HMO Health Ohio

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Pages 1--62

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

2
HMO Health Ohio http:// www. MedMutual. com 2003
A Health Maintenance Organization

Serving: Northeast Ohio
Enrollment in this Plan is limited. You must live or work in our
Geographic service area to enroll. See page 7 for requirements.

Enrollment codes for this Plan:
L41 Self Only L42 Self and Family

RI 73-157

This Plan has an excellent
accreditation from the NCQA. See the
2003 Guide for more information on
accreditation.

For changes
in benefits see
page 8. 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management 's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU
MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO
THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits
(FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held
by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is

protected
To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For
example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.

To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give our your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical
information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.

By law, you have the right to: 3.
3 Page 4 5
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information.

Get a listing of those getting your personal medical information from OPM in the last 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any

information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay
for health care or a disputed claim.

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).

Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above,
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You
may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You may also file a complaint with the
Secretary of the Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your
personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6
2003 HMO Health Ohio Introduction/ Plain Language 2
Table of Contents
Introduction .................................................................................................................................................................. 4
Plain Language .............................................................................................................................................................. 4
Stop Health Care Fraud.................................................................................................................................................. 5
Section 1. Facts about this HMO plan .......................................................................................................................... 6
How we pay providers ................................................................................................................................. 6
Your Rights.................................................................................................................................................. 6
Service Area................................................................................................................................................. 7
Section 2. How we change for 2003 ............................................................................................................................. 8
Program-wide changes................................................................................................................................. 8
Changes to this Plan................................................................................................................................. 8
Section 3. How you get care .................................................................................................................................. 9
Identification cards....................................................................................................................................... 9
Where you get covered care......................................................................................................................... 9

Plan providers........................................................................................................................................ 9
Plan facilities ......................................................................................................................................... 9
What you must do to get covered care ......................................................................................................... 9

Primary care........................................................................................................................................... 9
Specialty care....................................................................................................................................... 10
Hospital care........................................................................................................................................ 10
Circumstances beyond our control............................................................................................................. 11
Services requiring our prior approval ........................................................................................................ 11
Section 4. Your costs for covered services ................................................................................................................. 12

Copayments ......................................................................................................................................... 12
Deductible ........................................................................................................................................... 12
Coinsurance ......................................................................................................................................... 12
Your catastrophic protection out-of-pocket maximum.............................................................................. 12
Section 5. Benefits ...................................................................................................................................................... 13
Overview.................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ........... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 23
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 27
(d) Emergency services/ accidents......................................................................................................... 30
(e) Mental health and substance abuse benefits.................................................................................... 32
(f) Prescription drug benefits................................................................................................................ 34
(g) Special features ............................................................................................................................... 37

Flexible benefits option ............................................................................................................ 37 5.
5 Page 6 7
2003 HMO Health Ohio Introduction/ Plain Language 3
Heart Sense ............................................................................................................................... 37
Baby Link ................................................................................................................................. 37

Dental benefits........................................................................................................................................ 38
Section 6. General exclusions --things we don't cover .............................................................................................. 39
Section 7. Filing a claim for covered services ............................................................................................................ 40
Section 8. The disputed claims process ...................................................................................................................... 41
Section 9. Coordinating benefits with other coverage ................................................................................................ 43
When you have other health coverage.. 43

What is Medicare. 43
Medicare managed care plan... 46
TRICARE and CHAMPVA 47
Workers' Compensation.. 47
Medicaid.. 47
Other Government Agencies 48
When others are responsible for injuries. 48
Section 10. Definitions of terms we use in this brochure............................................................................................ 49
Section 11. FEHB facts............................................................................................................................................... 50

Coverage information ................................................................................................................................ 50
No pre-existing condition limitation .................................................................................................. 50

Where you get information about enrolling in the FEHB Program................................................... 50
Types of coverage available for you and your family........................................................................ 50
Children's Equity Act ........................................................................................................................ 51
When benefits and premiums start..................................................................................................... 52
When you retire ................................................................................................................................ 52
When you lose benefits.............................................................................................................................. 52

When FEHB coverage ends............................................................................................................... 52
Spouse equity coverage .................................................................................................................... 52
Temporary Continuation of Coverage (TCC) ................................................................................... 52
Converting to individual coverage.................................................................................................... 52
Getting a Certificate of Group Health Plan Coverage....................................................................... 53

Long term care insurance is still available 54
Index ................................................................................................................................................................ 55
Summary of benefits.................................................................................................................................................... 57
Rates .................................................................................................................................................. Back cover 6.
6 Page 7 8
2003 HMO Health Ohio Introduction/ Plain Language 4
Introduction
This brochure describes the benefits of HMO Health Ohio under our contract (CS 2015) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law.

Medical Mutual of Ohio, dba HMO Health Ohio
2060 East Ninth Street
Cleveland, Ohio 44115-1355

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan you are entitled to the benefits described in this brochure. If you are enrolled in Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2003, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and
changes are summarized on page 8. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the
public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means HMO Health Ohio.

