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JMH Health Plan

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Notice of the Office of Personnel Managements Privacy Practices
Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
- How we pay providers
- Who provides my health care
- Your Rights
- Service Area
Section 2. We are a new plan
Section 3. How you get care
- Identification cards
- Where you get covered care
  - Plan providers
  - Plan facilities
- What you must do to get covered care
- Circumstances beyond our control
- Services requiring our prior approval
Section 4. Your costs for covered services
- Copayments
- Deductible
- Coinsuance
- Your catastrophic protection out-of-pocket maximum for coinsurance and copayments
Section 5. Benefits -- OVERVIEW
- Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
- Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
- Section 5 (c). Services provided by a hospital or other facility, and ambulance services
- Section 5 (d). Emergency services/accidents
- Section 5 (e). Mental health and substance abuse benefits
- Section 5 (f). Prescription drug benefits
- Section 5 (g). Special features
- Section 5 (h). Dental benefits
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
- When you have other health coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
- No pre-existing condition limitation
- Where you can get information about enrolling in the FEHB Program
- Types of coverage available for you and your family
- Childrens Equity Act
- When benefits and premuims start
- When you retire
When you lose benefits
- When FEHB coverage ends
- Spouse equity coverage
- Temporary continuation of coverage (TCC)
- Converting to individual coverage
- Getting a Certificate of Group Health Plan Coverage
Long Term Care Insurance Is Still Available!
Index
Summary of benefits for the JMH Health Plan - 2003
2003 Rate Information for JMH Health Plan

Pages 1--60

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
2003 JMH Health Plan
JMH Health Plan
2003

Serving: Miami-Dade and Broward Counties
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:
J81 Self Only J82 Self and Family

Special notice: This Plan is offered for the first time under the Federal Employees
Health Benefits Program during the 2003 Open Season.

RI 73-818

A Health Maintenance Organization 1.
1 Page 2 3
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.
2 Page 3 4
2003 JMH Health Plan
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 out 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:
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 past 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 your 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). 3.
3 Page 4 5
2003 JMH Health Plan
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 also may 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

Index ....................................................................................................................................................................................................... 55
Summary of benefits ...................................................................................................................................................................................... 56
Rates ................................................................................................................................................................................................. Back cover 6.
6 Page 7 8
2003 JMH Health Plan 4
Introduction
This brochure describes the benefits of the JMH Health Plan under our contract (CS 2870) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. The address for the JMH Health Plan administrative offices is:

JMH Health Plan 1801 NW 9 th Avenue, Suite 700
Miami, FL 33136
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. 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" or "us" means JMH Health Plan.

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 JMH Health Plan 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/ 721-2993 and explain the situation.
If we do not resolve the issue:

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.

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 8.
8 Page 9 10
2003 JMH Health Plan 6 Section 1
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 and coinsurance 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 or coinsurance.

Who provides my health care
Each family member that is covered by the JMH Health Plan must choose a Primary Care Physician from the Provider Directory. This list includes more than 1500 doctors who specialize in Family Practice, Internal Medicine, or Pediatrics. The
Primary Care Physician you choose will coordinate your overall medical care, including arranging for hospital admissions or care by a specialist when medically necessary. The JMH Health Plan strives to keep the Provider Directory as up-to-date as
possible. However, information may change after the Directory is printed. If the physician you wish to select is no longer
accepting patients, please select another. You may want to call the physician you have chosen prior to calling the JMH Health Plan Member Service Department at 1 (800) 721-2993 with your selection.

Your Rights
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.

JMH Health Plan service area
JMH Health Plan Federal brochure
Member rights and responsibilities
Continuity of treatment
Arrange for the continuation of treatment by a provider
Assist the member in selecting a new provider
Additional Information
Provider information
Physician credentials
Physician status/ discipline
Who to contact 9.
9 Page 10 11
2003 JMH Health Plan 7 Section 1
Information Disclosure
A detailed description of the authorization and referral process for health care services
A detailed description of the process used to determine whether health care services are "medically necessary"
A description of the organization's quality assurance program
Policies and procedures relating to the organization's prescription drug benefits
Policies and procedures relating to the confidentiality and disclosure of the subscriber's medical records
Decision making process used for approving or denying experimental or investigational medical treatments
Information regarding the absence of malpractice insurance coverage
Years in existence
Profit status

If you want more information about us, call 800/ 721-2993, or write to JMH Health Plan, 1801 NW 9 th Avenue, Suite 700; Miami, FL 33136. You may also contact us by fax at 305/ 545-5212.

