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JMH Health Plan

Federal Employees Health Benefits Program
2004 Plan Brochure
Accessible Version

Document Outline

Table of Contents
Introduction
Plain Language
Stop Health Care Fraud!
Preventing Medical Mistakes
Section 1. Facts about this HMO plan
- How we pay providers
- Who provides my health care
- Your Rights
- Service Area
Section 2. How we change for 2004
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
- · Coinsurance
- Your catastrophic protection out-of-pocket maximum
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
  - Flexible Benefits Option
  - Centers of Excellence/High Risk Pregnancies
- 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
- Coverage information
- When you lose benefits
Two new Federal Programs complement FEHB benefits
- The Federal Flexible Spending Account Program - FSAFEDS
- The Federal Long Term Care Insurance Program
Index
Summary of benefits for the JMH Health Plan - 2004
2004 Rate Information

Pages 1--64 from JMH HEALTH PLAN

Page 1 2

2004 JMH Health Plan
JMH Health Plan http:// www. jmhhp. com
2004

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

RI 73-818

A Health Maintenance Organization
For changes in
benefits see
page 9. 1.
1 Page 2 3

2004 JMH Health Plan
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits (FEHB) Program plan brochure. The brochure describes the benefits this plan offers you for 2004. Because benefits vary from year to year, you should review your plan's brochure every Open
Season – especially Section 2, which explains how the plan changed.
It takes a lot of information to help a consumer make wise healthcare decisions. The information in this brochure, our FEHB Guide, and our web-based resources, make it easier than ever to get information about plans, to compare benefits and to read customer
service satisfaction ratings for the national and local plans that may be of interest. Just click on www. opm. gov/ insure!
The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector competition
to keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in 1960, is sound and has stood the test of time. It enjoys one of the highest levels of customer satisfaction of any healthcare program in the country.

I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health benefits. We demand cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies and departments to pay the
full FEHB health benefit premium for their employees called to active duty in the Reserve and National Guard so they can continue
FEHB coverage for themselves and their families. Our carriers have also responded to my request to help our members to be prepared by making additional supplies of medications available for emergencies as well as call-up situations and you can help by

getting an Emergency Preparedness Guide at www. opm. gov. OPM's HealthierFeds campaign is another way the carriers are
working with us to ensure Federal employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain healthcare costs and keep premiums down by living a healthy life style.

Open Season is your opportunity to review your choices and to become an educated consumer to meet your healthcare needs. Use this brochure, the FEHB Guide, and the web resources to make your choice an informed one. Finally, if you know someone
interested in Federal employment, refer them to www. usajobs. opm. gov.
Sincerely,

Kay Coles James
Director 2.
2 Page 3 4
2004 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 United States 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 health care 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
2004 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 Compla ints
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. 4.
4 Page 5 6

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, 2004, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004 and changes are summarized on page 9. 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 United
States 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 United States Office of Personnel Management, Insurance Services Program, Program Planning & Evaluation Group, 1900
E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2004 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 your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage.

· 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 20415-1100 8.
8 Page 9 10

2004 JMH Health Plan 6
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death is the most tragic outcome,
medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can improve the safety of your own
health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
· Ask questions and make sure you understand the answers.
· Choose a doctor with whom you feel comfortable talking.
· Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take.

· Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines.
· Tell them about any drug allergies you have.
· Ask about side effects and what to avoid while taking the medicine.
· Read the label when you get your medicine, including all warnings.
· Make sure your medicine is what the doctor ordered and know how to use it.
· Ask the pharmacist about your medicine if it looks different than you expected. 3. Get the results of any test or procedure.

· Ask when and how you will get the results of test or procedures.
· Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
· Call your doctor and ask for your results.
· Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
· Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.

· Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery.
· Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
· Ask your doctor, "Who will manage my care when I am in the hospital?"
· Ask your surgeon: Exactly what will you be doing?

About how long will it take?
What will happen after surgery? How can I expect to feel during recovery?

· Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications
you are taking.

