Government Employees Hospital Association Inc
Benefit Plan 2000
A Managed FeeforService Plan
with Preferred Provider Organizations
and a Point of Service product
changes For
benefits in
see pages 7
6 and
Sponsored by Government Employees Hospital Association Inc
Who may enroll in this Plan All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program may become members of GEHA You must be or must become a member
of Government Employees Hospital Association Inc
To become a member You join simply by signing a completed Standard Form 2809 Health Benefits Registration Form evidencing your enrollment in the Plan
Membership dues There are no membership dues for the Year 2000
Enrollment code for this Plan
311 Self Only
312 Self and Family
Visit the OPM website at httpwwwopmgovinsure
and
this Plans website at httpwwwgehacom
Authorized for distribution by the
GEHA Health Plan 2000
Table of Contents
Introduction
3
Plain language
3
How to use this brochure
4
Section 1 FeeForService Plans
56
Section 2 How we change for 2000
67
Section 3 How to get benefits
711
Section 4 What if we deny your claim or request for preauthorization
1113
Section 5 Benefits 1330
Section 6 How to file a claim
3132
Section 7 General exclusions Things we dont cover
3233
Section 8 Limitations Rules that affect your benefits
3338
Section 9 FeeforService Facts 3943
Section 10 FEHB facts
4446
Department of DefenseFEHB Demonstration Project
4748
Inspector General Advisory Stop Health Care Fraud
48
Index
49
Summary of Benefits
5051
Premiums
Back cover
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GEHA Health Plan 2000
Introduction
Government Employees Hospital Association Inc PO Box 4665
Independence Missouri 640514665
This brochure describes the benefits you can receive from the GEHA Benefit Plan under its contract CS1063 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law
This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits
described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these
benefits Nothing anyone says can modify or otherwise affect the benefits limitations and exclusions of this brochure
Because OPM negotiates benefits and premiums annually they change each year This brochure describes the only benefits available
to you under this Plan in 2000 Benefit changes are effective January 1 2000 and are shown on pages 6 and 7 You do not have a
right to benefits that were available before January 1 2000 unless those benefits are also contained in this brochure Premiums are
listed at the end of this brochure
Plain language
The President and Vice President are making the Governments communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences
We refer to Government Employees Hospital Association Inc as this Plan throughout this brochure even though in other legal
documents you will see a plan referred to as a carrier
Sections one two four and ten are now in plain language as well as portions of sections three and eight We will rewrite the
remaining sections of this brochure including the benefits section for year 2001 Please note that the format and organization of this
brochure have changed as well
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable
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GEHA Health Plan 2000
How to use this brochure
This brochure has ten sections Each section has important information you should read If you want to compare this Plans benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 FeeforService Plan FFS This Plan is a FFS Plan Turn to this section for a brief description of FeeforService plans and how
they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get benefits and how we operate
4 What if we deny your claim or request for preauthorization This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about nonFEHB benefits
6 How to file a claim Look here to find specific information on how to file claims with us
7 General exclusions Things we dont cover Look here to see benefits that we will not provide
8 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
9 FeeforService Facts This section contains information about precertification protection against catastrophic expenses and a
definition section
10 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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GEHA Health Plan 2000
Section 1 FeeforService Plans
Feeforservice plans reimburse you or your provider for covered services They do not typically provide or arrange for health care
Feeforservice plans let you choose your own physicians hospitals and other health care providers
The FFS plan reimburses you for your health care expenses usually on a percentage basis These percentages as well as
deductibles methods for applying deductibles to families and the percentage of coinsurance you must pay vary by plan The type
and extent of covered services varies by plan There is a detailed explanation of the benefits we offer in this brochure you should
read it carefully
This FFS plan offers a preferred provider organization PPO arrangement This arrangement with health care providers gives you
enhanced benefits or limits your outofpocket expenses
Benefits under this Plan are available from facilities such as hospitals and from providers such as pharmacies doctors and other
health care personnel who provide covered services This Plan covers two types of facilities and providers 1 those who participate
in a preferred provider organization PPO and 2 those who do not Who these health care providers are and how benefits are paid
for their services are explained below In general it works like this
PPO facilities and providers have agreed to provide most services to Plan members at a lower cost than youd usually pay a nonPPO
provider Although PPOs are not available in all locations or for all services when you use these providers you help contain health
care costs and reduce what you pay out of pocket The selection of PPO providers is solely the Carriers responsibility continued
participation of any specific provider cannot be guaranteed While PPO providers agree with the Carrier to provide covered services
final decisions about health care are the sole responsibility of the doctor and patient and are independent of the terms of the
insurance contract
PPO benefits apply only when you use a PPO provider Provider networks may be more extensive in some areas than others The
availability of every specialty in all areas cannot be guaranteed If no PPO provider is available or you do not use a PPO provider the
standard nonPPO benefits apply
When you use a PPO hospital keep in mind that the professionals who provide services to you in the hospital such as radiologists
anesthesiologists and pathologists may not all be preferred providers If they are not they will be paid by this Plan as nonPPO
providers
NonPPO facilities and providers do not have special agreements with the Carrier The Plan makes its regular payments toward their
bills and youre responsible for any balance
This Plans PPO The Plan has entered into arrangements with Alliance PPO Inc Benefit Source Inc Community Care Network Inc Private Healthcare Systems PPO Oklahoma PPO USA SouthCare and United Payors
United Providers Inc UPUP which are Preferred Providers or networks of hospitals andor doctors
in all states The doctors and hospitals participating in these networks have agreed to provide
services to Plan members You always have the right to choose a PPO provider or a nonPPO provider
for medical treatment
When a PPO hospital is utilized for Inpatient Medical or Surgical services the Plan prorates the
discount between room and board charges and the other hospital charges The discounted room and
board charges will then be paid at 100 and the discounted other hospital charges will be paid at
90 Although mental conditions and substance abuse confinement will continue to be paid at
50 members may receive a benefit from lower negotiated fees for covered services received from a
PPO provider Precertification of all hospital admissions is still required as outlined on pages 13 and 39
of this brochure
When a PPO participating doctor is used the Plan will increase its payment to 90 for those services
normally paid at 75 If a nonPPO provider is utilized the Plan will pay benefits as shown in this
brochure
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GEHA Health Plan 2000
Section 1 FeeforService Plans continued
PPO networks are now available in many metropolitan areas and additional coverage areas will be
added throughout the year Enrollees residing in a PPO network area will receive a directory of the PPO
providers in their service area These providers are required to meet licensure and certification
standards established by State and Federal authorities however inclusion in the network does not
represent a guarantee of professional performance nor does it constitute medical advice To locate a
participating provider in your area call 8002960776 or visit the GEHA web site at wwwgehacom
When you phone for an appointment please remember to verify that the physician is still a PPO
provider
Section 2 How we change for 2000
Programwide changes This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your provider is leaving our PPO network at our request without cause we will notify you
You may continue to receive our PPO level benefits for your specialists services for up to 90 days
after you receive notice We will provide regular nonPPO benefits for the specialists services
after the 90 day period expires
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your
record you may add a brief statement to it If they do not provide you your records call us and
we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Plan Your share of the premium will increase by 261 for Self Only or 266 for Self and Family
The copayment for doctors office visits has increased to 15 Previously the copayment was 10
Services rendered by the doctor in conjunction with an office visit such as diagnostic Xrays and laboratory tests will be subject to the calendar year deductible and paid at 90 if the provider is in
the PPO network Previously these charges were paid at 100 after the office visit copayment
The coinsurance for nonPPO providers will be 75 Previously the coinsurance for nonPPO providers was 80
The calendar year deductible will be 300 Previously the calendar year deductible was 250
The family limit on deductibles will be 600 Previously the family limit on deductibles was 500
The copayments at Mail Order for nonMedicare members including members with Part A or Part B only will be 10 for generic drugs and 30 for brand name drugs Previously the copayments at
Mail Order were 7 for generic drugs and 28 for brand name drugs
Members with Medicare Part A B primary will now have a copayment for drugs at Mail Order and Retail At Mail Order the copayment for members with Medicare A B is 5 for generic drugs
and 15 for brand name drugs At retail the copayment is 3 for generic drugs and 10 for brand
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GEHA Health Plan 2000
Section 2 How we change for 2000 continued
name drugs for the initial prescription and first refill For subsequent refills at retail the copayment is
the greater of 3 or 50 for generic drugs and the greater of 10 or 50 of brand name drugs
Previously members with Medicare A B did not have a copayment at Mail Order or for the initial
prescription and first refill at retail
Section 3 How to get benefits
How do I keep my health care
expenses down
You can help FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment measures in place All feeforservice plans include two specific provisions in their benefits packages
precertification of all inpatient admissions and the flexible benefits option Some include managed care
options such as PPOs to help contain costs
As a result of your cooperative efforts the FEHB Program has been able to control premium costs
Please keep up the good work and continue to help keep costs down
Precertification Precertification evaluates the medical necessity of proposed admissions and the number of days
required to treat your condition You are responsible for ensuring that the precertification requirement
is met You or your doctor must check with Intracorp before being admitted to the hospital If that
doesnt happen your Plan will reduce benefits by 500 Be a responsible consumer Be aware of your
Plans cost containment provisions You can avoid penalties and help keep premiums under control by
following the procedures specified on page 39 of this brochure
Flexible Benefits Under the flexible benefits option the Carrier has the authority to determine the most effective way to Option
provide services The Carrier may identify medically appropriate alternatives to traditional care and
coordinate the provision of Plan benefits as a less costly alternative benefit Alternative benefits are
subject to ongoing review The Carrier may decide to resume regular contract benefits at its sole
discretion Approval of an alternative benefit is not a guarantee of any future alternative benefits
The decision to offer an alternative benefit is solely the Carriers and may be withdrawn at any time It
is not subject to OPM review under the disputed claims process
PPO This Plan offers most of its members the opportunity to reduce outofpocket expenses by choosing
providers who participate in the Plans preferred provider organization PPO or PPO designations
Consider the PPO cost savings when you review Plan benefits and check with the Carrier to see
whether PPO providers are available in your area
POS This Plan offers a Point of Service POS program called GEHA Select in the Omaha Nebraska service
area The POS program provides a higher level of benefits when services are provided by a
participating primary care physician or an approved referral to a participating specialist physician or
NonPPO benefits for services received without a referral An addendum and a POS selection form
that outline benefit levels and special requirements of the POS program are available by calling GEHA
at 8008216136
How much do I pay You must share the cost of some services These cost sharing measures include deductibles for services coinsurance and copayments These and other measures are described in more detail below