We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM know. Visit
OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at fehbwebcomments@ opm. gov. You may
also write to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation Division,
1900 E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2003 HMO Health Ohio Introduction/ Plain Language 5
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
Let only the appropriate medical professionals review your medical record or recommend services. Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us. Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or

service.
If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

Call the provider and ask for an explanation. There may be an error. If the provider does not resolve the matter, call us at 800/ 522-2066 and explain the situation.
If we do not resolve the issue:

CALL -THE HEALTH CARE FRAUD HOTLINE 202/ 418-3300
OR WRITE TO:
The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street, NW, Room 6400
Washington, DC 20415.

Do not maintain as a family member on your policy: Your former spouse after a divorce decree or annulment is final (even if a court order stipulates
otherwise); or
Your child over age 22 (unless he/ she is disabled and incapable of self-support). If you have any questions about the eligibility of a dependent, check with your personnel office if you are

employed or with OPM if you are retired.
You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer

enrolled in the Plan. 8.
8 Page 9 10
2003 HMO Health Ohio Section 1 6
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay
the copayments described in this brochure. When you receive emergency services from non-Plan providers, you may
have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available.
You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments.

Your Rights
HMO Health Ohio is a mixed model prepayment plan that provides care through a network of doctors, using groups of
doctors, staff model arrangements, and IPA systems. Both primary care and specialist doctors are part of the network.
Different members of the same family may select different centers or doctors.

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.

Medical Mutual of Ohio is the oldest health insurance company in Ohio. HMO Health Ohio has been in existence since January 1, 1989.
HMO Health Ohio has over 28,000 participating physicians. Medical Mutual of Ohio has been awarded Excellent accreditation status for HMO Health Ohio
by the National Committee for Quality Assurance (NCQA), a leading independent evaluator of health plans.
If you want more information about us, call 800/ 522-2066, or write to HMO Health Ohio, P. O. Box 6018, Cleveland,
Ohio 44101, Attn: HMO Member Services. You may also contact us by fax at 216/ 694-2910 or visit our website at
http:// www. MedMutual. com. 9.
9 Page 10 11
2003 HMO Health Ohio Section 1 7
Service Area
To enroll in this plan, you must live in or work in our service area. This is where our providers practice.
Our service area is:
The Ohio counties of Ashland, Ashtabula, Carroll, Columbiana, Cuyahoga, Geauga, Holmes, Huron, Lake, Lorain,
Medina, Portage, Richland, Stark, Summit, Tuscarawas and Wayne.

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 benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependants live out of the area (for example, if your child goes to college in a 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 employer or retirement
office. 10.
10 Page 11 12
2003 HMO Health Ohio Section 2 8
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes

A Notice of the Office of Personnel Management's Privacy Practices is included. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family
coverage.
Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend their FEHB Program enrollment.

Program information on Medicare is revised. By law, the DoD/ FEHB Demonstration project ends December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 3. 8% for Self Only or decrease by 12. 9% for Self and Family.
The Plan will no longer waive the $10 office visit copayment for Medicare primary members. For the eye refraction benefit, the member must receive services from a Cole Network Managed Vision provider.
In addition, the member is responsible for paying the difference between the cost of an examination for glasses
and the cost of an examination for contact lenses.

The Plan added a $10 copayment for physical, occupational and chiropractic therapies. Previously, the $10 copayment only applied to office visits. 11.
11 Page 12 13
2003 HMO Health Ohio Section 3 9
Section 3. How you get care
Identification cards We will send you an identification (ID) card. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or obtain a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at
800/ 522-2066 or write to us at Medical Mutual of Ohio, 2060 E. 9 th
Street, Cleveland, OH 44115-1355. You may also request replacement
cards through our website at http:// www. MedMutual. com.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and you will not have to file claims.

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
Both primary care and specialist doctors are part of the network.
Different members of the same family may select different centers or
doctors.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website. (www. MedMutual. com)

Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically. The list is also
on our website. (www. MedMutual. com)

What you must do to get The first and most important decision each member must make is the covered care selection of a primary care doctor. The decision is important since it
is through this doctor that all other health services, particularly those of
specialists, are obtained. It is the responsibility of your primary care
doctor to obtain any necessary authorizations from the Plan before
referring you to a specialist or making arrangements for hospitalization.
Services of other providers are covered only when there has been a
referral by a member's primary care doctor.

Primary Care Your primary care physician can be a physician, or group of physicians, trained in family or general practice, internal medicine, pediatrics or
osteopathic medicine who has a contractual obligation with HMO Health
Ohio to provide the primary care services listed in this brochure. Your
primary care physician will provide most of your health care, or give you
a referral to see a specialist. 12.
12 Page 13 14
2003 HMO Health Ohio Section 3 10
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see a Plan Obstetrician/ Gynecologist without a
referral. For mental conditions and substance abuse call HMO Health
Ohio Behavioral Health Care Management Department at 800/ 258-3186.

Here are other things you should know about specialty care:

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
(the physician may have to get an authorization or approval
beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist
until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:

terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program
and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90
days after you receive notice of the change. Contact us, or if we
drop out of the program, contact your new Plan.