Want more information on patient safety?
Ø www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality healthcare providers

and improve the quality of care you receive.
Ø www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare for you and your family.

Ø www. talkaboutrx. org/ consumer. html . The National Council on Patient Information and Education is dedicated to
improving communication about the safe, appropriate use of medicines. Ø www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.

Ø www. ahqa. org. The American Health Quality Association represents organizations and healthcare professionals
working to improve patient safety. Ø www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help prevent

mistakes in the nation's healthcare delivery system. 9.
9 Page 10 11
2004 JMH Health Plan 7 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 provi der 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 mu st 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 10.
10 Page 11 12

2004 JMH Health Plan 8 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 or access our website at http:// www. jmhhp. com.

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. 11.
11 Page 12 13
2004 JMH Health Plan 9 Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also,
we edited and clarified language throughout this brochure; any language change not shown here is a clarification that does not change benefits.

Program-wide changes
· We added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible Spending Account Program -FSAFEDS and the Federal Long Term Care Insurance Program. See page 55.
· We added information regarding Preventing medical mistakes. See page 6.
· We added information regarding enrolling in Medicare. See page 45
· We revised the Medicare Primary Payer Chart. See page 47.

Changes to this Plan
Your share of the non-Postal premium will increase by 36.9% for Self Only and 37.7% for Self and Family. 12.
12 Page 13 14
2004 JMH Health Plan 10 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 13.
13 Page 14 15
2004 JMH Health Plan 11 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 14.
14 Page 15 16
2004 JMH Health Plan 12 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. . If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member's benefits under the new plan begin on the effective date
of enrollment.

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 15.
15 Page 16 17
2004 JMH Health Plan 13 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 16.
16 Page 17 18
2004 JMH Health Plan 14 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 ........................................... 15-24
·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 ....................................... 25-28

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

(c) Services provided by a hospital or other facility, and ambulance services........................................................................... 29-31
·Inpatient hospital
·Outpatient hospital or ambulatory surgical center
·Extended care benefits/ skilled nursing care facility benefits

·Hospice care
·Ambulance

(d) Emergency services/ accidents ...................................................................................................................................................... 32-33
·Medical emergency ·Ambulance
(e) Mental health and substance abuse benefits............................................................................................................................... 34-35
(f) Prescription drug benefits.............................................................................................................................................................. 36-38
(g) Special features .................................................................................................................................................................................... 39
·Flexible Benefits Option
·High Risk Pregnancies
·Centers of Excellence for Trauma/ Burns/ Transplants

(h) Dental benefits ...................................................................................................................................................................................... 40
Summary of benefits ....................................................................................................................................................................................... 60 17.
17 Page 18 19
2004 JMH Health Plan 15 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
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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.
· 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.

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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 18.
18 Page 19 20
2004 JMH Health Plan 16 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 19.
19 Page 20 21
2004 JMH Health Plan 17 Section 5( a)
Preventive care, children You pay
· Childhood immunizations recommended by the American Academy of Pediatrics

· Examinations done on the day of immunizations (through age
22)

· 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

$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 12
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 circumcis ion.

· 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. 20.
20 Page 21 22
2004 JMH Health Plan 18 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. 21.
21 Page 22 23
2004 JMH Health Plan 19 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 27.

· 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 22.
22 Page 23 24
2004 JMH Health Plan 20 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 You pay
· 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. 23.
23 Page 24 25
2004 JMH Health Plan 21 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:
· 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. 24.
24 Page 25 26
2004 JMH Health Plan 22 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 artificia l 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. 25.
25 Page 26 27
2004 JMH Health Plan 23 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

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

$25 per episode of illness for listed durable medical equipment items.
.
Coverage for durable medical equipment not listed above is limited to $500 per member per calendar year. $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 26.
26 Page 27 28
2004 JMH Health Plan 24 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 You pay
· 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 27.
27 Page 28 29
2004 JMH Health Plan 25 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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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. 28.
28 Page 29 30
2004 JMH Health Plan 26 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 You pay
· 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 s uch 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;
-breas t 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. 29.
29 Page 30 31
2004 JMH Health Plan 27 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 30.
30 Page 31 32
2004 JMH Health Plan 28 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 31.
31 Page 32 33
2004 JMH Health Plan 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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T

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.