Deductibles A deductible is the amount of expense an individual must incur for covered services and supplies before the Plan starts paying benefits for the expense involved A deductible is not reimbursable by
the Plan and benefits paid by the Plan do not count toward a deductible When a benefit is subject to
a deductible only expenses allowable under that benefit count toward the deductible
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GEHA Health Plan 2000
Section 3 How to get benefits continued
Calendar Year The calendar year deductible is the amount of expenses an individual must incur for covered services
and supplies each calendar year before the Plan pays certain benefits There is no deductible for
Inpatient hospital benefits except under Mental Conditions and Substance Abuse Benefit
prescription drugs or for outpatient charges incurred for accidental injuries within 72 hours of an
accident
You can count toward the deductibles any and all covered reasonable and customary expenses except
expenses paid by the Plan
The amount of the calendar year deductible is 300 When combined covered expenses applied to the
deductible for all family members reach 600 during a calendar year the family deductible is satisfied
and benefits are payable for all family members
There is a separate 500 deductible per person per calendar year for hospital inpatient and intensive
day treatment under the Mental Conditions and Substance Abuse Benefit
Carryover If you changed to this Plan during open season from a plan with a deductible and the effective date of
the change was after January 1 any expenses that would have applied to that plans deductible in the
prior year will be covered by your old plan if they are for care you got in January before the effective
date of your coverage in this Plan If you have already met the deductible in full your old plan will
reimburse these covered expenses If you have not met it in full your old plan will first apply your
covered expenses to satisfy the rest of the deductible and then reimburse you for any additional
covered expenses The old plan will pay these covered expenses according to this years benefits
benefit changes are effective on January 1
Family Limit There is a separate calendar year deductible of 300 per person Under a family enrollment the
deductible is considered satisfied and benefits are payable for all family members when the combined
covered expenses applied to the deductible for all family members reach 600 during a calendar year
This benefit applies only to families with more than two members Each family member can only
contribute the individual deductible of 300 toward the family deductible
Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductible The Plan will base this percentage on either the billed charge or the usual
reasonable and customary charge whichever is less For instance when a Plan pays 75 of
reasonable and customary charges for a covered service you are responsible for 25 of the
reasonable and customary charges ie the coinsurance In addition you may be responsible for any
excess charge over the Plans usual reasonable and customary allowance For example if the provider
ordinarily charges 100 for a service but the Plans usual reasonable and customary allowance is 95
the Plan will pay 75 of the allowance 7125 You must pay the 25 coinsurance 2375 plus the
difference between the actual charge and the usual reasonable and customary allowance 5 for a
total member responsibility of 2875 Remember if you use preferred providers your share of covered
charges after meeting any deductible is limited to the stated coinsurance amount
When hospital When inpatient claims are paid according to a Diagnostic Related Group DRG limit for instance for charges are limited
admissions of certain retirees who do not have Medicare see page 38 the Plan will pay 30 of the by law
total covered amount as room and board charges and 70 as other charges and will apply your
coinsurance accordingly
Copayments A copayment is the stated amount the Plan requires you to pay for a covered service such as 30 per prescription by mail or 15 per office visit charge at a PPO provider
If provider waives If a provider routinely waives does not require you to pay your share of the charge for services your share
rendered the Plan is not obligated to pay the full percentage of the amount of the providers original
charge it would otherwise have paid A provider or supplier who routinely waives coinsurance
copayments or deductibles is misstating the actual charge This practice may be in violation of the
law The Plan will base its percentage on the fee actually charged For example if the provider 8
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GEHA Health Plan 2000
Section 3 How to get benefits continued
ordinarily charges 100 for a service but routinely waives the 25 coinsurance the actual charge is
75 The Plan will pay 5625 75 of the actual charge of 75
Lifetime Benefits for inpatient treatment of substance abuse are limited to one treatment program 30 day Maximums
maximum per member per lifetime
Benefits for durable medical equipment are limited to 10000 per person
Benefits for smoking cessation are limited to 100 per member
Benefits for vision therapy are limited to 30 visits per person
Do I have to You usually do not have to submit claims to us if you use preferred providers If you file a claim submit claims please send us all of the documents for your claim as soon as possible You must submit claims by
December 31 of the year after the year you received the service Either OPM or we can extend this
deadline if you show that circumstances beyond your control prevented you from filing on time
Please see section 6 How to file a claim for specific information you need to know before you file a
claim with us
Who provides my In a FeeforService Plan you may choose any covered facility or provider health care
Covered facilities
Freestanding A facility which meets the following criteria has permanent facilities and equipment for the primary ambulatory
purpose of performing surgical andor renal dialysis procedures on an outpatient basis provides facility
treatment by or under the supervision of doctors and nursing services whenever the patient is in the
facility does not provide inpatient accommodations and is not other than incidentally a facility used
as an office or clinic for the private practice of a doctor or other professional
Hospice A facility which meets all of the following
1 primarily provides inpatient hospice care to terminally ill persons
2 is certified by Medicare as such or is licensed or accredited as such by the jurisdiction it is in
3 is supervised by a staff of MDs or DOs at least one of whom must be on call at all times
4 provides 24 hour a day nursing services under the direction of an RN and has a fulltime
administrator and
5 provides an ongoing quality assurance program
Hospital 1 An institution which is accredited as a hospital under the Hospital Accreditation Program of the
Joint Commission on Accreditation of Healthcare Organizations JCAHO or
2 A medical institution which is operated pursuant to law under the supervision of a staff of
doctors and with 24 hour a day nursing service and which is primarily engaged in providing
general inpatient care and treatment of sick and injured persons through medical diagnostic and
major surgical facilities all of which facilities must be provided on its premises or have such
arrangements by contract or agreement or
3 An institution which is operated pursuant to law under the supervision of a staff of doctors and
with 24 hour a day nursing service and which provides services on the premises for the diagnosis
treatment and care of persons with mentalsubstance abuse disorders and has for each patient a
written treatment plan which must include diagnostic assessment of the patient and a description
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GEHA Health Plan 2000
Section 3 How to get benefits continued
of the treatment to be rendered and provides for followup assessments by or under the direction
of the supervising doctor
In no event shall the term hospital include a convalescent home or skilled nursing facility or any
institution or part thereof which a is used principally as a convalescent facility nursing facility or
facility for the aged b furnishes primarily domiciliary or custodial care including training in the
routines of daily living or c is operating as a school or residential treatment facility
Covered Providers A licensed doctor of medicine MD or a licensed doctor of osteopathy DO Other covered providers include a chiropractor nurse midwife nurse anesthetist dentist optometrist qualified
clinical social worker qualified clinical psychologist podiatrist speech physical and occupational
therapist nurse practitionerclinical specialist and nursing school administered clinic For purposes of
this FEHB brochure the term doctor includes all of these providers when the services are performed
within the scope of their license or certification
Coverage in medically Within States designated as medically underserved areas any licensed medical practitioner will be underserved areas treated as a covered provider for any covered services performed within the scope of that license For
2000 the States designated as medically underserved are Alabama Idaho Kentucky Louisiana
Mississippi Missouri New Mexico North Dakota South Carolina South Dakota Utah and Wyoming
What do I do if Im First call our customer service department at 8008216136 If you are new to the FEHB Program we in the hospital when will reimburse your covered expenses If you are currently in the FEHB Program and are switching to
I join this Plan us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
You exhaust the benefits available from your former plan or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
What if I have a Please contact us if you believe your condition is chronic or disabling If it is you may be able to serious illness and continue seeing your provider for up to 90 days after you receive notice that we are terminating our
my provider leaves contract with the provider unless the termination is for cause If you are in the second or third the Plan or this Plan
trimester of pregnancy you may continue to see your OBGYN until the end of your postpartum care leaves the Program
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide your
care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you
are in your second or third trimester your new plan will pay for the OBGYN care you receive from
your current provider until the end of your postpartum care
If you continue seeing your specialist or OBGYN under these conditions your cost will be no more
than you would normally pay for the services covered
How do you decide A drug device or biological product is experimental or investigational if the drug device or biological if a service is product cannot be lawfully marketed without approval of the US Food and Drug Administration
experimental or FDA and approval for marketing has not been given at the time it is furnished Approval means all investigational
forms of acceptance by the FDA
A medical treatment or procedure or a drug device or biological product is experimental or
investigational if 1 reliable evidence shows that it is the subject of ongoing phase I II or III clinical
trials or under study to determine its maximum tolerated dose its toxicity its safety its efficacy or its
efficacy as compared with the standard means of treatment or diagnosis or 2 reliable evidence shows
that the consensus of opinion among experts regarding the drug device or biological product or
10 medical treatment or procedure is that further studies or clinical trials are necessary to determine its
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GEHA Health Plan 2000
Section 3 How to get benefits continued
maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the
standard means of treatment or diagnosis
Reliable evidence shall mean only published reports and articles in the authoritative medical and
scientific literature the written protocol or protocols used by the treating facility or the protocols of
another facility studying substantially the same drug device or medical treatment or procedure or the
written informed consent used by the treating facility or by another facility studying substantially the
same drug device or medical treatment or procedure
Determination of experimentalinvestigational status may require review of appropriate government
publications such as those of the National Institute of Health National Cancer Institute Agency for
Health Care Policy and Research Food and Drug Administration and National Library of Medicine
Independent evaluation and opinion by Board Certified Physicians who are professors associate
professors or assistant professors of medicine at recognized United States Medical Schools may be
obtained for their expertise in subspecialty areas
Section 4 What if we deny your claim or request for preauthorization
What should I do Before you ask us to reconsider your claim you should first check with your provider or facility to be before filing a sure that the claim was filed correctly For instance did the provider use the correct procedure code for
disputed claim the services performed surgery laboratory test Xray office visit etc Have your provider indicate
any complications of any surgical procedures performed Your provider should also include copies of
an operative or procedure report or other documentation that supports your claim
If we deny your request for preauthorization or wont pay your claim you may ask us to reconsider
our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time
limit if you show that you were unable to make a timely request due to reasons beyond your
control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Approve your request for preauthorization or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must
make a decision within 30 days after we receive the additional information If we do not receive the
requested information within 60 days we will make our decision based on the information we already