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: Miami-Dade and Broward Counties.

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 dependents live out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait
until Open Season to change plans. Contact your employing or retirement office. 10.
10 Page 11 12
2003 JMH Health Plan 8 Section 2
Section 2. We are a new plan
This Plan is new to the FEHB Program. We are being offered for the first time during the 2003 open season. 11.
11 Page 12 13
2003 JMH Health Plan 9 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive
services from a Plan provider, or fill 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 1-800-721-2993 or (305) 575-3700 or write to us at JMH Health Plan, 1801 NW 9 th Avenue, Suite 700, Miami, FL

33136.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments and coinsurance 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. Health care services

must be obtained through, or under the direction of your Primary Care Physician.
He or she will coordinate your health care, and when medically necessary, refer you to a specialist from our network of health care providers. Your role is to

always work with your Primary Care Physician for your health care needs.
We list Plan providers in the provider directory, which we update periodically.
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.
First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for
most of your health care. As a member, you must choose a Primary Care Physician (PCP) for yourself and your dependents, if any, on the date of
enrollment. If you do not choose a Primary Care Physician, we will assign one to
you and notify you of the assignment.

Primary care Your primary care physician can be a family practitioner, internist, general
practitioner or pediatrician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

If for any reason you become dissatisfied with your assigned primary care physician and/ or service location, you may select a new physician and/ or service
location at anytime by notifying our Member Services Department at (800) 721-
2993 or (305) 575-3700. The effective date of the change will be the first day of the following month. You must notify us before receiving covered services from a

new Primary Care Physician.

Specialty care Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the
primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary
care physician or the specialist may request authorization any follow-up care. Do

What you must do
to get covered care 12.
12 Page 13 14
2003 JMH Health Plan 10 Section 3
not go to the specialist for return visits unless your primary care physician or the specialist gives you a referral. However, you may see a chiropractor, podiatrist,
dermatologist and a gynecologist (one annual visit) without a referral.
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 or you are not
satisfied with the services you are receiving from this specialist, 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.

If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at (800) 721-2993 or (305) 575-3700. 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 13.
13 Page 14 15
2003 JMH Health Plan 11 Section 3
The 92 nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

Circumstances beyond our Under certain extraordinary circumstances, such as natural disasters, we may control 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.
Your primary care physician has authority to refer you for most services. For
certain services, however, your physician must obtain approval from us. Your physician must obtain authorization for services such as, but not limited to: follow-up

consultations by specialists, hospitalization, Growth Hormone Therapy (GHT),
Home Health Service, Durable Medical Equipment, and other comprehensive diagnostic and treatment services. 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 for precertification.

Your Primary Care Physician or specialist, to whom you have been appropriately
referred, is responsible for coordinating any necessary hospitalizations. Scheduled admissions require advance authorization from the JMH Health Plan.

Emergency admissions require notification of the JMH Health Plan within 24
hours, or as soon thereafter as possible. Authorization occurs when we approve the admission and issue a complete authorization number to the hospital. The

telephone number to call is on the back of your identification card.

Services requiring our
prior approval 14.
14 Page 15 16
2003 JMH Health Plan 12 Section 4
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: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay nothing per admission.
Deductible We have no deductible.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.
After your copayments total $1,500 per person or $3,000 per family enrollment in
any calendar year, you do not have to pay any more for covered services. When the covered person has paid copayments that total the annual maximum, no further

copayments shall be required by that covered person for the remainder of the
calendar year. The covered person is responsible for providing documentation of the amount of copayments paid.

Your catastrophic protection out-of-pocket maximum for
coinsurance and copayments 15.
15 Page 16 17
2003 JMH Health Plan 13 Section 5
Section 5. Benefits --OVERVIEW
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) 721-

2993 or (305) 575-3700.