If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility. 13.
13 Page 14 15
2003 HMO Health Ohio Section 3 11
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/ 522-2066. If you
are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

You are discharged, not merely moved to an alternative care center; or
The day your benefits from your former plan run out; or
The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the hospital benefit of the hospitalized
person; we cover your other non-hospital care.

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

Services requiring our Your primary care physician has authority to refer you for most prior approval services . For certain services, however, your physician must obtain
approval from us. Before giving approval, we consider if the service is
covered, medically necessary, and follows generally accepted medical
practice.

We call this review and approval process precertification. Your physician
must obtain approval before sending you to a hospital, referring you to a
specialist, or recommending follow-up care. 14.
14 Page 15 16
2003 HMO Health Ohio Section 4 12
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: You pay a copayment of $10 per office visit or outpatient
therapy session.

Deductible We do not have a deductible.
Coinsurance We do not have coinsurance.

Your catastrophic protection Your out-of-pocket expenses for benefits under this Plan are limited to out-of-pocket maximum the stated copayments required for a few benefits.
for copayments 15.
15 Page 16 17
FFS Plan 13
Section 5. Benefits OVERVIEW
(See page 8 for how our benefits changed this year and page 57 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 800/ 522-2066 or at our website at www. MedMutual. com.
(a) Medical services and supplies provided by physicians and other health care professionals. 14-22

Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies
Physical and occupational therapies

Speech therapy Hearing services (testing, treatment, and
supplies)
Vision services (testing, treatment, and supplies)

Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 23-26
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................... 27-29

Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ........................................................................................................................ 30-31
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ................................................................................................... 32-33
(f) Prescription drug benefits ............................................................................................................................... 34-36
(g) Special features..................................................................................................................................................... 37

Flexible Benefits Option Baby Link Heart Sense

(h) Dental benefits...................................................................................................................................................... 38
Summary of benefits.................................................................................................................................................... 57 16.
16 Page 17 18
2003 HMO Health Ohio Section 5( a) 14
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
In physician's office
In an urgent care center
Office medical consultations
Second surgical opinion (in office)

$10 per office visit

Professional services of physicians
During a hospital stay
In a skilled nursing facility

Nothing

Professional services of physicians
At home
Nothing

Diagnostic and treatment services --Continued on next page 17.
17 Page 18 19
2003 HMO Health Ohio Section 5( a) 15
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing if you receive these
services during your office visit;
otherwise, $10 per visit.

Preventive care, adult
Routine screenings, such as:
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50

Nothing if you receive these
services during your office visit;
otherwise, $10 per visit.

Routine Prostate Specific Antigen (PSA) test one annually for men age 40
and older
$10 per office visit

Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnosis and Treatment, above.

$10 per office visit 18.
18 Page 19 20
2003 HMO Health Ohio Section 5( a) 16
Preventive care, adult (Continued) You pay
Routine mammogram covered for women age 35 and older, as
follows:

From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years

$10 per office visit

Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges.

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and over (except as provided for under childhood immunizations)

Influenza/ vaccines, annually
Pneumococcal vaccine, age 65 and over

$10 per office visit

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit

Well-child care charges for routine examinations, immunizations and care (through age 22)
Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

Ear exams through age 17 to determine the need for hearing correction
Examinations done on the day of immunizations ( through age 22)

$10 per office visit 19.
19 Page 20 21
2003 HMO Health Ohio Section 5( a) 17
Maternity care You pay
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:

You do not need to pre-certify your normal delivery.
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

Circumcision is a surgical benefit, not a maternity benefit.

$10 per office visit; initial visit
only

Not covered: Routine sonograms to determine fetal age, size or sex All charges.
Family planning
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b)
Surgically implanted contraceptives
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices (IUDs)
Diaphragms
Note: We cover oral contraceptives under the prescription drug benefit.

$10 per office visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges. 20.
20 Page 21 22
2003 HMO Health Ohio Section 5( a) 18
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

$10 per office visit

Not covered:
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures

Cost of donor sperm
Cost of donor egg

All charges.

Allergy care
Testing and treatment
Allergy injection
$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges.

Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 25.

Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.

$10 per office visit 21.
21 Page 22 23
2003 HMO Health Ohio Section 5( a) 19
Physical and occupational therapies You pay
Physical therapy and occupational therapy --
For the greater of 20 visits or up to two months per condition, on an inpatient or outpatient basis, if significant improvement can be

expected within two months, for each of the following:
qualified physical therapists
occupational therapists and
Note: We only cover therapy to restore bodily function when there
has been a total or partial loss of bodily function due to illness
or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery
or a myocardial infarction, provided at a Plan facility as
prescribed by your primary care doctor.

$10 copayment
Nothing per visit during covered
inpatient admission.

Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges.

Speech therapy
For the greater of 20 visits or up to two months per condition $10 copayment per office visit.
Nothing per visit during covered
inpatient admission.

Hearing services (testing, treatment, and supplies)

Hearing evaluations $10 per office visit
Not covered:
hearing aids, testing and examinations for hearing aids
All charges. 22.
22 Page 23 24
2003 HMO Health Ohio Section 5( a) 20
Vision services (testing, treatment, and supplies) You pay
We provide the following vision care benefits when received from Cole
Network Managed Vision Providers:

One eye refraction, including lens prescription, every year.
Members must use a Cole Network Managed Vision provider.
Member is responsible for any difference in cost between an examination for glasses and an examination for contact lenses.