have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a denial will determine if we correctly applied the terms of our contract when we denied your claim or request
for preauthorization
What if I have a serious Call us at 8008216136 and we will expedite our review or life threatening
condition and you havent responded to
my request for preauthorization
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Section 4 What if we deny your claim or request for preauthorization continued
What if you have denied If we expedite your review due to a serious medical condition and deny your request we will inform my request for care and
OPM so that they can give your claim expedited treatment too Alternatively you can call OPMs my condition is serious
health benefits Contract Division II at 2026063818 between 8 am and 5 pm Serious or life or life threatening
threatening conditions are ones that may cause permanent loss of bodily functions or death if they are
not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial time limits denial or refusal You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days
In this case OPM must receive your request within 120 days of the date we asked you for
additional information
What do I send Your request must be complete or OPM will return it to you You must send the following information to OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which
claim
Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
persons representative They must send a copy of the persons specific written consent with the
review request
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim Contracts Division II PO Box 436 Washington DC 20044
to OPM
What if OPM upholds OPMs decision is final There are no other administrative appeals If OPM agrees with our decision the Plans denial your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
12 recover only the amount of benefits in dispute
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Section 4 What if we deny your claim or request for preauthorization continued
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us the Privacy Act to determine if our denial of your claim is correct The information OPM collects during the review
process becomes a permanent part of your disputed claims file and is subject to the provisions of the
Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record
Section 5 Benefits
Inpatient Hospital Benefits
What is covered The Plan pays for inpatient hospital services as shown below
Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan
benefits Emergency admissions not precertified must be reported within two business days following
the day of admission even if you have been discharged Otherwise the benefits payable will be
reduced by 500 See page 39 for details
Waiver This does not apply to persons whose primary coverage is Medicare Part A or another health
insurance policy or when the hospital admission is outside the United States and Puerto Rico For
information on when Medicare is primary see page 34
Room and board The Plan pays 100 of covered charges no deductible for semiprivate ward and intensive care
accommodations in a hospital including meals and special diets and general nursing care
Private room Charges for use of private room will be paid at 100 if determined to be medically
necessary by the Plan Use of a private room for any other reason will be paid at the rate of the
hospitals average semiprivate accommodations The remaining balance is not a covered expense
Other charges The Plan pays for other hospital charges as shown below
PPO benefit The Plan pays 90 of other hospital charges
NonPPO The Plan pays 75 of other hospital charges benefit
Other hospital charges include but are not limited to
operating recovery and other treatment rooms
diagnostic laboratory tests and Xrays
drugs and medicines
administration of blood blood plasma and oxygen
dressings plaster casts and sterile trays service
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
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GEHA Health Plan 2000
Section 5 Benefits continued
Limited Benefits
Hospitalization The Plan pays benefits as shown above for covered room and board and covered hospital services for for dental work
hospitalization in connection with dental procedures only when a nondental physical impairment
exists which makes hospitalization necessary to safeguard the health of the patient
Related Benefits Professional Charges for professional services of a doctor or any other practitioner covered by the Plan even
charges though billed by a hospital as part of hospital services are covered under Other Medical Benefits
pages 2024 and Surgical Benefits pages 1417
Takehome items Medical supplies appliances medical equipment and any covered items billed by a hospital but to be
used at home are covered only under Other Medical Benefits
What is not covered Charges by institutions which do not meet the definition of covered facility
Custodial care as defined on page 41 even when provided by a hospital
Hospital room and board when in the Plans judgment an admission or portion of an admission is not medically necessary ie the medical services did not require the acute hospital inpatient
overnight setting but could have been provided in a doctors office the outpatient department
of a hospital or some other setting without adversely affecting the patients condition or the
quality of medical care rendered
Personal comfort items eg charges for television radios barber services
Surgical Benefits What is covered The Plan pays for the following services
After the 300 calendar year deductible has been met the Plan pays as follows for surgery performed
on either an inpatient or outpatient basis
PPO benefit 90 of reasonable and customary charges incurred in or out of the hospital
NonPPO 75 of reasonable and customary charges incurred in or out of the hospital benefit
Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are procedures performed during the same operative session the Plan pays as follows
PPO benefit 90 of the reasonable and customary charge for the primary procedure
90 of half of the reasonable and customary charge for the secondary procedure
90 of 25 of the reasonable and customary charge for the subsequent procedures
NonPPO 75 of the full reasonable and customary charge for the primary procedure benefit
75 of half of the reasonable and customary charge for the secondary procedure
75 of 25 of the reasonable and customary charge for subsequent procedures
Incidental Incidental and subset procedures are considered as part of the primary surgery procedures
Surgical This Plan will pay reasonable and customary charges in or out of a hospital to the extent shown services
above for
charges of a surgeon including oral surgery
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
14 When no PPO provider is available nonPPO benefits apply
14
14
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GEHA Health Plan 2000
Section 5 Benefits continued
post operative care is considered to be included in the fee charged for a surgical procedure by a doctor Any additional fees charged by a doctor are not covered unless such charge is for an
unrelated condition
surgicallyinduced sterilization even if elective
surgical correction of congenital anomalies see Definitions
breast reconstruction surgery following a mastectomy including surgery to produce a symmetrical appearance of the other breast Benefits will be provided for all stages of breast reconstruction
following a mastectomy including treatment of any physical complications including
lymphedemas and for breast prostheses including surgical bras and replacements
Assistant When deemed medically necessary benefits will be covered up to 20 of the Plans maximum surgeon
reasonable and customary allowance for the surgical procedure
Second opinion The Plan pays as shown above for charges for a second surgical opinion prior to elective surgery voluntary
recommended by a surgeon qualified to perform the surgery if
the recommended procedure is covered and
the doctor rendering the opinion is not associated or in practice with the doctor who recommended and will perform the surgery
Charges for a third opinion are payable if the second opinion does not confirm the initial
recommendation
Anesthesia After the 300 calendar year deductible has been met the Plan pays as follows for professional fees for
the administration of anesthesia
PPO benefit 90 of reasonable and customary charges
NonPPO 75 of reasonable and customary charges benefit
Organtissue The following human organtissue transplant procedures are covered subject to the conditions and transplants and
limitations below donor expenses
What is Cornea heart heartlung kidney and liver transplants covered
Pancreas transplants limited to patients whose condition is not treatable by insulin therapy
Single or double lung transplants limited to patients for the following endstage pulmonary diseases 1 Primary fibrosis 2 Primary pulmonary hypertension or 3 Emphysema double lung
transplants limited to patients with cystic fibrosis
Bone marrow transplants and stem cell support as follows
Allogeneic bone marrow transplants limited to patients with 1 Acute leukemia 2 Advanced Hodgkins lymphoma 3 Advanced nonHodgkins lymphoma 4 Advanced neuroblastoma
limited to children over age one 5 Aplastic anemia 6 Chronic myelogenous leukemia
7 Infantile malignant osteopetrosis 8 Severe combined immunodeficiency 9 Thalassemia
major or 10 WiskottAldrich syndrome
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
15
15
15
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GEHA Health Plan 2000
Section 5 Benefits continued
Autologous bone marrow transplants autologous stem cell support and autologous peripheral stem cell support limited to patients with 1 Acute lymphocytic or nonlymphocytic leukemia
2 Advanced Hodgkins lymphoma 3 Advanced nonHodgkins lymphoma 4 Advanced
neuroblastoma limited to children over age one 5 Breast cancer or 6 Testicular Mediastinal
Retroperitoneal and Ovarian germ cell tumors 7 Multiple myeloma or 8 Epithelial ovarian cancer
All reasonable and customary charges incurred for a surgical transplant whether incurred by the
recipient or donor will be considered expenses of the recipient and will be covered the same as for any
other illness or injury subject to the limitations stated below This benefit applies only if the recipient
is covered by the Plan and if the donors expenses are not otherwise covered
Transportation The Plan will also provide up to 10000 per covered transplant for transportation to the designated benefit
facility and reasonable temporary living expenses ie lodging and meals for the recipient and one
other individual or in the case of a minor two other individuals if the recipient lives more than 100
miles from the designated transplant facility Transportation benefits are payable for followup care up
to one year following the transplant The transportation benefit is not available for cornea or kidney
transplants You must contact Customer Service for what are considered reasonable temporary living
expenses
Limitations The following limitations apply to all covered transplants except for cornea and kidney
The process for preauthorizing organ transplants is more extensive than the normal precertification process Before your initial evaluation as a potential candidate for a transplant
procedure you or your doctor must contact the Plans Medical Director so that the Plan can
arrange to review the clinical results of the evaluation and determine if the proposed procedure
meets the Plans definition of medically necessary and is on the list of covered transplants
Coverage for the transplant must be authorized in advance in writing by the Plans Medical
Director
The transplant must be performed at a Plandesignated organ transplant facility to receive maximum benefits
If prior approval is not obtained or a Plandesignated organ transplant facility is not used the benefits will be limited to 90 for PPO hospital expenses 90 for PPO physician expenses or
75 of reasonable and customary charges for nonPPO hospital and surgery expenses up to a
maximum of 100000 per transplant If the Plan cannot refer a member in need of a transplant to a
designated facility the 100000 maximum will not apply
If benefits are limited to 100000 per transplant included in the maximum are all charges for hospital medical and surgical care incurred while the patient is hospitalized for a covered
transplant surgery and subsequent complications related to the transplant Outpatient expenses
for chemotherapy and any process of obtaining stem cells or bone marrow associated with
autologous bone marrow transplant autologous stem cell support are included in benefits limit of
100000 per transplant Expenses for aftercare such as outpatient prescription drugs are not a part
of the 100000 limit
Simultaneous transplants such as kidneypancreas heartlung heartliver are considered as one transplant procedure and are limited to 100000 when not performed at a Plandesignated organ
transplant facility
What is Services or supplies for or related to surgical transplant procedures including administration of not covered
high dose chemotherapy for artificial or human organtissue transplants not listed as specifically
covered
Donor search expense for bone marrow transplants
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
16 When no PPO provider is available nonPPO benefits apply
16
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GEHA Health Plan 2000
Section 5 Benefits continued
Oral and Oral surgery benefits are limited to the following procedures maxillofacial
Extraction of impacted unerupted or partially erupted teeth surgery
Alveoloplasty partial or radical removal of the lower jaw with bone graft
Correction of cleft palate fractures of the jaw andor facial bones
Excision of bony cysts of the jaw unrelated to tooth structure
Excision of tori tumors leukoplakia premalignant and malignant lesions and biopsy of hard and soft oral tissues
Open reduction of dislocations and excision manipulation aspiration or injection of temporomandibular joints
Removal of foreign body skin subcutaneous areolar tissue reactionproducing foreign bodies in the musculoskeletal system and salivary stones and incisionexcision of salivary glands and