(a) Medical services and supplies provided by physicians and other health care professionals ........................................... 14-23
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
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 ....................................... 24-27

Surgical procedures
Reconstructive surgery
Oraland maxillofacial surgery
Organ/ tissue transplants
Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services .......................................................................... 28-30

Inpatient hospital
Outpatient hospital or ambulatory surgical
center

Extended care benefits/ skilled nursing care facility benefits
Hospice care
Ambulance

(d) Emergency services/ accidents ...................................................................................................................................................... 31-32
Medical emergency Ambulance

(e) Mental health and substance abuse benefits .............................................................................................................................. 33-34
(f) Prescription drug benefits ............................................................................................................................................................. 35-37
(g) Special features .................................................................................................................................................................................... 38
High Risk Pregnancies

Centers of Excellence for Trauma/ Burns/ Transplants
(h) Dental benefits ..................................................................................................................................................................................... 39
Summary of benefits ........................................................................................................................................................................................ 56 16.
16 Page 17 18
2003 JMH Health Plan 14 Section 5( a)
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
$10 per office visit

In an urgent care center
During a hospital stay
In a skilled nursing facility
Office medical consultations
Second surgical opinion
At home

Nothing
Nothing
Nothing
$10 per office visit
$10 per office visit
$10 per office visit

Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
CAT Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing 17.
17 Page 18 19
2003 JMH Health Plan 15 Section 5( a)
Preventive care, adult You pay
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
Routine Prostate Specific Antigen (PSA ) test one annually for men
age 40 and older

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

$10 per office visit

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

Nothing

Not covered
Examinations, reports, or any other service related to requirements or documentation of health status for
employment, licenses, insurance, travel, or for educational or sports/ recreational purposes.

All charges.

Routine immunizations, limited to:
Tetanus-diphtheria (Td) booster once every 10 years, ages19 and over (except as provided for under Childhood

immunizations)
Influenza vaccine, annually
Pneumococcal vaccine, age 65 and over

$10 per office visit 18.
18 Page 19 20
2003 JMH Health Plan 16 Section 5( a)
Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics

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

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 precertify your normal delivery; see page xx for other circumstances, such as extended stays for you or your

baby.
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.
Surgical benefits, not maternity benefits, apply to circumcision.
We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

$10 per office visit

Not covered: Routine sonograms to determine fetal age, size or sex All charges. 19.
19 Page 20 21
2003 JMH Health Plan 17 Section 5( a)
Family planning You pay
A range of voluntary family planning services, limited to:
Voluntary sterilization (See Surgical procedures Section 5 (b))
Surgically implanted contraceptives (such as Norplant)
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.
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

Infertility services if one of the partners has previously
undergone surgical sterilization or if one of the partners is menopausal or post menopausal

All services related to a surrogate parenting arrangement of any
kind

Cost of donor sperm
Cost of donor egg
Fertility drugs

All charges. 20.
20 Page 21 22
2003 JMH Health Plan 18 Section 5( a)
Allergy care You pay
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 xx.
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.
Note: We will only cover GHT when we preauthorize the treatment. Call (800) 721-2993 or (305) 575-3700 for preauthorization. We will

ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date

you submit the information. If you do not ask or if we determine GHT
is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in

Section 3.

Nothing 21.
21 Page 22 23
2003 JMH Health Plan 19 Section 5( a)
Physical and occupational therapies You pay
Two consecutive months per condition per year are covered if significant improvement can be expected within the two months.
Services are covered for each of the following:
-qualified physical therapists and -occupational therapists.

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, is provided with the same limitations listed

above.

$10 per visit

Not covered:
Long-term rehabilitative therapy
Exercise programs
Massage therapy

All charges.

Speech therapy
Up to two consecutive months per calendar year, for the services of qualified speech therapists. $10 per visit

Hearing services (testing, treatment, and supplies) You pay
Hearing testing for children through age 17 (see Preventive care, children) $10 per office visit

Not covered:
All other hearing testing
Hearing aids, testing and examinations for them

All charges. 22.
22 Page 23 24
2003 JMH Health Plan 20 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
Annual eye refraction

Nothing
$10 per visit
Eye exam to determine the need for vision correction for children
through age 17 (see Preventive care, children)
$10 per office visit

Not covered:
Refractions
Eyeglasses or contact lenses and, after age 17, examinations for them

Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

Eyeglasses for ocular surgery

All charges.