NOTE: For medical and surgical benefits provided for the diagnosis and
treatment of diseases of the eye, members must continue to be referred to a
HMO Health Ohio optometrist or ophthalmologist for care.

$10 per visit

Not covered:
Corrective lenses or frames
Eye exercises and orthoptics
Sunglasses

All charges.

Foot care
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe
inserts.

$10 per office visit

Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges. 23.
23 Page 24 25
2003 HMO Health Ohio Section 5( a) 21
Orthopedic and prosthetic devices You pay
Orthopedic devices, such as braces; foot orthotics
Artificial limbs and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: We pay internal prosthetic devices as
hospital benefits; see Section 5( c) for payment information. See
5( b) for coverage of the surgery to insert the device.

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing

Not covered:
arch supports
heel pads and heel cups
trusses, elastic stockings, support hose, and other supportive devices

All charges.

Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.

Note: Call us at 800/ 522-2066 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

Nothing

Not covered:
Specially designed wheel chairs for use in sporting events
All charges. 24.
24 Page 25 26
2003 HMO Health Ohio Section 5( a) 22
Home health services You pay
Home health services of nurses and health aides, including intravenous fluids and medications, when prescribed by your Plan
doctor, who will periodically review the program for continuing
appropriateness and need.

Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not Covered:
nursing care requested by, or for the convenience of, the patient or the patient's family

home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or
rehabilitative.

All charges

Chiropractic
Manipulation of the spine and extremities
Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$10 copayment

Alternative treatments
Acupuncture by a doctor of medicine or osteopathy for: anesthesia, pain relief $10 copayment

Not covered:
naturopathic services hypnotherapy

biofeedback

All charges

Educational classes and programs
Coverage is limited to:

Smoking cessation drugs and medication, including nicotine patches
Diabetes self-management

$10 per office visit 25.
25 Page 26 27
2003 HMO Health Ohio Section 5( b) 23
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
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Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Any costs associated with the facility charge (i. e. hospital, surgical center, etc.) are

covered in Section 5 (c).
Your physician must get precertification of some surgical procedures.

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Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures Treatment of fractures, including casting

Normal pre-and post-operative care by the surgeon Correction of amblyopia and strabismus
Endoscopy procedures Biopsy procedures
Removal of tumors and cysts Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over

Insertion of internal prosthetic devices. See 5( a) Orthopedic and prosthetic devices for device coverage information.

$10 per office visit; nothing for
hospital visits

Surgical procedures continued on next page. 26.
26 Page 27 28
2003 HMO Health Ohio Section 5( b) 24
Surgical procedures (Continued) You pay
Voluntary sterilization (e. g. Tubal Ligation, Vasectomy) Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per office visit; nothing for
hospital visits

Not covered:
Reversal of voluntary sterilization Surgery primarily for cosmetic purposes

Routine treatment of conditions of the foot; see Foot care.

All charges.

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance and

the condition can reasonably be expected to be corrected by such surgery
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

$10 per office visit; nothing for
hospital visits 27.
27 Page 28 29
2003 HMO Health Ohio Section 5( b) 25
Reconstructive surgery (Continued) You pay
All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

$10 per office visit; nothing for
hospital visits

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones; Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
Removal of stones from salivary ducts; Excision of leukoplakia or malignancies;

Excision of cysts and incision of abscesses when done as independent procedures; and
Other surgical procedures that do not involve the teeth or their supporting structures.

$10 per office visit

Not covered:
Oral implants and transplants Procedures that involve the teeth or their supporting structures

(such as the periodontal membrane, gingiva, and alveolar bone)
Dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges. 28.
28 Page 29 30
2003 HMO Health Ohio Section 5( b) 26
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic 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

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach, and pancreas
National Transplant Program (NTP) Ohio Department of Health and Ohio Organ Transplant Consortium

Limited Benefits Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved
by the Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.

Nothing

Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia You pay
Professional services provided in

Hospital (inpatient) Hospital outpatient department
Skilled nursing facility Ambulatory surgical center
Office

Nothing 29.
29 Page 30 31
2003 HMO Health Ohio Section 5( c) 27
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
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Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in
Sections 5( a) or (b).

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require

precertification.

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Benefit Description You pay
Inpatient hospital
Room and board, such as
Ward, semiprivate, or intensive care accommodations; General nursing care; and

Meals and special diets.

NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

Nothing

Inpatient hospital continued on next page. 30.
30 Page 31 32
2003 HMO Health Ohio Section 5( c) 28
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms Prescribed private nursing care

Prescribed drugs and medicines Diagnostic laboratory tests and X-rays
Administration of blood and blood products Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care Non-covered facilities, such as schools

Personal comfort items, such as telephone, television, barber services, guest meals and beds
Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Not covered:
Blood and blood derivatives not replaced by the member
All charges. 31.
31 Page 32 33
2003 HMO Health Ohio Section 5( c) 29
Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit:
The Plan provides a comprehensive range of benefits for up to 100 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. 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.