ducts
Repair of traumatic wounds
Incision of the sinus and repair of oral fistulas
Surgical treatment of trigeminal neuralgia
Incision and drainage of infected tissue unrelated to tooth structure
Repair of accidental injury to sound natural teeth including but not limited to expenses for Xrays drugs crowns bridgework inlays and dentures performed within 12 months of the
accident Masticating biting or chewing incidents are not considered to be accidental injuries
Accidental dental injury is covered at 100 for charges incurred within 72 hours of an accident
see page 24
Mastectomy Women who undergo mastectomies may at their option have this procedure performed on an surgery
inpatient basis and remain in the hospital up to 48 hours after the procedure
What is Cosmetic surgery see Definitions except for prompt repair of injury caused by an accident not covered
congenital anomalies and breast reconstruction following a mastectomy
Charges for removal of corns calluses or trimming of toenails
Reversal of sterilization
Orthodontic treatment
Radial keratotomy or other keratoplasties
Intraoral soft tissue grafts
Any oral or maxillofacial surgery not specifically listed as covered
Orthognathic surgery even if necessary because of TMJ dysfunction or disorder
Maternity Benefits
What is covered The Plan pays the same benefits for hospital surgery delivery laboratory tests and other medical expenses as for illness or injury The mother at her option may remain in the hospital up to 48 hours
after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if
medically necessary
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
17
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GEHA Health Plan 2000
Section 5 Benefits continued
Inpatient Hospital bassinet or nursery charges for days on which mother and child are both confined are hospital
considered other hospital expenses of the mother and not expenses of the child However when a
newborn requires definitive treatment or evaluation for medical or surgical reasons during or after the
mothers confinement the newborn is considered a patient in his or her own right Under these
circumstances expenses of the newborn including incubation charges by reason of prematurity are
eligible for benefits only if the child is covered by a family enrollment
Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan
benefits Unscheduled or emergency admissions not precertified must be reported within two business
days following the day of admission even if you have been discharged Newborn confinements that
extend beyond the mothers discharge must also be precertified If any of the above are not done the
benefits payable will be reduced by 500 See page 39 for details
Intracorp offers a high risk pregnancy program at no cost to you To take full advantage of this service
and obtain valuable information concerning prenatal care you should call Intracorp at 800747GEHA as
soon as your pregnancy is confirmed
Room and board 100 for covered room and board charges
Other charges The Plan pays for other hospital charges as explained on page 13
PPO benefit The Plan pays 100 of other hospital charges as explained on page 13
NonPPO benefit The Plan pays 75 of other hospital charges as explained on page 13
Obstetrical care The Plan pays for the following maternity care including care delivery or miscarriage by a doctor
MD or DO or licensed nurse midwife The 300 calendar year deductible applies to nonPPO
providers Prenatal and postnatal care is considered to be included in the delivery fee for nonPPO
providers There is no deductible for PPO providers
PPO benefit The Plan pays 100 of the reasonable and customary charges incurred in or out of hospital
NonPPO benefit The Plan pays 75 of reasonable and customary charges incurred in or out of the hospital
Related benefits
Contraceptive Devices and drugs obtainable only by written prescription see pages 25 and 26 devices and drugs
Diagnosis and Charges related to diagnosis and treatment of infertility will be covered up to a maximum of 3000 per treatment of
calendar year per person Drugs to treat infertility are not covered infertility
Voluntary Surgicallyinduced sterilization even if elective see page 15 sterilization
Well child care Routine doctor visits and immunizations are paid under Additional Benefits see page 25
Wellness See page 25 for additional services available for you program
For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
18 When no PPO provider is available nonPPO benefits apply
18
18
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GEHA Health Plan 2000
Section 5 Benefits continued
What is Charges related to abortions except when the life of the mother would be endangered if the fetus not covered were carried to term or when the pregnancy is result of rape or incest
Routine sonograms to determine fetal age andor size
Charges for services and supplies incurred after termination of coverage
Reversal of sterilization
Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization embryo transfer and GIFT as well as services and supplies related to ART procedures
are not covered
Home uterine monitoring devices unless preauthorized by the Plan Medical Director
Mental ConditionsSubstance Abuse Benefits
What is covered The Plan pays for the following services
Mental conditions
Inpatient Inpatient hospital expenses are limited to 50 of reasonable and customary charges subject to the care
500 hospital inpatient and intensive day treatment mental conditionssubstance abuse deductible per
member per calendar year for treatment of mental conditions All reasonable and customary charges
count toward the deductible and benefits are limited to 100 days per calendar year
Precertification The medical necessity of your admission to a hospital or other covered facility must be precertified for
you to receive full Plan benefits Emergency admissions must be reported within two business days
following the day of admission even if you have been discharged Otherwise the benefits payable will
be reduced by 500 See page 39 for details
Inpatient The Plan pays 50 of reasonable and customary charges for inpatient visits by covered providers visits
and for psychotherapy sessions after the Plans overall 300 calendar year deductible has been met
All reasonable and customary charges count toward the calendar year deductible Benefits are limited
to 100 inpatient visits per calendar year
Substance abuse
Inpatient Inpatient care for the treatment of alcoholism and drug abuse is available for one treatment program care
30 day maximum per lifetime Inpatient care for treatment of alcoholism and drug abuse is subject to
ongoing review for need for acute inpatient care
The Plan pays 50 of reasonable and customary charges for inpatient hospital charges and inpatient
visits by covered providers and psychotherapy sessions Benefits are subject to the 500 hospital
inpatient and intensive day treatment mental conditionssubstance abuse deductible
Precertification The medical necessity of your admission to a hospital or other covered facility must be precertified for
you to receive full Plan benefits Emergency admissions must be reported within two business days
following admission even if you have been discharged Otherwise the benefits payable will be
reduced by 500 See page 39 for details
Lifetime maximum Benefits are limited to one treatment program 30 day maximum per lifetime for alcoholism and drug
abuse
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
19
19
19
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GEHA Health Plan 2000
Section 5 Benefits continued
Mental conditions and substance
abuse
Outpatient The following describes the outpatient mental conditions and substance abuse benefits care
Outpatient Home and office visits by covered providers are covered including visits for psychotherapy sessions visits
and group sessions up to a maximum of 30 sessions per calendar year for the treatment of mental
conditions and substance abuse The Plan pays 50 of reasonable and customary charges for up to
30 sessions per calendar year after the Plans overall 300 calendar year deductible has been met All
reasonable and customary charges count toward the calendar year deductible
Intensive The Plan provides intensive hospital day treatment limited to 50 of reasonable and customary day
charges after the 500 hospital inpatient and intensive day treatment mental conditionssubstance treatment
abuse deductible per member per calendar year All reasonable and customary charges count toward
the deductible Benefits are limited to 60 days of treatment per calendar year If you are uncertain if
treatment will be considered intensive day treatment you may contact the Plans Customer Service
Department
Calendar year Benefits for the treatment of mental conditions on an inpatient basis are limited to 100 days per calendar maximum
year Benefits for Intensive Day Treatment are limited to 60 days per calendar year
Catastrophic When the deductibles and coinsurance for all covered family members or an individual under Self protection
Only exceeds 8000 for the treatment of mental conditions inpatient or outpatient and outpatient
substance abuse in any one calendar year the Plan will pay in full all remaining reasonable and
customary charges incurred during the remainder of that same year up to the calendar year maximum
What is Marital family and other counseling services including therapy for sexual problems not covered
Services rendered or billed by a school or halfway house or a member of its staff
Other Medical Benefits
What is covered After the 300 calendar year deductible has been met the Plan pays expenses for the services listed below and on page 2124 as follows except where noted
PPO benefit The Plan pays 90 of reasonable and customary charges except
You pay a 15 copayment for the doctors professional fee for each office visit These expenses are not
subject to the 300 calendar year deductible nor counted toward the maximum out of pocket limits
Services rendered by the doctor or any other provider in conjunction with the office visit such as
diagnostic Xray or laboratory tests will be subject to the annual deductible of 300 and are paid at
90
NonPPO benefit The Plan pays 75 of reasonable and customary charges
The following services and supplies are covered if prescribed by a doctor and rendered by a covered
provider
Allergy treatment
Anesthetics and their administration
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
20 When no PPO provider is available nonPPO benefits apply
20
20
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GEHA Health Plan 2000
Section 5 Benefits continued
Artificial eyes and limbs and orthopedic devices other than orthotics
Chemotherapy
Breast prostheses and bras following a mastectomy
First pair of contact lenses or ocular implant lenses if required to correct an impairment existing after intraocular surgery or accidental injury
Local ambulance service within 100 miles to the first hospital where treated from that hospital to the next nearest one if necessary treatment is unavailable or unsuitable at the first hospital then
to either the home if ambulance transport is medically necessary or other medical facility if
required for the patient to receive necessary treatment and if ambulance transport is medically
necessary Air ambulance to nearest facility where necessary treatment is available is covered if
no emergency ground transportation is available or suitable and the patients condition warrants
immediate evacuation
Oxygen
Professional services of doctors including home office and hospital visits
Renal dialysis
Splints casts and similar devices used for reduction of fractures and dislocations
Transfusions and blood and blood plasma not donated or replaced
Ultraviolet and radiant heat treatments and diathermy
Xray radium and radioactive isotope therapy and antibiotic therapy
Xrays laboratory tests electrocardiograms basal metabolism readings and other diagnostic tests
Initial evaluation and laboratory data by physician for weight loss and medically indicated surgery for morbid obesity Surgery must be approved prior to the surgery by the Plan All other types of
treatment for weight loss are not covered
Outpatient Coverage is provided for the services and supplies described in Other Medical Benefits when such hospital services and supplies are rendered in and billed by the outpatient department of a hospital
Emergency room
services
PPO benefit You pay 75 copayment per occurrence for services and supplies billed by the hospital for emergency
room treatment of an illness These expenses are not applied to the 300 calendar year deductible nor
counted toward the maximum outofpocket limits
NonPPO benefit You pay 75 copayment per occurrence for services and supplies billed by the hospital for emergency
room treatment of an illness These expenses are not applied to the 300 calendar year deductible nor
counted toward the maximum outofpocket limits
Other Coverage is provided for the services and supplies described in Other Medical Benefits when such outpatient
services and supplies are rendered in and billed by the outpatient department of a hospital hospital
services
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
21
21
21
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GEHA Health Plan 2000
Section 5 Benefits continued
PPO benefit The Plan pays 90 of covered charges
Services must be rendered in and billed by a covered hospital Only services and supplies billed by a
hospital qualify for the 90 PPO benefit
NonPPO benefit The Plan pays 75 of covered charges
Routine and In addition to coverage on page 21 of diagnostic Xrays laboratory and pathological services and preventive
machine diagnostic tests the following routine screening services are covered as preventive care services
Breast cancer Mammograms are covered for diagnostic andor routine screening services screening
Cervical cancer Annual coverage of one pap smear for women age 18 and older screening
Colorectal cancer Annual coverage of one fecal occult blood test for members age 40 and older screening
Coverage of one sigmoidoscopy every five years beginning at age 50
Prostate cancer Annual coverage of one PSA Prostate Specific Antigen test for men age 40 and older screening