Foot care You pay
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 JMH Health Plan 21 Section 5( a)
Orthopedic and prosthetic devices You pay
Artificial limbs and eyes
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Internal prosthetic devices, such as artificial joints, pacemakers,
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.

Coverage for orthotic appliances is limited to leg, arm, back, and neck custom-made braces when related to a surgical procedure or
when used in an attempt to avoid surgery and are necessary to
carry out normal activities of daily living, excluding sports activities.

Nothing

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Splints for carpal tunnel syndrome
Prosthetic replacements unless the Plan or your Plan physician determines it is necessary because of growth or change.

All charges. 24.
24 Page 25 26
2003 JMH Health Plan 22 Section 5( a)
Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of medically necessary durable medical equipment prescribed by your Plan

physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

standard wheelchairs;
crutches;
walkers;
nebulizers, and
breast pumps
insulin pumps

Coverage for durable medical equipment not listed above is limited to $500 per member per calendar year.

Note: Blood glucose monitoring machines are covered under our prescription drug benefit.

$25 per episode of illness for listed durable medical equipment items.
$25 per episode of illness up to our maximum Plan benefit for durable
equipment not listed.

Not covered:
Motorized wheel chairs

Custom wheel chairs
Modifications to motor vehicles or homes such as wheelchair lifts or ramps

Water therapy devices such as jacuzzis, hot tubs or whirlpools and
exercise equipment

Any equipment that is not deemed medically necessary or is an upgrade to accepted standards

Any repairs or adjustments on equipment that is purchased for you

All charges.

Home health services You pay
Home health care ordered by a Plan physician and provided by a
registered nurse (R. N.), licensed practical nurse (L. P. N.), or home health aide.

Services include oxygen therapy, intravenous therapy and medications.

Nothing 25.
25 Page 26 27
2003 JMH Health Plan 23 Section 5( a)
Home health services (continued) You pay
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.
Personal comfort or convenience items such as television and telephone services

Private duty nursing

All charges.

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

$10 per office visit

Alternative treatments You pay
No benefits All charges

Educational classes and programs You pay
Coverage is limited to:

Smoking Cessation Up to $100 for one smoking cessation program per member per lifetime, including all related expenses
such as drugs.
Diabetes self-management

$10 per office visit up to our benefit maximum.
$10 per office visit 26.
26 Page 27 28
2003 JMH Health Plan 24 Section 5( b)
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. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical

center, etc.).
YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require

precertification and identify which surgeries require precertification.

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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. Surgery for morbid obesity should be performed only as a last resort, when the member's

health is endangered and more conservative medical measures,
including prescription drugs such as appetite suppressants, have not been successful.

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

Note: The internal prosthetic device must be medically necessary to restore bodily function and require a surgical incision (as opposed to

an external prosthetic device). Examples: artificial knuckles and joints, pacemakers, defibrillator, penile implants, breast implants and
artificial eyes.

$10 per office visit

Surgical procedures continued on next page. 27.
27 Page 28 29
2003 JMH Health Plan 25 Section 5( b)
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

Not covered:
Reversal of voluntary sterilization
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.

Nothing

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.

Nothing

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.

Surgical procedures continued on next page. 28.
28 Page 29 30
2003 JMH Health Plan 26 Section 5( b)
Oral and maxillofacial surgery You pay
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.

Nothing

Not covered:
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges.

Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
Allogeneic (donor) bone marrow transplants
Autologous bone marrow transplants (autologous stem cell and
peripheral stem cell support) for the following conditions: acute
lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial
ovarian cancer; and testicular, mediastinal, retroperitoneal and
ovarian germ cell tumors
Intestinal transplants (small intestine) and the small intestine with
the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas

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 29.
29 Page 30 31
2003 JMH Health Plan 27 Section 5( b)
Organ/ tissue transplants (continued) You pay
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Medical expenses incurred by a non-member who donates an
organ or tissue to a Member will only be covered if the non-member does not have coverage for these services

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
Nothing 30.
30 Page 31 32
2003 JMH Health Plan 28 Section 5( c)
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.

