoking cessation chemical dependency or alcohol treatment
Drugs given or administered in a physician's office hospital nursing home or other institutional facility
Other Benefits
Dental care
What is covered
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound
benefit natural teeth The need for these services must result from an accidental injury You pay
10 copay if office visit is required
What is not covered Other dental services not shown as covered
Vision care In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye the following vision care benefits are available from Plan providers
You pay a 10 copay per visit
What is covered Annual eye refraction including the written lens prescription for eyeglasses
Glaucoma test
Initial placement of post cataract extraction contact lens in surgically affected eye
You may receive a 15 20 discount off regular prices for eyeglasses and contact lenses purchased at participating optometrists office
What is not covered Corrective lenses or frames
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
22
22
22
Page 23
24
CommunityCare HMO 2000
Non FEHB Benefits Available to Plan Members
The benefits 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 or out of pocket
maximums These benefits are not subject to the FEHB disputed claims procedure
Dental Plan
Protective Dental Care Prepaid Dental Plan is provided for FEHB CommunityCare members
No Monthly Premium includes family coverage
Free Periodic Oral Exams
No Deductibles
No Lifetime or Annual Maximum Benefit Limits
No Limitation on Pre Existing Conditions
No Claim Forms or Pre Authorizations
Orthodontics Coverage
Enrollment information provider list and schedule of services and copayments is included in the Open
Season packet or can be obtained by contacting Protective Dental Care directly at 1 800 443 0225
25,000 A D D
As an FEHB employee or annuitant you automatically receive at no charge to you 25,000 in
Accidental Death Dismemberment coverage when you enroll in CommunityCare HMO
CommunityCare Wellness Benefits
As a member of CommunityCare you receive many wellness benefits including
Personal Health Advisor AudioHealth Library No Charge
24 hour Nurse Line No Charge
Personal Wellness Profile Personal Health Assessment Evaluation No Charge
Health Education Services Provided by CommunityCare's owner hospitals Cost for these programs if any
can be obtained from participating hospitals
Healthy Heart Course Stress Management
Smoking Cessation Nutritional Counseling
Diabetic Education Childbirth Preparation
Parenting Education CPR Instruction
Weight Management Fitness Discounts
Senior Health Plan If you are Medicare eligible you may be interested in learning about CommunityCare's Senior Health Plan To obtain
more information about the Medicare Choice Plan sponsored by CommunityCare please refer to materials included
in FEHB Open Season packet or contact our Member Services Department at 1 800 777 4890
BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
23
23
23
Page 24
25
CommunityCare HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it
unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term
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 For information on the Medicare Choice plan offered by this
Plan see page 23
24
24
24
Page 25
26
CommunityCare HMO 2000
Other group When anyone has coverage with us and with another group health plan it is called double coverage You
insurance must tell us if you or a family member has double coverage You must also send us documents about other
coverage 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 are When you receive money to compensate you for medical or hospital care for injuries or illness that another
responsible for person caused you must reimburse us for whatever services we paid for We will cover the cost of
injuries treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for our subrogation
procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage
Workers 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
25
25
25
Page 26
27
CommunityCare HMO 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 find
your HMO out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 1 800 777 4890 or write to 218 West 6 th Street
Tulsa Oklahoma 74119 You may also contact us by fax at 405 843 2040 or visit our website at
www ccmhp com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the FEHB an informed decision about
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 benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
and premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1
26
26
26
Page 27
28
CommunityCare HMO 2000
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
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for my unmarried dependent children under age 22 including any foster or step children your employing or
family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage
for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member
Your employing or 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 access
claims records to it
confidential
OPM this Plan and subcontractors when they administer this contract
This Plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form
SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use
an Employee Express confirmation letter
27
27
27
Page 28
29
CommunityCare HMO 2000
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my
old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
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 under
spouse coverage 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 exspouse'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
28
28
28
Page 29
30
CommunityCare HMO 2000
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
How can I convert to You may convert to an individual policy if
individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have
to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of
Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
29
29
29
Page 30
31
CommunityCare HMO 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 1 800 777 4890 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
30
30
30
Page 31
32
CommunityCare HMO 2000
Summary of Benefits for CommunityCare HMO 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and
exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If
you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your
enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN
WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR
ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or
Care day limit Includes in hospital doctor care room and board general nursing care private room and private nursing care if medically necessary diagnostic
tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing 16
Extended care All necessary services up to 60 consecutive days You pay nothing 16 17
Mental Diagnosis and treatment of acute psychiatric conditions for unlimited
Conditions number of days of inpatient care per year You pay nothing 20
Substance Unlimited number of days per year in a substance abuse treatment
Abuse program You pay 80 per inpatient day 20
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or
Care injury including specialist's care preventive care including well baby care periodic check ups and routine immunizations lab tests and X rays complete
maternity care You pay a 10 copay per office visit copays are waived
for maternity care after the initial visit 10 per house call by a doctor 14 17
Home health All necessary visits by home health care professionals You pay nothing 14
Care
Mental Unlimited number of outpatient visits per year You pay a 10 copay per visit 20
Conditions
Substance Unlimited number of outpatient visits per year You pay a 25 copay per visit 20
Abuse
Emergency Reasonable charges for services and supplies required because of a medical
care emergency You pay a 50 copay to the hospital for each emergency room visit a 15 copay per urgent care center visit and any charges for services that are not
covered by this Plan 18 19
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per formulary drug and 10 copay per non formulary drug 21 22
Dental care Accidental injury benefit you pay a 10 Office copay 22
Vision care One refraction annually You pay a 10 copay per visit 22
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket Expenses reach a maximum of 400 per Self Only or 1,200 per Self and Family
enrollment per calendar year covered benefits will be provided at 100 This
copay maximum does not include charges for outpatient prescriptions or durable
medical equipment 6
31
31
31
Page 32
CommunityCare HMO 2000
2000 Rate Information for
CommunityCare HMO
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category
refer to the FEHB Guide for that category or contact the agency that maintains your health
benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of
contribution rates referred to as Category A rates and Category B rates will apply for certain
career employees If you are a career postal employee but not a member of a special postal
employment class refer to the category definitions in The Guide to Federal Employees Health
Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate
applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal
employment classes or associate members of any postal employee organization Such persons not
subject to postal rates must refer to the applicable Guide to Federal Employees Health Benefits
Plans
Non Postal Premium Postal Premium Postal Premium A B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Self Only 7C1 65.09 21.70 141.04 47.01 77.03 9.76 77.03 9.76
Self and 7C2 167.77 55.92 363.50 121.16 198.52 25.17 198.52 25.17
Family
32 32