Routine Routine physical examinations and diagnostic laboratory tests including pap smears cholesterol physical
screenings and Xrays
Immunizations Influenza and pneumonia
Tetanus and diptheria
Limited benefits Acupuncture The plan will provide benefits for medically necessary acupuncture treatments if performed by a
Medical Doctor MD or Doctor of Osteopathy DO Benefits are limited to 20 procedures per calendar
year
Allergy The Plan will provide benefits for medically necessary allergy testing Benefits are limited to 500 per Testing
calendar year
Chiropractor The following services of a chiropractor will be covered subject to the calendar year deductible to the
following extent
a adjustments by handsonly of the spinal column up to a maximum of 30 adjustments per calendar
year and up to a maximum payable by the Plan of 9 per adjustment and
b use of Xrays to detect and determine the presence or absence of nerve interferences due to spinal
subluxations or misalignments up to a maximum payable by the Plan of 25 per calendar year
Charges exceeding these amounts are not applied toward the calendar year deductible
No other benefits for these services of a chiropractor are covered under any other provision of this
Plan In medically underserved areas services of a chiropractor that are listed above are subject to the
stated limitations In medically underserved areas services of a chiropractor that are within the scope
of hisher license and are not listed above are eligible for regular Plan benefits
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
22 When no PPO provider is available nonPPO benefits apply
22
22
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GEHA Health Plan 2000
Section 5 Benefits continued
Durable The Plan will provide benefits for the purchase or rental at the option of the Plan of durable medical medical
equipment including respirators oxygen equipment wheelchairs hospital beds crutches and other equipment
items determined by the Plan to be durable medical equipment To obtain maximum benefits contact
our Customer Service Department or Medical Management Department before the rental or purchase of
any durable medical equipment
Benefits are limited to a lifetime maximum of 10000 per person
Hospice care
What is covered 100 of the covered charges subject to the 300 calendar year deductible for a hospice care program
for each period of care up to
2000 for hospice care on an outpatient basis
150 per day for room and board and care while an inpatient in a hospice up to a maximum of 3000
These benefits will be paid if the hospice care program begins after a persons primary doctor certifies
terminal illness and life expectancy of six months or less and any service or inpatient hospice stay that
is a part of the program is
provided while the person is covered by this Plan
ordered by the supervising doctor
charged by the hospice care program and
provided within six months from the date the person entered or reentered after a period of remission a hospice care program
Remission Halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred A readmission within three months of a prior discharge is considered
as the same period of care A new period begins after three months from a prior discharge with maximum
benefits available
What is Charges incurred during a period of remission not covered
Charges incurred for treatment of a sickness or injury of a family member that are covered under another Plan provision
Charges incurred for services rendered by a close relative
Bereavement counseling
Funeral arrangements
Pastoral counseling
Financial or legal counseling
Homemaker or caretaker services
Occupational Outpatient visits for any services provided by an occupational or speech therapist when prescribed by and speech
a doctor and rendered by a qualified professional therapist are available up to a combined total of 30 therapy
visits per person per calendar year Speech therapy must be to restore functional speech when there
has been a loss of attained functional speech due to illness or injury such as stroke or brain trauma
and when therapy is rendered in accordance with a doctors specific instructions as to duration and
type
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
23
23
23
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25
GEHA Health Plan 2000
Section 5 Benefits continued
Outpatient The Plan pays benefits under Other Medical Benefits for covered outpatient hospital services in dental
connection with dental procedures only when a nondental physical impairment exists which makes
hospitalization necessary to safeguard the health of the patient
Physical Outpatient visits for physical therapy when prescribed by a doctor and rendered by a qualified therapy
physical therapist are available up to a total of 50 visits per calendar year
Prior to beginning physical therapy treatments you should contact our Medical Management
Department to preauthorize benefits Continuing physical therapy claims will be subject to concurrent
review for medical necessity Physical therapy claims will be denied if the plan determines the therapy
is not medically necessary Please preauthorize
Skilled The Plan will provide benefits for inhome services of a registered nurse RN and licensed practical nursing
nurse LPN but not to exceed one visit up to two hours per day of skilled nursing care for up to a care
total of 25 visits per calendar year Covered services are based on review by the Plan for medical
necessity
Smoking After satisfaction of the calendar year deductible the Plan will pay up to 100 for enrollment in one cessation
smoking cessation program per member per lifetime Drugs to aid in smoking cessation are covered benefit
under this benefit subject to the calendar year deductible and subject to the 100 lifetime maximum
You must purchase these drugs and file the receipt from the pharmacy including the name of drug
patients name date and amount of purchase with the GEHA claim office
Vision Outpatient visits for vision therapy provided by an ophthalmologist or optometrist are available up to therapy
a total of 30 visits per person per lifetime
What is Routine eye examinations eyeglasses contact lenses or hearing aids except as described above not covered
Air purifiers air conditioners heating pads whirlpool bathing equipment sun and heat lamps exercise devices even if ordered by a doctor and other equipment that does not meet the
definition of durable medical equipment page 42
Orthopedic shoes arch supports or other supportive devices for the feet
Travel even when prescribed by a doctor except as described for organ transplants as outlined on page 16
Treatment other than by surgery of Temporomandibular Joint TMJ dysfunction and disorders
Custodial care as defined on page 41
Wigs Lifts such as seat chair or van lifts
Additional Benefits The following services are covered and are not subject to the calendar year deductible
Accidental 100 of covered charges subject to reasonable and customary allowance no calendar year injury deductible incurred within 72 hours of an accident for treatment outside a hospital or in the outpatient
department of a hospital Emergency room charges associated directly with an inpatient admission are
considered Other charges under Inpatient Hospital Benefits see page 13 and are not part of this
benefit even though an accidental injury may be involved Expenses incurred after 72 hours even if
related to the accident are subject to regular benefits and are not paid at 100 This provision also
applies to dental care required as a result of accidental injury to sound natural teeth Masticating
chewing incidents are not considered to be accidental injuries
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
24 When no PPO provider is available nonPPO benefits apply
24
24
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GEHA Health Plan 2000
Section 5 Benefits continued
Well child For covered dependents under age 22 the Plan pays 100 of the reasonable and customary charges care for the following covered services
Doctor office visits including the costs associated with routine physical examinations laboratory tests and routine childhood immunizations recommended by the American Academy of Pediatrics
The first routine newborn examination including routine screening inpatient or outpatient
24Hour For any of your health concerns 24 hours a day 7 days a week 365 days a year you may call 800 Nurse 747GEHA at any time and talk with a registered nurse who will discuss treatment options and answer
Phone your health questions Service
In addition to participate in our enhanced maternity program call 800747GEHA at any time as soon
as you think you or your covered dependent may be pregnant Early participation in the program
guarantees you ongoing communication with a registered nurse throughout you or your covered
dependents pregnancy Complimentary educational materials include the book From Here to
Maternity
The 24hour phone service also makes available a registered nurse who will take precertification
information outside of regular business hours Call 800747GEHA
Prescription Drug Benefits
What is covered This program enables you to purchase medication which requires a prescription by Federal law and is prescribed by your doctor from a local pharmacy or receive up to a 90day supply of maintenance
medication through the Mail Order Drug Program Prescription drugs are not subject to the calendar
year deductible and any coinsurance or copayments paid by you do not count toward the catastrophic
protection benefit
Drugs that by Federal law of the United States require a doctors prescription
Insulin
Needles and syringes for the administration of covered medications
Ostomy supplies
What is Drugs to aid in smoking cessation except those limited to the 100 lifetime maximum as part of the not covered
smoking cessation benefit see page 24 You may not obtain smoking cessation drugs with your
PAID Prescription card or through the Mail Order Drug Program You must purchase these drugs
and file the claim with the GEHA claim office
Drugs available without a prescription
Vitamins and nutritional supplements
Medical supplies such as dressings and antiseptics
Drugs which are investigational
Drugs prescribed for weight loss
Drugs to treat infertility
Drugs to treat impotency
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
25
25
25
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GEHA Health Plan 2000
Section 5 Benefits continued
From a pharmacy You will be provided with a combination GEHA PAID Prescription identification card In most cases you simply present the card together with the prescription to the pharmacist For the initial amount
prescribed by a doctor not to exceed a 30day supply and the first refill you pay 5 for generic drugs
and 15 for brand name drugs except for drugs that cost plus any dispensing fee less than the
copayment in which case the drug will be made available at cost plus any dispensing fee The
second refill and all subsequent refills will require that you pay the greater of 5 or 50 coinsurance
for generic drugs or the greater of 15 or 50 coinsurance for brand name drugs Each purchase is
limited to a 30day supply Refills cannot be obtained until 75 of the drug has been used Refills for
maintenance medications are not considered new prescriptions except when the doctor changes the
strength or 180 days has elapsed since the previous purchase As part of the administration of the
prescription drug program GEHA reserves the right to maximize the participants quality of care as it
relates to the utilization of pharmacies For longterm prescription needs you should use the Mail
Order Drug Program to receive higher benefits You may fill your prescription at any pharmacy
participating in the PAID TelePAID system You may obtain the names of participating pharmacies by
calling 8005517675
Each participating pharmacy has a TelePAID system which calculates the coinsurance The Pharmacist
receives an electronic message displaying the correct amount to charge you You will be required to
sign a signature log to prove you have received the prescription drug You do not file a PAID
prescription card claim with GEHA
Some medications may require prior approval by Medco or GEHA
Medicare If you have Medicare A B primary you pay a smaller copay for your prescriptions copayments
At a PAID Pharmacy you pay
New Prescription and first refill 3 generic 10 brand name
Second and subsequent refills 3 or 50 whichever is greater for generic 10 or 50 whichever is
greater for brand name
To claim benefits If a participating pharmacy is not available where you reside or you do not use your identification
card you must submit your claim to
PAID Prescriptions LLC
PO Box 712
Parsippany NJ 070540712
Your claim will be calculated on the 50 coinsurance or 15 or 5 copayments described above
Reimbursement will be based on GEHAs cost had you used a participating pharmacy
You must submit original drug receipts
By mail Through the Mail Order Drug Program you may receive up to a 90day supply of maintenance medications for drugs which require a prescription ostomy supplies diabetic supplies and insulin
syringes and needles for covered injectable medication and oral contraceptives You may receive
refills of the original prescription for up to one year You must pay a copayment of 10 for generic
drugs and 30 for brand name drugs Controlled substances may not be available in a 90day supply
from MerckMedco RX even though the prescription is for 90 days A 30 or 10 copayment is
charged for each supply of medication received from MerckMedco RX Services Even though insulin
syringes diabetic supplies and ostomy supplies do not require a physicians prescription to obtain
through mail order drug program you should obtain a prescription from your physician for a 90day
supply Some medications may require prior approval by Medco or GEHA Not all drugs are available
through Mail Order Each enrollee will receive an installment kit that includes a brochure describing the
Mail Order Drug Program including a Patient Profile Questionnaire and a preaddressed postage paid
order envelope
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
26 When no PPO provider is available nonPPO benefits apply
26
26