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 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

Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
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
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home.

Nothing

Not covered:
Custodial or domiciliary care, basic care or housekeeping
Non-covered facilities, such as nursing homes, schools
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care
Services or products provided by Convalescent Homes, Homes for the Aged, or Adult Foster Care Facilities

Blood and blood derivatives not replaced by member

All charges. 31.
31 Page 32 33
2003 JMH Health Plan 29 Section 5( c)
Outpatient hospital or ambulatory surgical center You pay
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:
Custodial or domiciliary care, basic care or housekeeping
Personal comfort items, such as telephone, television, barber
services, guest meals and beds
Private nursing care
Blood and blood derivatives not replaced by member

All charges.

Extended care benefits/ skilled nursing care facility benefits You pay
Extended care benefit: We provide a comprehensive range of benefits for
up to 60 post-hospital 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

All charges. 32.
32 Page 33 34
2003 JMH Health Plan 30 Section 5( c)
Hospice care You pay
We provide supportive and palliative care for a terminally ill member in the home or hospice facility. Services included:
Inpatient and outpatient care;
Family counseling

These services are provided under the direction of a Plan doctor who
certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Nothing

Not covered:
Custodial or domiciliary care, basic care or housekeeping
Independent nursing, homemaker services
Personal comfort items, such as telephone, television, barber services, guest meals and beds

Private nursing care
Skilled nursing services provided on a twenty-four (24) hour basis in the home

All charges.

Ambulance
Local professional ambulance service when medically appropriate Nothing 33.
33 Page 34 35
2003 JMH Health Plan 31 Section 5( d)
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.
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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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:
The procedure the covered person should follow for emergency care, as defined in this section, depends on whether the
treatment is rendered inside or outside the service area.

Emergencies within our service area: You are covered for treatment when a true emergency exists. If you are in doubt of the seriousness of the medical condition and have time to call your Primary Care Physician, you should do so.
If your physician feels that the problem requires immediate attention, he or she will direct your treatment. Please note: Emergency health services rendered by a non-participating provider within our service area are covered. Also service
will be covered if they are rendered by a non-participating provider because an emergency prevents you from receiving services from a participating provider.

Emergencies outside our service area: In case of an emergency when you are out of the Plan's service area, we provide coverage for necessary emergency care. If your problem is too serious, and prevents you from returning to the
service area, you may go to the closest urgent or emergency care facility. Emergency admissions require notification of
the JMH Health Plan within 24 hours, or as soon thereafter as possible. You may call the JMH Health Plan 24 hours a day at the number on the back of your JMH Health Plan identification card. Please call the Plan within 24 hours if it is

reasonable to do so after an emergency in order to confirm coverage, ensure proper follow-up care and assure payment for
covered services.

Note: We reserve the right not to pay for non-emergency treatment received at emergency facilities. If you are
hospitalized at an out-of-network hospital, you may be transferred to an in-network hospital as soon as it is medically appropriate in the opinion of the attending physician. Should you, or your designee, refuse a transfer to an in-network

hospital, continued care provided to you at an out-of-network shall not constitute covered services and shall no longer be
the financial responsibility of Us. Follow-up visits shall be provided by participating providers, your Primary Care Physician will coordinate your follow-up care. 34.
34 Page 35 36
2003 JMH Health Plan 32 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital,
including doctors' services

$10.00 per office visit
$25.00 per visit
$50.00 per visit (waived if admitted)

Not covered:
Elective care or non-emergency care
All charges.

Emergency outside our service area
Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctors' services

$10.00 per office visit
$25.00 per visit
$50.00 per visit (waived if admitted)

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.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance All charges. 35.
35 Page 36 37
2003 JMH Health Plan 33 Section 5( e)
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:
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.
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.

YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the
instructions after the benefits description below.