I M
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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. 32.
32 Page 33 34
2004 JMH Health Plan 30 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

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. 33.
33 Page 34 35
2004 JMH Health Plan 31 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 You pay
· Local professional ambulance service when medically appropriate Nothing 34.
34 Page 35 36
2004 JMH Health Plan 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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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.

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. 35.
35 Page 36 37
2004 JMH Health Plan 33 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. 36.
36 Page 37 38
2004 JMH Health Plan 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

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
P O
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A N
T

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 37.
37 Page 38 39
2004 JMH Health Plan 35 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. 38.
38 Page 39 40
2004 JMH Health Plan 36 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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A N
T

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.

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 when available. If you (or your physician) request a brand name product when a generic is available, you will pay the
cost difference between the generic and brand name product in addition to the applicable brand co-payment. Retail pharmacy prescriptions are limited to 30 days per prescription. Mail order
prescriptions are a benefit option for defined maintenance medications as needed for chronic or long term health conditions. It is best to get an initial prescription filled at your retail pharmacy and then
ask your physician for an additional prescription for a 90 day supply of your medication to be
ordered through the mail order pharmacy. You pay two times the co-payment for generic drugs or 50% of the cost per brand name up to a maximum of $200 plus the cost difference if you or your

doctor requests a brand name when a generic equivalent is available.
Members called to active military duty in a time of national or other emergency who need to obtain a greater-than-normal supply of prescribed medications should call our Member Services
Department at (305) 575-3640.
· 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. 39.
39 Page 40 41
2004 JMH Health Plan 37 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. 40.
40 Page 41 42
2004 JMH Health Plan 38 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 $200.

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. 41.
41 Page 42 43
2004 JMH Health Plan 39 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 42.
42 Page 43 44
2004 JMH Health Plan 40 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 subje ct 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 b elow.

· 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. 43.
43 Page 44 45
2004 JMH Health Plan 41 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.
. 44.
44 Page 45 46
2004 JMH Health Plan 42 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 pharma cies,
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. 45.
45 Page 46 47
2004 JMH Health Plan 43 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: United States Office of Personnel Management, Insurance Services Program, Health Insurance Group 3, 1900 E Street, NW, Washington, DC 20415-3630. 46.
46 Page 47 48
2004 JMH Health Plan 44 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 initia l 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 denia l, we will inform OPM so that they can give your claim expedited treatment too, or

· You may contact OPM's Health Insurance Group 3 at 202/ 606 -0737 between 8 a. m. and 5 p. m. eastern time. 47.
47 Page 48 49
2004 JMH Health Plan 45 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.

· Should I enroll in Medicare The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It's easy. Just call the Social Security
Administration toll-free number 1-800-772-1213 to set up an appointment to apply. If you do not apply for one or both Parts of Medicare, you can still be covered under the FEHB
Program.
If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you
don't have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the
information and decide if it makes sense for you to buy the Medicare Part B coverage. 48.
48 Page 49 50
2004 JMH Health Plan 46 Section 9
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,
specialis t, 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.

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 cla im, 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.)

·The Original Medicare Plan
(Part A or Part B) 49.
49 Page 50 51
2004 JMH Health Plan 47 Section 9
Medicare always makes the final determination as to whether they are the primary payer. The following chart illustrates whether Medicare 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 correctlyPrimary Payer Chart

The primary payer for the individual with Medicareis… A. When you -or your covered spouse -are age 65 or over and have Medicare and you…
Medicare This Plan
1) Are an active employee with the Federal government and…
· You have FEHB coverage on your own or through your spouse who is also an active employee ü

· You have FEHB coverage through your spouse who is an annuitant ü
2) Are an annuitant and…
· You have FEHB coverage on your own or through your spouse who is also an annuitant ü
· You have FEHB coverage through your spouse who is an active employee ü

3) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the