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GEHA Health Plan 2000
Section 5 Benefits continued
Medicare If you have Medicare A B primary you pay a smaller copay for your prescriptions copayments
At Mail Order
5 for 90 day supply of generic 15 for 90 day supply of brand name
Preferred Your prescription drug program includes a voluntary formulary feature The Preferred Prescriptions Prescriptions Drug Formulary is a list of selected FDA approved prescription medications reviewed by an
voluntary independent group of distinguished health care professionals Prescription drugs are subjected to formulary
rigorous clinical analysis from the standpoint of efficacy safety side effects drugtodrug
interactions dosage and costbenefit in determining whether they are included on or excluded from
the formulary
A formulary is a list of commonly prescribed medications from which your physician may choose to
prescribe The formulary is designed to inform you and your physician about quality medications that
when prescribed in place of other nonformulary medications can help contain the increasing cost of
prescription drug coverage without sacrificing quality
In many therapeutic categories there are several drugs of similar effectiveness Many doctors are
often unaware of the significant variations in price among these similar drugs and as a result their
prescribing decisions often do not consider cost However when the cost difference is brought to
their attention doctors will frequently prescribe the less costly medications
Your physicians will be contacted to discuss their prescribing decision No change in the medication
prescribed will be made without your physicians approval Compliance with this formulary list is
voluntary and there is no financial penalty for obtaining drugs not on the formulary list
To claim Complete the Patient Profile Questionnaire kit the first time you order under this program Complete the benefits information on the back of the preaddressed postage paid envelope enclose your prescriptions and
your 30 or 10 copayment per prescription and mail to
MerckMedco RX Services
PO Box 98830
Las Vegas NV 891950249
Members should receive their medication within 14 days from the date they mail their prescription
along with reorder instructions
If you have any questions about your prescription you may call the Mail Order Drug Program tollfree
at 8005517675 from 5 am to 9 pm Monday through Friday and 5 am through 3 pm on
Saturday PST Emergency consultation is available seven days a week 24 hours per day Forms
necessary for refills and future prescription orders will be provided each time you receive a supply of
medication from the program
Coordinating If you also have drug coverage through another carrier and GEHA is secondary follow these with other procedures instead of those outlined above in order to receive maximum reimbursement
drug coverage
At participating pharmacies do not present your drug card Purchase your drug and submit the bill to
your primary carrier When they have made payment file the claim and Explanation of Benefits EOB
with GEHAs claims office see page 31 If you use GEHAs prescription drug card when another
carrier is primary you will be responsible for reimbursing GEHA any amount in excess of GEHAs
secondary benefit
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan When no PPO provider is available nonPPO benefits apply
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GEHA Health Plan 2000
Section 5 Benefits continued
Drug purchases at nonparticipating pharmacies should be submitted to GEHAs claims office see
page 31 along with the primary carriers EOB GEHA will accept either the drug receipts or a PAID
Prescriptions Inc drug claim form Do not submit these claims to Paid Prescriptions Inc when GEHA
is secondary
If another carrier is primary you should use that carriers drug benefit If you elect to use the Mail
Order Drug Program MerckMedco RX Services will bill you directly Pay MerckMedco RX the
amount billed and submit the bill to your primary carrier When they make payment file the claim and
the primary carriers EOB to GEHAs claims office see page 31
In some cases Medicare covers prescription drugs and supplies If Medicare is your primary payer
and you use prescription drugs or supplies that Medicare covers GEHA will attempt to recover the
cost of the drug or supply from Medicare You must cooperate with GEHA in obtaining this
reimbursement If we are unsuccessful in recovering our payment from Medicare GEHA reserves the
right to require you to purchase the medication and then file a claim with Medicare After Medicare
makes payment you may file a claim with GEHA for the outofpocket cost in excess of your GEHA
copayment
PPO benefits apply only when you use a PPO provider The nonPPO benefits are the standard benefits of this plan
28 When no PPO provider is available nonPPO benefits apply
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GEHA Health Plan 2000
Section 5 Benefits continued
Dental Benefits What is covered The following is a complete list of preventive and restorative services covered by the Plan subject to
benefit limits
Preventive Diagnostic and preventive services up to 22 a visit limited to two visits per year including care
examination prophylaxis cleaning Xrays of all types and fluoride treatment Benefits are payable per
visit not per service
Restorative ADA Code Description Plan Pays care
AMALGAM RESTORATIONS including polishing
2110 Amalgamone surface 21
2120 Amalgamtwo surfaces 28
2130 Amalgamthree surfaces 28
2131 Amalgamfour surfaces 28
2140 Amalgamone surface 21
2150 Amalgamtwo surfaces 28
2160 Amalgamthree surfaces 28
2161 Amalgamfour surfaces 28
SILICATE RESTORATION
2210 Silicate cement per restoration 21
SILICATE OR PLASTIC OR COMPOSITE RESTORATIONS
2330 Acrylic or plastic or composite resinone surface 21
2331 Acrylic or plastic or composite resintwo surfaces 28
2332 Acrylic or plastic or composite resinthree surfaces 28
2335 Acrylic or plastic or composite resininvolving incisal angle or four or
more surfaces 28
2337 Composite resinone surface 21
2338 Composite resintwo surfaces 28
2339 Composite resinthree surfaces 28
GOLD FOIL RESTORATIONS
2410 Gold Foil one surface 21
2420 Gold Foil two surfaces 28
2430 Gold Foil three surfaces 28
2435 Gold Foil three surfaces including inlay 28
GOLD INLAY RESTORATIONS
2510 Gold Inlay one surface 21
2520 Gold Inlay two surfaces 28
2530 Gold Inlay three surfaces 28
PORCELAIN RESTORATIONS
2610 Porcelain Inlay one surface 21
2620 Porcelain Inlay two surfaces 28
2630 Porcelain Inlay three surfaces 28
Extractions SIMPLE EXTRACTIONS includes local anesthesia and postoperative care
7110 Single tooth 21
7120 Each additional tooth 21
7210 Surgical Extractions each 21
There is no limit to the number of covered fillings or extractions in a calendar year
Related benefits
Oral and For covered oral surgery see page 17 maxillofacial
surgery
What is Orthodontia periodontal and any other services not listed as covered not covered 29
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GEHA Health Plan 2000
NonFEHB Benefits Available to Plan Members
NonCovered Certain prescription drugs not covered by GEHAs Prescription Drug Program are available to members Prescription
at a discount If your physician writes a prescription for a noncovered drug to treat impotency or hair Drugs
loss you can purchase it through mail order paying 100 of the discounted amount To order 8004171893
complete the mail order envelope and enclose your prescription along with a check or credit card
number If paying by a check please call first to obtain the cost of the medication Full payment must
be included with your order Mail to
MerckMedco Rx Services of Nevada Inc
PO Box 98830
Las Vegas NV 891950249
CONNECTION Free to all members CONNECTION Dental offers cost savings at 20000 providers nationwide Dental
Participating dentists agree to limit their charges to a fee schedule for GEHA members When you 8002960776
choose a participating dentist you pay only up to the maximum charge on the CONNECTION Dental
fee schedule If your dentist has not yet joined ask your dentist to call GEHA for a CONNECTION
Dental information packet Call for a list of providers in your area
CONNECTION Available for an additional premium CONNECTION Dental Plus is a comprehensive dental benefit plan Dental Plus
that supplements regular GEHA dental coverage Benefits are payable for more than 140 dental 8007939335
procedures including crowns root canals gum surgery bridgework dentures orthodontia and routine
care such as cleanings exams and fillings Enrollment for members is open yearround This optional
supplemental dental insurance is provided directly by GEHA Certain waiting periods and limitations
apply
CONNECTION Free to all members CONNECTION Hearing offers cost savings at 1500 Miracle Ear locations Hearing
nationwide The program provides a free hearing evaluation up to a 20 discount off the retail price 8004566801
of hearing aids a 30day satisfaction refund guarantee free unlimited followup visits and free annual
checkups of hearing aids Program benefits are available to GEHA members and their families
including parents and grandparents The member must be present with hisher CONNECTION ID card
for family members to receive CONNECTION Hearing benefits Call to locate providers in your area
CONNECTION Available for an additional premium CONNECTION LongTerm Care offers GEHA members a 10 LongTerm Care
premium discount on longterm care insurance Applicants may also qualify for additional discounts 888469GEHA
due to good health or by applying at the same time as their spouse The program is available through
CNA Longterm care policies from CNA provide coverage for home health care adult day care
assisted living nursing home and hospice care
CONNECTION Free to all members CONNECTION Vision offers cost savings at more than 10000 eye care locations Vision
nationwide GEHA members get discounts off the retail price of lenses frames and specialty items 800800EYES
such as tints lightweight plastics and scratchresistant coatings New this year are discounts on
surgical procedures including LASIK RK PRK and ALK not covered under the GEHA health plan
For discounts on mailorder contact lenses and nonprescription sunglasses call 8008783901 This
program is offered through Coast to Coast Vision Call to locate providers in your area
CONNECTION Free to all members CONNECTION Vitamins offers members a 5 discount on vitamins and other Vitamins
nutritional supplements ordered by mail Youll also receive 5 off your first order This program is 8007388482
offered through SDV Vitamins a mailorder division of Rexall Sundown When you call to request a
catalog or place an order indicate the GEHA source code GEHA99
Benefits described on this page are neither offered nor guaranteed under contract with the FEHB Program but are made available
to GEHA members and their covered dependents enrolled in GEHA in 2000 The cost of CONNECTION programs is not included in
the health plan premium you pay Charges for these services do not count toward your GEHA deductible or outofpocket
maximum The GEHA PPO copayment does not apply CONNECTION benefits are not subject to the FEHB disputed claims
procedure GEHA does not guarantee that providers are available in all areas or that prices at a participating provide are lower
than prices that may be available from a nonparticipating provider
Benefits on this page are not part of the FEHB contract
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GEHA Health Plan 2000
Section 6 How to File a Claim
Claim forms If you do not receive your identification cards within 60 days after the effective date of your identification cards enrollment call the Carrier at 8008216136 to report the delay In the meantime use your copy of the
and questions SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when
you obtain services This is also the number to call for claim forms or advice on filing claims
If you have a question concerning Plan benefits contact the Carrier at 8008216136 or you may write
to the Carrier at PO Box 4665 Independence MO 640514665 You may also contact the Carrier by fax
at 8162573233 at its web site at httpwwwgehacom or by email at csgehagehacom
If you made your open season change by using Employee Express and have not received your new ID
card by the effective date of your enrollment call the Employee Express HELP number to request a
confirmation letter Use that letter to confirm your new coverage with providers
How to file claims Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on the form HCFA 1500 Health Insurance Claim Form Claims submitted by enrollees may be submitted on the
HCFA 1500 or a claim form that includes the information shown below Bills and receipts should be
itemized and show
Name of patient and relationship to enrollee
Plan identification number of enrollee
Name and address of person or firm providing the service or supply
Dates that services or supplies were furnished
Type of each service or supply and the charge
Diagnosis
In addition
A copy of the explanation of benefits EOB from any primary payer must be sent with your claim
A copy of the Medicare Summary Notice MSN if Medicare is primary must be sent with your claim
Bills for private duty nurses must show that the nurse is a registered or licensed practical nurse and should include nursing notes
Claims for rental or purchase of durable medical equipment private duty nursing and physical occupational and speech therapy require a written statement from the doctor specifying the
medical necessity for the service or supply and the length of time needed
Claims for prescription drugs and medicine that are not ordered through the mail order drug program must include a receipt that includes prescription number name of drug prescribing
doctors name date and charge
Claims for overseas foreign services should include an English translation Charges should be converted to US dollars using the exchange rate applicable at the time the expense was incurred
If possible include a receipt showing the exchange rate on the date the claimed services were
performed
To control administrative costs the Plan will not issue benefit checks that do not exceed 1
Canceled checks cash register receipts or balance due statements are not acceptable