I M
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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 office visit

Diagnostic tests Nothing
Services provided by a hospital or other facility
Services in approved alternative care settings such as partial
hospitalization, full-day hospitalization, facility based intensive
outpatient treatment

Nothing 36.
36 Page 37 38
2003 JMH Health Plan 34 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
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 all the following authorization processes:
You must call University Behavioral Health (UBH) at (800) 294-8642. You do not need a referral from your primary care physician or approval from us. UBH
is a managed behavioral health care firm with over 500 providers in our service
area. A UBH provider will evaluate you and develop a treatment plan. Once the treatment plan has been approved, you must follow it. If you need inpatient care,

your UBH provider will arrange it for you. Call UBH for the participating
providers in your area.

Limitation We may limit your benefits if you do not obtain a treatment plan. 37.
37 Page 38 39
2003 JMH Health Plan 35 Section 5( f)
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.

I M
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There are important features you should be aware of. These include:
Who can write your prescription. A plan physician or licensed dentist authorized to prescribe drugs within the scope of his or her license must write the prescription.

Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail for a
maintenance medication..

We have an open formulary. The prescription drug co-payments for generic and brand name, are shown below. To order a prescription drug brochure, call 1-888-243-6250.

These are the dispensing limitations. 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 have to pay the difference in cost between the
name brand drug and the generic in addition to the higher preferred and non-preferred brand name co-payment. If the prescribing physician or other participating provider authorized to

prescribe drugs within the scope of his or her license indicates on the prescription "brand name
medically necessary" or "dispense as written" for a drug for which there is a generic equivalent, or if a brand name drug is prescribed and there is no generic equivalent, the brand name drug

shall be dispensed for the brand name co-payment only. Retail pharmacy is limited up to 30
days per prescription. Maintenance drugs may be filled up to a 90 day supply for three times the co-payment and mail order drugs may be supplied in the same manner for two times the co-payment.

Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-name drugs. They must contain the same active ingredients and must be
equivalent in strength and dosage to the original brand-name product. Generics cost less than the
equivalent brand-name product. The U. S. Food and Drug Administration sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-name

drugs.

You can save money by using generic drugs. However, you and your physician have the option to request a name-brand if a generic option is available. Using the most cost-effective medication
saves money. 38.
38 Page 39 40
2003 JMH Health Plan 36 Section 5( f)
When you have to file a claim. Our members may occasionally receive bills for health care services. This may occur for a number of reasons, such as computer errors or out-of-area
emergency treatment. If you receive a bill or statement, or are requesting reimbursement, mail
the bills to us within 90 days of the date of service. Please be sure that the bill contains the following information.

Patient name
Subscriber number and the patients two-digit relationship code as shown on your identification card

Amount billed
Amount paid
Description of service and procedure codes
Diagnosis and diagnosis codes
Location of service
Date of Service
Address the envelop as follows:
JMH Health Plan Attention: Claims Department

1801 NW 9 th Avenue, Suite 700
Miami, FL 33136

If you need further assistance, or have questions, pleas call our Member Services Department at
(800) 721-2993. 39.
39 Page 40 41
2003 JMH Health Plan 37 Section 5( f)
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 and medicines that by Federal law of the United States require a physician's prescription for their purchase, except those
listed as Not covered.
Insulin and FDA approved glucose strips and tablets, and chemstrip test tapes

Disposable needles and syringes for the administration of covered medications
Blood glucose monitoring machines
Drugs for sexual dysfunction
Oral contraceptive drugs (contraceptive devices and diaphragms are covered under Medical Services, see section 5 ( a ) ).

Growth hormone

Retail Pharmacy
$5 per generic
50% of cost per brand name up to a maximum payment of $100.

Mail Order ( Up to 90-day supply)
$10 per generic
50% of cost per brand name up to a maximum payment of $100.

Note: If there is no generic equivalent available, you will still have to pay the
brand name copay.

Not covered:
Drugs and supplies for cosmetic purposes
Drugs to enhance athletic performance
Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

Vitamins, nutrients and food supplements even if a physician prescribes or administers them
Nonprescription medicines
Any portion of a prescription or refill that exceeds 30 days unless specified above

Prescription refills in excess of the number specified by the
physician or dispensed more than one year from the date of the original order of the physician or other participating provider

authorized to prescribe drugs within the scope of his or her license.

Fertility drugs

All charges. 40.
40 Page 41 42
2003 JMH Health Plan 38 Section 5( g)
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.