Nothing

Not covered:
Custodial care, rest cures, domiciliary or convalescent care
Personal comfort items, such as telephone and television

All charges

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, family counseling, and durable medical equipment; 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.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 32.
32 Page 33 34
2003 HMO Health Ohio Section 5( d) 30
Section 5 (d). Emergency services/ accidents
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Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

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What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are medical emergencies what
they all have in common is the need for quick action.

What to do in case of emergency:
If you are in an emergency situation, please call your primary care doctor. In 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.

Emergencies within our service area:
Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You
or a family member should notify the Plan within 48 hours, unless it was not reasonably possible to do so.
It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working 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.

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

Emergencies outside our service area:
Benefits are available for any medically necessary health service that is immediately required because of
injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day
following your admission, unless it was not reasonably possible to notify the Plan within that time. If a
Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically
feasible with any ambulance charges covered in full. 33.
33 Page 34 35
2003 HMO Health Ohio Section 5( d) 31
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.

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

Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit
Emergency care at an urgent care center Nothing
Emergency care as an outpatient at a hospital, including doctors' services.

Note: If the emergency results in admission to a hospital, the emergency
care copayment is waived.

$50 copayment per visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

Emergency care at a doctor's office $10 per office visit

Emergency care at an urgent care center Nothing
Emergency care as an outpatient or inpatient at a hospital, including doctors' services.

Note: If the emergency results in admission to a hospital, the emergency
care copayment is waived.

$50 copayment per visit

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges.

Ambulance
Professional ambulance service when medically appropriate.
Air ambulance when ordered or authorized by a Plan doctor
See 5( c) for non-emergency service.

Nothing 34.
34 Page 35 36
2003 HMO Health Ohio Section 5( e) 32
Section 5 (e). Mental health and substance abuse benefits
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When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefit description below.

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Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

Your cost sharing
responsibilities are no
greater than for other illness
or conditions.

Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

Medication management

$10 per visit

Mental health and substance abuse benefits -Continued on next page 35.
35 Page 36 37
2003 HMO Health Ohio Section 5( e) 33
Mental health and substance abuse benefits (Continued) You pay
Diagnostic tests Nothing

Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

Nothing

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow the following authorization process:
Call the HMO Health Ohio Behavioral Health Care Management
Department at 800/ 258-3186. It is not necessary to obtain a referral from
your primary care doctor.

Limitation We may limit your benefits if you do not obtain a treatment plan. 36.
36 Page 37 38
2003 HMO Health Ohio Section 5( f) 34
Section 5 (f). Prescription drug benefits
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Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

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There are important features you should be aware of. These include:
Who can write your prescription. A plan or referral physician must write the prescription.
Where you can obtain them. You must fill the prescription at a plan pharmacy, except for out-of-area emergencies, or by mail for a maintenance medication.

We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary. A formulary is a list of selected FDA approved, prescription medications
reviewed by an independent Pharmacy and Therapeutics Committee brought together by Medco
Health Services, Inc. These drugs are made by many different pharmaceutical manufacturers,
including Merck & Co., Inc.

Mail Order Program. To receive mail order prescription drug benefits, you mail your prescription order and the prescription drug deductible amount which is specified above to a contracting mail

order pharmacy. No benefits are payable if your prescription order is sent to a pharmacy other than
a contracting mail order pharmacy. The contracting mail order pharmacy will fill your prescription
order and send you up to a 90-day supply of the mail order prescription drug which your physician
has prescribed. The contracting mail order pharmacy will dispense the medication and mail it to you
within 72 hours. If the contracting mail order pharmacy fails to send you the mail order prescription
drug within ten days after you mailed in your prescription order, you may call the contracting mail
order pharmacy directly to determine the status of the prescription order.

These are the dispensing limitations. Prescription drugs obtained at a Plan pharmacy will be dispensed for up to a 30-day supply. You pay a $10 copayment per prescription unit or refill for

generic drugs or for name brand drugs when a generic substitution is not permissible. When a
generic substitution is permissible (i. e., 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 a $20 copayment per prescription
unit or refill. Prescription drugs obtained by using the mail order prescription drug program will be
dispensed for up to a 90-day supply. You pay a $20 copayment for all generic drugs and a $40
copayment for all name brand drugs.

Why use generic drugs? To reduce your out-of-pocket expenses! A generic drug is the chemical equivalent of a corresponding brand name drug. Generic drugs are less expensive than brand name

drugs; therefore, you may reduce your out-of-pocket costs by choosing to use a generic drug.
When you have to file a claim. You should contact Medco Health at 800/ 417-1961 for prescription drug claim forms. You should submit all claims to Medco Health , P. O. Box 709, Lee Summit, MO

64063. Normally, when you use plan pharmacies, you will not have to file claims.

Prescription drug benefits begin on the next page. 37.
37 Page 38 39
2003 HMO Health Ohio Section 5( f) 35
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

Drugs for which a prescription is required by Federal Law Insulin

Disposable needles and syringes for the administration of covered medications
Contraceptive drugs and devices Smoking cessation drugs and medication, including nicotine patches
Growth hormone
Limited benefits:
Sexual dysfunction drugs have dispensing limitations. Contact the Plan for details.