After completing a claim form E1 and attaching proper documentation send claims to
Government Employees Hospital Association Inc
P O Box 4665
Independence Missouri 640514665
If you need help in filing your claim get in touch with GEHA at 8162575500 tollfree 8008216136 or
TDD 8008214833 31
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GEHA Health Plan 2000
Section 6 How to File a Claim continued
Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person Save copies of all medical bills including those
you accumulate to satisfy a deductible In most instances they will serve as evidence of your claim
The Carrier will not provide duplicate or year end statements
Submit claims Claims should be filed within 90 days from the date the expense for which claim is being made was promptly incurred unless timely filing was prevented by administrative operations of Government or legal
incapacity provided the claim was submitted as soon as reasonably possible The Plan will not accept
a claim submitted later than December 31st of the calendar year following the one in which the expense
for which the claim is being made was incurred except where the enrollee was legally incapable Once
benefits have been paid there is a three year limitation on the reissuance of uncashed checks
Direct payment to If you wish to authorize direct payment to a hospital in addition to filing the Employee Statement of hospital or provider Claim E1 show your identification card upon admission The hospital will furnish their own form or
of care will send an itemized statement to GEHA Payments may be made directly to providers of service even
when assignment has not been submitted unless evidence is submitted that member has paid
provider
Submit hospital and doctor bills itemized to show
name of the person for whom service was rendered
name of the attending doctor andor admitting hospital and address and
date charge was incurred statement of the diagnosis treatment rendered and amount of the charge for each service
When more Reply promptly when the Carrier requests information in connection with a claim If you do not information respond the Carrier may delay processing or limit the benefits available
is needed
Section 7 General exclusions Things we dont 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 we
determine it is medically necessary to prevent diagnose or treat your illness or condition The fact that one of our covered providers
has prescribed recommended or approved a service or supply does not make it medically necessary or eligible for coverage under
this Plan
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice in the United States
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act
of rape or incest
Procedures services drugs and supplies related to sex transformations sexual dysfunction or sexual inadequacy
Services or supplies you receive from a provider or facility barred from the FEHB Program
Expenses you incurred while you were not enrolled in this Plan
Services or supplies for which no charge would be made if the covered individual had no health insurance coverage
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GEHA Health Plan 2000
Section 7 General exclusions Things we dont cover continued
Services or supplies furnished without charge except as described on page 37 while in active military service or required for illness or injury sustained on or after the effective date of
enrollment 1 as a result of an act of war within the United States its territories or possessions or
2 during combat
Services or supplies furnished by immediate relatives or household members such as spouse parents children brothers or sisters by blood marriage or adoption
Services or supplies furnished or billed by a noncovered facility except that medically necessary prescription drugs and physical speech and occupational therapy rendered by a qualified
professional therapist on an outpatient basis are covered subject to plan limits
Services or supplies for cosmetic purposes
Services or supplies not specifically listed as covered
Services or supplies not reasonably necessary for the diagnosis or treatment of an illness or injury except for routine physical examinations and immunizations
Any portion of a providers fee or charge ordinarily due from the enrollee but that has been waived If a provider routinely waives does not require the enrollee to pay a deductible copay
or coinsurance the Carrier will calculate the actual provider fee or charge by reducing the fee or
charge by the amount waived
Charges the enrollee or Plan has no legal obligation to pay such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A andor B see page 38 doctor
charges exceeding the amount specified by the Department of Health and Human Services when
benefits are payable under Medicare limiting charge see page 36 or State premium taxes
however applied
Charges in excess of reasonable and customary charges as defined on page 43
Rest cures
Biofeedback educational recreational or milieu therapy either in or out of a hospital
Inpatient private duty nursing
Standby physicians and surgeons
Clinical ecology and environmental medicine
Chelation therapy except for acute arsenic gold or lead poisoning
Treatment for impotency even if there is an organic cause for impotency Exclusion applies to medicalsurgical treatment as well as prescription drugs
Computer devices to assist with communications
Computer programs of any type including but not limited to those to assist with vision therapy or speech therapy
Section 8 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a MedicareChoice plan and also remain enrolled
with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
MedicareChoice plan when one is available in your area For information on suspending your FEHB
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GEHA Health Plan 2000
Section 8 Limitations Rules that affect your benefits continued
enrollment and changing to a MedicareChoice plan contact your retirement office If you later want
to reenroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the MedicareChoice service area you may re
enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare
For information on MedicareChoice plans contact your local Social Security Administration SSA
office or call SSA at 8006386833
This Plan and Medicare Coordinating The following information applies only to enrollees and covered family members who are entitled to
benefits benefits from both this Plan and Medicare You must disclose information about Medicare coverage
including your enrollment in a Medicare prepaid plan to this Carrier this applies whether or not you
file a claim under Medicare You must also give this Carrier authorization to obtain information about
benefits or services denied or paid by Medicare when they request it It is also important that you
inform the Carrier about other coverage you may have as this coverage may affect primarysecondary
status of this Plan and Medicare see page 36
This Plan covers most of the same kinds of expenses as Medicare Part A hospital insurance and Part
B medical insurance except that Medicare does not cover prescription drugs
The following rules apply to enrollees and their family members who are entitled to benefits from both
a FEHB plan and Medicare
This Plan is 1 You are age 65 or over have Medicare Part A or Parts A and B and are employed by the Federal primary if Government
2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are
employed by the Federal Government
3 The patient you or a covered family member is within the first 30 months of eligibility to receive
Medicare Part A benefits due to End Stage Renal Disease ESRD except when Medicare based
on age or disability was the patients primary payer on the day before he or she became eligible
for Medicare Part A due to ESRD or
4 The patient you or a covered family member is under age 65 and eligible for Medicare solely on
the basis of disability and you are employed by the Federal Government
For purposes of this section employed by the Federal Government means that you are eligible for
FEHB coverage based on your current employment and that you do not hold an appointment
described under Rule 6 of the following Medicare is primary section
Medicare is 1 You are an annuitant age 65 or over covered by Medicare Part A or Parts A and B and are not primary if employed by the Federal Government
2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are
not employed by the Federal Government
3 You are age 65 or over and a you are a Federal judge who retired under title 28 USC b you
are a Tax Court judge who retired under Section 7447 of title 26 USC or c you are the covered
spouse of a retired judge described in a or b
4 You are an annuitant not employed by the Federal Government and either you or a covered family
member who may or may not be employed by the Federal Government is under age 65 and
eligible for Medicare on the basis of disability
5 You are enrolled in Part B only regardless of your employment status
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GEHA Health Plan 2000
Section 8 Limitations Rules that affect your benefits continued
6 You are age 65 or over and employed by the Federal Government in an appointment that excludes
similarly appointed nonretired employees from FEHB coverage and have Medicare Part A or Part
A and B or
7 You are a former Federal employee receiving workers compensation and the Office of Workers
Compensation has determined that you are unable to return to duty
8 The patient you or a covered family member has completed the 30month ESRD coordination
period and is still eligible for Medicare due to ESRD or
9 The patient you or a covered family member becomes eligible for Medicare due to ESRD after
Medicare assumed primary payer status for the patient under rules 1 through 7 above
When Medicare When Medicare is primary all or part of your Plan deductibles and coinsurance will be waived as is primary follows
Inpatient Hospital Benefits If you are enrolled in Medicare Part A the Plan will waive the deductible
and coinsurance
Surgical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and
coinsurance applicable to surgical and medical care
Mental ConditionsSubstance Abuse Benefits If you are enrolled in Medicare Part A the Plan waives
the inpatient deductible and coinsurance for hospital charges If you are enrolled in Medicare Part B
the Plan waives the deductible and coinsurance for doctors inpatient services and outpatient care
Other Medical Benefits If you are enrolled in Medicare Part B the Plan waives the calendar year
deductible and coinsurance
Additional Benefits If you are enrolled in both Medicare Parts A and B the Plan waives the
coinsurance for outpatient treatment
Prescription Drugs If you have Medicare Parts A and B you will pay a 5 copayment for generic
drugs and a 15 copayment for brand name drugs through the Mail Order Drug Program If you use
your identification card to buy prescription drugs through a participating pharmacy you will pay a 3
copayment for generic drugs and a 10 copayment for brand name drugs for the initial amount
prescribed by the doctor not to exceed a 30day supply and the first refill Subsequent refills are
subject to a copayment of the greater of 3 or 50 of the cost for generic drugs and 10 or 50 of
the cost for brand name drugs
When Medicare is the primary payer this Plan will limit its payment to an amount that supplements the
benefits that would be payable by Medicare regardless of whether or not Medicare benefits are paid
However the Plan will pay its regular benefits for emergency services to an institutional provider such
as a hospital that does not participate with Medicare and is not reimbursed by Medicare
If you are enrolled in Medicare you may be asked by a physician to sign a private contract agreeing
that you can be billed directly for services that would ordinarily be covered by Medicare Should you
sign such an agreement Medicare will not pay any portion of the charges and you may receive less or
no payment for those services under this Plan
When you also When you are enrolled in a Medicare prepaid plan while you are a member of this plan you may enroll in a continue to obtain benefits from this Plan If you submit claims for services covered by this Plan that
Medicare you receive from providers that are not in the Medicare plans network the Plan will not waive any prepaid plan
deductibles or coinsurance when paying these claims
Medicares If you are covered by Medicare Part B and it is primary you should be aware that your outofpocket payment and costs for services covered by both this Plan and Medicare Part B will depend on whether your doctor
this Plan accepts Medicare assignment for the claim
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GEHA Health Plan 2000
Section 8 Limitations Rules that affect your benefits continued
Doctors who participate with Medicare accept assignment that is they have agreed not to bill you for
more than the Medicareapproved amount for covered services Some doctors who do not participate
with Medicare accept assignment on certain claims If you use a doctor who accepts Medicare
assignment for the claim the doctor is permitted to bill you after the Plan has paid only when the
Medicare and Plan payments combined do not total the Medicareapproved amount
Doctors who do not participate with Medicare are not required to accept direct payment or
assignment from Medicare Although they can bill you for more than the amount Medicare would pay
Medicare law the Social Security Act 42 USC sets a limit on how much you are obligated to pay
This amount called the limiting charge is 115 percent of the Medicareapproved amount Under this
law if you use a doctor who does not accept assignment for the claim the doctor is permitted to bill
you after the Plan has paid only if the Medicare and Plan payments combined do not total the limiting
charge Neither you nor your FEHB Plan is liable for any amount in excess of the Medicare limiting
charge for charges of a doctor who does not participate with Medicare The Medicare Summary Notice
MSN will have more information about this limit
If your doctor does not participate with Medicare asks you to pay more than the limiting charge and