High risk pregnancies A case manager is assigned upon notification of a high risk pregnancy. The physician, member, and case manger develop a treatment plan specific
to the member's medical needs.

Centers of excellence for Trauma Facilities, Burn
Center, and Transplant Services

The following is a Center of excellence available when appropriately
referred:

University of Miami/ Jackson Memorial Medical Center, Miami, FL 41.
41 Page 42 43
2003 JMH Health Plan 39 Section 5( h)
Section 5 (h). Dental benefits
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 dentists must provide or arrange your care.
We have no calendar year deductible.
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
We cover restorative services and supplies for the treatment of non-dental injury to sound natural teeth. The need for these services must

result from an accidental injury.
Nothing

Dental benefits
We have no other dental benefits. 42.
42 Page 43 44
2003 JMH Health Plan 40 Section 6
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, disease,
injury, 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;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; or
Services, drugs, or supplies you receive without charge while in active military service.
. 43.
43 Page 44 45
2003 JMH Health Plan 41 Section 7
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, coinsurance, or deductible.

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, hospital and In most cases, providers and facilities file claims for you. Physicians must file on drug benefits 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) 731-2993 or (305) 575-3700.
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 of the 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: JMH Health Plan
Attention: Claims Department 1801 NW 9 th Avenue, Suite 700
Miami, FL 33136

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. 44.
44 Page 45 46
2003 JMH Health Plan 42 Section 8
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
1 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: JMH Health Plan, Attention: Claims Department, 1801 NW 9 th Avenue, Suite 700
Miami, FL 33136; 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.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, 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
Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request go
to step 3.

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.

4 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, 1900 E Street, NW, Washington, DC 20415-3630. 45.
45 Page 46 47
2003 JMH Health Plan 43 Section 8
The Disputed Claims process (Continued)
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.

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.

5 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 (305) 575-3700 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 contact OPM's Health Benefits Contracts Division 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 46.
46 Page 47 48
2003 JMH Health Plan 44 Section 9
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.
When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay
more than our allowance. The same limitations in regards to the number of visits allowed
apply when we are secondary.

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 (Original Medicare) is available everywhere in 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.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be
authorized by your Plan PCP, or precertified as required.

The Original Medicare Plan
(Part A or Part B) 47.
47 Page 48 49
2003 JMH Health Plan 45 Section 9
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 the Original Medicare Plan.
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 claim, call us at (800) 721-
2993 or (305) 575-3700.

If your Plan physician does not participate in Medicare , you will have to file a claim
with Medicare.

We do not waive any costs if the Original Medicare Plan is your primary payer.
(Primary payer chart begins on next page.) 48.
48 Page 49 50
2003 JMH Health Plan 46 Section 9
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. {bold face}
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 anactiveemployeewith theFederalgovernment(including whenyouora family member are eligible for Medicare solely becauseofadisability),

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 49.
49 Page 50 51
2003 JMH Health Plan 47 Section 9
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 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 Medicare managed care plan's network (if you use our Plan providers), but we
will not waive any of our copayments or coinsurance. You must use our Plan providers
and also follow our rules in order for us to cover your care. 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.

If you do not have one or both Parts of Medicare, you can still be covered 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.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in a 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.

If you do not enroll in
Medicare Part A or Part B 50.
50 Page 51 52
2003 JMH Health Plan 48 Section 9
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.

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 JMH Health Plan 49 Section 10
Section 10. Definitions of terms we use in this brochure
Accident Accidental bodily injury sustained by you and resulting in medical expenses
Accidental Dental Injury An injury to your mouth or parts within the mouth including teeth caused by a sudden unintentional or unexpected event.

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.
Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page xx.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial Care is care which shall not require skilled nursing care or rehabilitation services and is designed solely to assist you with the activities of
daily living, such as: help in walking, getting in and out of bed, bathing, dressing, eating, and taking medicine. Custodial care that lasts 90 days or more
is sometimes known as Long term care.

Dental Care Services or procedures which concern maintenance or repair of the teeth an/ or gums or are performed to prepare the mouth for dentures.

Durable Medical Equipment Equipment of the type approved by the Plan which is able to withstand repeated use, is primarily and customarily used to serve a medical purpose, and is not
generally useful to a person in the absence of illness or injury.