Retail Pharmacy (up to a 30-day
supply)

$10 copayment per prescription or
refill for generic drugs

$20 copayment per prescription or
refill for formulary name brand
drugs

Mail Order (up to a 90-day
supply)

$20 copayment per prescription or
refill for generic drugs

$40 copayment per prescription or
refill for formulary name brand
drugs 38.
38 Page 39 40
2003 HMO Health Ohio Section 5( f) 36
Covered medications and supplies (Continued) You pay
Things to keep in mind:
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a
name brand drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as Written
for the name brand drug, you will still have to pay the name brand
copayment.

We administer an open formulary. If your physician believes a name brand product is necessary or there is no generic available,
your physician may prescribe a name brand drug from a formulary
list. This list of name brand drugs is a preferred list of drugs that
we selected to meet patient needs at a lower cost. To order a
prescription drug brochure, call 800/ 417-1961.

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
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Diabetic supplies, except as specified, including glucose test tablets and test tape, Benedict's solution, or equivalent, and acetone test

tablets

All charges 39.
39 Page 40 41
2003 HMO Health Ohio Section 5( g) 37
Section 5 (g). Special features
Feature Description
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative
benefit.
Alternative benefits are subject to our ongoing review.
By approving an alternative benefit, we cannot guarantee you will get it in the future.

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

Congestive Heart Failure (Heart Sense) For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-877-726-2715 and talk with a cardiac nurse disease
manager who will set up a program of telephone and home visit( s) that
will help you learn more about your condition and how to manage
your symptoms.

Maternity Care (BabyLink) For any of your health concerns, 24 hours a day, 7 days a week, you may call 1-800-338-4114 and talk with a maternity care nurse who can
answer your questions and provide necessary information and
additional resources that you may need concerning maternity care,
during and after pregnancy. 40.
40 Page 41 42
2003 HMO Health Ohio Section 5( h) 38
Section 5 (h). Dental benefits
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We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient; See
Section 5 (c) for inpatient hospital benefits. We do not cover the dental procedure unless it
is described below.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T
Accidental injury benefit You pay

Restorative services and supplies necessary to promptly repair (but not
replace) sound natural teeth. The need for these services must result
from an accidental injury. These services must be initiated within 90
days from the date of the accident. We do not cover services necessary
because of injury as a result of chewing or biting.

Nothing.

Dental benefits
We have no other dental benefits. 41.
41 Page 42 43
2003 HMO Health Ohio Section 6 39
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:

Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

Services, drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or

incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
Services, drugs, or supplies you receive without charge while in active military service. 42.
42 Page 43 44
2003 HMO Health Ohio Section 7 40
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 800/ 522-2066.

When you must file a claim --such as for services you receive outside of
the Plan's service area --submit it on the HCFA-1500 or a claim form
that includes the information shown below. Bills and receipts should be
itemized and show:

Covered member's name and ID number;
Name and address physician or facility that provided the service or supply;

Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or supply;
A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and

Receipts, if you paid for your services.
Submit your claims to: HMO Health Ohio, P. O. Box 6018, Cleveland, Ohio 44101, Attn: HMO Member Services. You may also
contact us by fax at 216/ 694-2910, or visit our website
http:// www. MedMutual. com.

Prescription drugs Submit your claims to: Medco Health , P. O. Box 709, Lee Summit, MO 64063.

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative
operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 43.
43 Page 44 45
2003 HMO Health Ohio Section 8 41
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies including a request for preauthorization:

Step Description

. Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and

(b) Send your request to us at: HMO Health Ohio, P. O. Box 6018, Cleveland, Ohio 44101; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in
this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,
medical records, and explanation of benefits (EOB) forms.

. We have 30 days from the date we receive your request to:
(a) Pay the claim (or arrange for the health care provider to give you the care); or

(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your medical provider for more information. If we ask your provider, we will send you a copy of
our request go to step 3.

. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.
We will base our decision on the information we already have.

We will write to you with our decision.

. If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter upholding our initial decision; or
120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Health Benefits Contracts Division 3,
1990 E Street, NW, Washington, D. C. 20415-3630.

Send OPM the following information:
A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

Copies of all letters you sent to us about the claim;
Copies of all letters we sent to you about the claim; and
Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which
claim. 44.
44 Page 45 46
2003 HMO Health Ohio Section 8 42
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative,
such as medical providers, must include a copy of your specific written consent with the review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons
beyond your control.

. OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's 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,
drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline
that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This
information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit,
benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM
decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800/ 522-2066 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:

If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You may call OPM's Health Benefits Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 45.
45 Page 46 47
2003 HMO Health Ohio Section 9 43
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

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

What is Medicare? Medicare is a Health Insurance Program for:
People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment,

you should be able to qualify for premium-free Part A insurance. (Someone
who was a Federal employee on January 1, 1983 or since automatically
qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more information.

Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your

retirement check.
If you are eligible for Medicare, you may have choices in how you get your health
care. Medicare + Choice is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages
shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan (Original Medicare) is available everywhere in (Part A or B) the United States. It is the way everyone used to get Medicare benefits and is
the way most people get their Medicare Part A and Part B benefits now. You
may go to any doctor, specialist, or hospital that accepts Medicare. The
Original Medicare Plan pays its share and you pay your share. Some things
are not covered under Original Medicare, like prescription drugs. 46.
46 Page 47 48
2003 HMO Health Ohio Section 9 44
When you are enrolled in this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care. Your Plan
PCP must continue to authorize your care.

Claims process when you have the Original Medicare Plan You
probably will never have to file a claim form when you have both our
Plan and Medicare.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be coordinated
automatically and we will then provide secondary benefits for
covered charges. You will not need to do anything. To find out if
you need to do something to file your claims, call us at 800/ 522-
2066, or visit our website at http:// www. MedMutual. com.

We do not waive any costs if the Original Medicare Plan is your
primary payer.

(Primary payer chart begins on next page.) 47.
47 Page 48 49
2003 HMO Health Ohio Section 9 45
The following chart illustrates whether "The Original Medicare Plan" or this Plan should be the primary payer for
you according to your employment status and other factors determined by Medicare. It is critical that you tell us if
you or a covered family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer is A. When either you --or your covered spouse --are age 65 or over and

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solelybecause of a disability),

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when
a) The position is excluded from FEHB, or

b) The position is not excluded from FEHB
(Ask your employing office which of these applies to you.)

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, (for Part B
services)

(for other
services)

6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

(except for claims
related to Workers'
Compensation.)

B. When you --or a covered family member --have Medicare based on end stage renal disease (ESRD) and

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD,

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD,

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision,

C. When you or a covered family member have FEHB and
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee, or
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare. 48.
48 Page 49 50
2003 HMO Health Ohio Section 9 46
Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans provide
all the benefits that Original Medicare covers. Some cover extras, like
prescription drugs. To learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-
4227) or at www. medicare. gov.

If you enroll in a Medicare managed care plan, the following options are
available to you:

This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments, coinsurance,
or deductibles for your FEHB coverage.

This Plan and another plan's Medicare managed care plan: You
may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when
your Medicare managed care plan is primary, even out of the managed
care plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments. If you enroll in a
Medicare managed care plan, tell us. We will need to know whether you
are in the Original Medicare Plan or in a Medicare managed care plan so
we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your
FEHB coverage to enroll in a Medicare managed care plan, eliminating
your FEHB premium. (OPM does not contribute to your Medicare
managed care plan premium.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the
Medicare managed care plan's service area. 49.
49 Page 50 51
2003 HMO Health Ohio Section 9 47
If you do not enroll in If you do not have one or both Parts of Medicare, you can still be covered Medicare Part A or Part B under the FEHB Program. We will not require you to enroll in Medicare
Part B and, if you can't get premium-free Part A, we will not ask you to
enroll in it.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS
program. CHAMPVA provides health coverage to disabled Veterans and
their eligible dependents. If TRICARE or CHAMPVA and this Plan
cover you, we pay first. See your TRICARE or CHAMPVA Health
Benefits Advisor if you have questions about these programs.

Suspend FEHB coverage to enroll in TRICARE and CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in one of these programs, eliminating your FEHB
premium. (OPM does not contribute to any applicable plan premiums).
For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB program,
generally you may do so only at the next Open Season unless you
involuntarily lose coverage under the program.

Workers' Compensation We do not cover services that:
you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

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 OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in a one
of these State programs, eliminating your FEHB premium. For
information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB program,
generally you may do so only at the next Open Season unless you
involuntarily lose coverage under the State program. 50.
50 Page 51 52
2003 HMO Health Ohio Section 9 48
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for medical or hospital care for injuries for injuries or illness caused by another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 51.
51 Page 52 53
2003 HMO Health Ohio Section 10 49
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Covered services Care we provide benefits for, as described in this brochure.
Custodial Care Treatment or services that are mainly to help the patient with daily living activities. Custodial care that lasts 90 days or more is sometimes known
as Long term care.

Experimental or A drug, device or medical treatment or procedure is experimental or investigational services investigational:

If the drug or device does not have required Food and Drug Administration (FDA) approval.
If reliable evidence shows that the drug, device, medical treatment or procedure is the subject of on-going phase I, II, III clinical trials or is
under study to determine maximum tolerated does, toxicity, safety,
efficacy, or efficacy as compared with the standard means of treatment or
diagnosis.

Group Health Coverage Health care coverage that a member is eligible for because of employment by, membership in, or connection with, a particular
organization or group that provides payment for hospital, medical, or
other health care services or supplies.

Medical necessity A service, supply or Prescription Drug that is required to diagnose or treat a Condition and which HMO Health Ohio determines is:
appropriate with regard to the standards of good medical practice; not primarily for your convenience or the convenience of a Provider; and
the most appropriate supply or level of service which can be safely provided to you.

When applied to the care of an Inpatient, this means that your medical
symptoms or condition requires that the services cannot be safely or
adequately provided to you as an Outpatient. When applied to
Prescription Drugs, this means the Prescription Drug is cost effective
compared to alternative Prescription Drugs, which will produce
comparable effective clinical results.

Plan Allowance The amount a Contracting Institutional Provider or a Participating Professional Provider has agreed with HMO Health Ohio to accept as
payment in full for Covered Services.

Us/ We Us and we refer to HMO Health Ohio.
You You refers to the enrollee and each covered family member. 52.
52 Page 53 54
2003 HMO Health Ohio Section11 50
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials will tell you:

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
When the next open season for enrollment begins.
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.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue 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 that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.

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, or when your child
under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 53.
53 Page 54 55
2003 HMO Health Ohio Section 11 51
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled
for Self and Family coverage in the Federal Employees Health Benefits
(FEHB) Program, if you are an employee subject to a court or
administrative order requiring you to provide health benefits for your
child( ren).

If this law applies to you, you must enroll for Self and Family coverage
in a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have
obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows:

If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option,
If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing

office will change your enrollment to Self and Family in the same
option of the same plan; or

If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your

enrollment to Self and Family in the Blue Cross and Blue Shield
Service Benefit Plan's Basic Option.

As long as the court/ administrative order is in effect, and you have at
least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or
change to plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the
children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage,
you must continue into retirement (if eligible) and cannot make any
changes after retirement. Contact your employing office for further
information. 54.
54 Page 55 56
2003 HMO Health Ohio Section 11 52
When benefits and The benefits in this brochure are effective on January 1. If you joined this Plan premiums start during Open Season, your coverage begins on the first day of the first
pay period that starts on or after January 1. Annuitants' coverage and
premiums begin on January 1. If you joined at any other time during the
year, your employing office will tell you the effective date of coverage.

When you retire When you retire, you can usually stay in the FEHB Program. Generally, you 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 (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

Your enrollment ends, unless you cancel your enrollment, or
You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is

the case even when the court has ordered your former spouse to supply
health coverage to you. But, you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation Of
Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage choices. You can also download
the guide from OPM's website, www. opm. gov/ insure.

Temporary continuation If you leave Federal service, or if you lose coverage because you no of coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, if you are a covered dependent child and you turn 22
or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.

Enrolling in TCC 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 or from www. opm. gov/ insure.
It explains what you have to do to enroll.

Converting to You may convert to a non-FEHB 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 55.
55 Page 56 57
2003 HMO Health Ohio Section 11 53
You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. 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.

Getting a Certificate of The Health Insurance Portability and Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a Federal law that offers limited Federal protections for
health coverage availability and continuity to people who lose employer
group coverage. If you leave the FEHB Program, we will give you a
Certificate of Group Health Plan Coverage that indicates how long you
have been enrolled with us. You can use this certificate when getting
health insurance or other health care coverage. Your new plan must
reduce or eliminate waiting periods, limitations, or exclusions for health
related conditions based on the information in the certificate, as long as
you enroll within 63 days of losing your coverage under this Plan. If you
have been enrolled with us for at least 12 months, but were previously
enrolled in other FEHB plans, you may also request a certificate from
those plans.

For more information, get OPM pamphlet RI 79-27, Temporary
Continuation of Coverage (TCC) under the FEHB Program. See also the
FEHB web site (www. opm. gov/ insure/ health); refer to the "TCC and
HIPAA' frequently asked questions. These highlights HIPAA rules,
such as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health
coverage under HIPAA, and have information about Federal and State
agencies you can contract for more information. 56.
56 Page 57 58
2003 HMO Health Ohio Section 11 54
Long Term Care Insurance Is Still Available!
Open Season for Long Term Care Insurance
You can protect yourself against the high cost of long term care by applying for insurance in the Federal Long Term Care Insurance Program.
Open Season to apply for long term care insurance through LTC Partners ends on December 31, 2002. If you're a Federal employee, you and your spouse need only answer a few questions about your health
during Open Season.
If you apply during the Open Season, your premiums are based on your age as of July 1, 2002. After Open Season, your premiums are based on your age at the time LTC Partners receives your application.

FEHB Doesn't Cover It
Neither FEHB plans nor Medicare cover the cost of long term care. Also called "custodial care", long term care helps you perform the activities of daily living such as bathing or dressing yourself. It can also provide
help you may need due to a severe cognitive impairment such as Alzheimer's disease.

You Can Also Apply Later, But
Employees and their spouses can still apply for coverage after the Federal Long Term Care Insurance Program Open Season ends, but they will have to answer more health-related questions.
For annuitants and other qualified relatives, the number of health-related questions that you need to answer is the same during and after the Open Season.

You Must Act to Receive an Application
Unlike other benefit programs, YOU have to take action you won't receive an application automatically. You must request one through the toll-free number or website listed below.
Open Season ends December 31, 2002 act NOW so you won't miss the abbreviated underwriting available to employees and their spouses, and the July 1 "age freeze"!

Find Out More Contact LTC Partners by calling 1-800-LTC-FEDS (1-800-582-3337) (TDD for the hearing impaired: 1-800-843-3557) or visiting www. ltcfeds. com to get more information and to request an application. 57.
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2003 HMO Health Ohio Index 55
Index
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Accidental injury 30 Al