he or she is under contract with this Plan call the Plan If your doctor is not a Plan doctor ask the
doctor to reduce the charge or report him or her to the Medicare carrier that sent you the Medicare
Summary Notice MSN In any case a doctor who does not participate with Medicare is not entitled
to payment of more than 115 percent of the Medicareapproved amount
How to claim In most cases when services are covered by both Medicare and this Plan Medicare is the primary benefits payer if you are an annuitant and this Plan is primary if you are an employee When Medicare is the
primary payer your claims should first be submitted to Medicare The Carrier has contracted with
most Medicare Part B claims processors also known as the carriers to receive electronic copies of
your claims after Medicare has rendered payment of their benefits thus eliminating the need for you to
submit your Part B claims to this Carrier If you completed and returned a GEHA Express
participation form or received notice that you were preenrolled in the GEHA Express program and
did not decline to participate you are included in this program You may call the Plans GEHA
Express tollfree number 8002824342 to obtain additional information about this program
If your Medicare Part B carrier has not made arrangements with this Plan to receive electronic claims
you should initially submit your claims to Medicare and after Medicare has paid its benefits this
Carrier will consider the balance of any covered expenses To be sure your claims are processed by
this Carrier you must submit the Medicare Summary Notice MSN form from Medicare and duplicates
of all bills along with a completed claim form This Carrier will not process your claim without knowing
whether you have Medicare and if you do without receiving the Medicare Summary Notice MSN
Other group insurance coverage When anyone has coverage with us and with another group health plan it is called double coverage
You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan
is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
When this Plan is the secondary payer it will pay the lesser of 1 its benefits in full or 2 a reduced
amount that when added to the benefits payable by the other coverage will not exceed 100 of the
covered expenses When this Plan pays secondary it will only make up the difference between the
primary plans coverage and this Plans coverage Thus combined payments from both plans may not
equal the entire amount billed by the provider
Remember Even if you do not file a claim with your other plan you must still tell us that you have 36
double coverage
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GEHA Health Plan 2000
Section 8 Limitations Rules that affect your benefits continued
When others are responsible for
injuries
Liability insurance Subrogation applies when you are sick or injured as a result of the act or omission of another person and third party
or party If you or your dependent sustain an illness or injury caused by another person the Plan will actions
pay for the illness or injury subject to the requirements outlined below
1 The Plan being reimbursed in full from any recovery or right of recovery you or your dependent
has against that other party and the right if the Plan decides to bring suit in your name 2 your not
taking any action which would prejudice the Plans right to recover the benefits it paid to or for you
and 3 your cooperating in doing what is reasonably necessary to assist the Plan in any recovery
including disclosure of all settlement information requested by the Plan No GEHA benefits will be
paid until any Medpay PIP or NoFault benefits are exhausted
The member is required to notify the Plan when a recovery is received The Plan shall have a lien on
the proceeds of any and all recoveries resulting from an accident or illness caused by another person
or party whether received in an outofcourt settlement or by court order and regardless of how
characterized by the parties ie as pain and suffering The Plans lien shall be satisfied in full out of
the proceeds of such recoveryies prior to the satisfaction of the claimss of any other individual
including but not limited to the Plan enrollee covered family members andor that persons
attorney GEHAs lien extends to and includes payments made by any source including but not limited
to Medpay PIP NoFault 3 rd party and uninsured or underinsured motorists provisions of any auto
policy No reduction in the Plans lien can occur without the Plans written consent The lien remains
the obligation of the member until the Plan is reimbursed Failure to notify the Plan promptly of the
claim for damages or to cooperate with the Plans reimbursement efforts may result in an overpayment
by the Plan subject to recoupment from the member Any reimbursements received by the Plan shall
not exceed the total amount paid by the Plan Payment of benefits prior to the Plans being advised of
the thirdparty claim does not waive the Plans right to withhold benefits where an enrollee or covered
family member has not cooperated in protecting the Plans lien
If you or your dependent are injured by the actions of another person or organization and a claim for
benefits is submitted for the treatment of that injury you are required to promptly notify the
subrogation unit of GEHA of the date circumstances and all pertinent information relating to the loss
The phone number is 8008214742
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military
TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage
Workers We do not cover services that compensation
You need because of a workplacerelated disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly or Government
indirectly pays for Agencies
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GEHA Health Plan 2000
Section 8 Limitations Rules that affect your benefits continued
Overpayments The Carrier will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments
Limit on your costs The information in the following paragraphs applies to you when 1 you are not covered by either if youre age 65 Medicare Part A hospital insurance or Part B medical insurance or both 2 you are enrolled in this
or older and dont Plan as an annuitant or as a former spouse or family member covered by the family enrollment of an have Medicare
annuitant or former spouse and 3 you are not employed in a position which confers FEHB coverage
Inpatient hospital If you are not covered by Medicare Part A are age 65 or older or become age 65 while receiving care inpatient hospital services and you receive care in a Medicare participating hospital the law 5 USC
8904b requires the Plan to base its payment on an amount equivalent to the amount Medicare would
have allowed if you had Medicare Part A This amount is called the equivalent Medicare amount
After the Plan pays the law prohibits the hospital from charging you for covered services after you
have paid any deductibles coinsurance or copayments you owe under the Plan Any coinsurance
you owe will be based on the equivalent Medicare amount not the actual charge You and the Plan
together are not legally obligated to pay the hospital more than the equivalent Medicare amount
The Carriers explanation of benefits EOB will tell you how much the hospital can charge you in
addition to what the Plan paid If you are billed more than the hospital is allowed to charge ask the
hospital to reduce the bill If you have already paid more than you have to pay ask for a refund If you
cannot get a reduction or refund or are not sure how much you owe call the Plan at 8008216136 for
assistance
Physician services Claims for physician services provided for retired FEHB members age 65 and older who do not have Medicare Part B are also processed in accordance with 5 USC 8904b This law mandates the use of
Medicare Part B limits for covered physician services for those members who are not covered by
Medicare Part B
The Plan is required to base its payment on the Medicareapproved amount which is the Medicare fee
schedule for the service or the actual charge whichever is lower If your doctor is a member of the
Plans preferred provider organization PPO and participates with Medicare the Plan will base its
payment on the lower of these two amounts and you are responsible only for any deductible and the
PPO copayment or coinsurance
If you go to a PPO doctor who does not participate with Medicare you are responsible for any
deductible and the copayment or coinsurance In addition unless the doctors agreement with the
Carrier specifies otherwise you must pay the difference between the Medicareapproved amount and
the limiting charge 115 of the Medicareapproved amount
If your physician is not a Plan PPO doctor but participates with Medicare the Plan will base its regular
benefit payment on the Medicareapproved amount For instance under this Plans surgery benefit
the Plan will pay 75 of the Medicareapproved amount You will only be responsible for any
deductible and coinsurance equal to 25 of the Medicareapproved amount
If your physician does not participate with Medicare the Plan will still base its payment on the
Medicareapproved amount However in most cases you will be responsible for any deductible the
coinsurance or copayment amount and any balance up to the limiting charge 115 of the Medicare
approved amount
Since a physician who participates with Medicare is only permitted to bill you up to the Medicare fee
schedule amount even if you do not have Medicare Part B it is generally to your financial advantage
to use a physician who participates with Medicare
The Carriers explanation of benefits EOB will tell you how much the physician can charge you in
addition to what the Plan paid If you are billed more than the physician is allowed to charge ask the
physician to reduce the bill If you have already paid more than you have to pay ask for a refund If
you cannot get a reduction or refund or are not sure how much you owe call the Plan at 8008216136
for assistance
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GEHA Health Plan 2000
Section 9 FeeForService Facts
Precertification Precertification is not a guarantee of benefit payments Precertification of an inpatient admission is a
Precertify before predetermination that based on the information given the admission meets the medical necessity admission requirements of the Plan It is your responsibility to ensure that precertification is obtained I f
precertification is not obtained and benefits are otherwise payable benefits for the admission will be
reduced by 500
To precertify a scheduled admission
You your representative your doctor or your hospital must call Intracorp prior to admission The tollfree number is 800747GEHA 8007474342 and is available 24 hours per day
Provide the following information enrollees name and Plan identification number patients name birth date and phone number reason for hospitalization proposed treatment or surgery
name of hospital or facility name and phone number of admitting doctor and number of planned
days of confinement
Intracorp will then tell the doctor and hospital the number of approved days of confinement for the
care of the patients condition Written confirmation of the Carriers precertification decision will be
sent to you your doctor and the hospital If the length of stay needs to be extended follow the
procedures below
Need additional A review coordinator will contact your doctor before the certified length of stay ends to determine if days you will be discharged on time or if additional inpatient days are medically necessary If the admission
is precertified but you remain confined beyond the number of days certified as medically necessary
the Plan will not pay for charges incurred on any extra days that are determined to not be medically
necessary by the Carrier during the claim review
You dont need to Medicare Part A or another group health insurance policy is the primary payer for the hospital certify an admission
confinement see pages 3435 Precertification is required however when Medicare hospital when
benefits are exhausted prior to using lifetime reserve days
You are confined in a hospital outside the United States and Puerto Rico
Maternity or When there is an unscheduled maternity admission or an emergency admission due to a condition that emergency admissions puts the patients life in danger or could cause serious damage to bodily function you your
representative the doctor or the hospital must telephone 800747GEHA within two business days
following the day of admission even if the patient has been discharged from the hospital Otherwise
inpatient benefits otherwise payable for the admission will be reduced by 500
Newborn confinements that extend beyond the mothers discharge date must also be certified You
your representative the doctor or hospital must request certification for the newborns continued
confinement within two business days following the day of the mothers discharge Intracorp offers a
high risk pregnancy program at no cost to you To take full advantage of this service and obtain
valuable information concerning prenatal care you should call Intracorp at 800747GEHA as soon as
your pregnancy is confirmed
Other considerations An early determination of need for confinement precertification of the medical necessity of inpatient admission is binding on the Carrier unless the Carrier is misled by the information given to it After
the claim is received the Carrier will first determine whether the admission was precertified and then
provide benefits according to all of the terms of this brochure
If you do not If precertification is not obtained before admission to the hospital or within two business days precertify following the day of a maternity or emergency admission or in the case of a newborn the mothers
discharge a medical necessity determination will be made at the time the claim is filed If the Carrier
determines that the hospitalization was not medically necessary the inpatient hospital benefits will not
be paid However medical supplies and services otherwise payable on an outpatient basis will be
paid 39
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GEHA Health Plan 2000
Section 9 FeeForService Facts continued
If the claim review determines that the admission was medically necessary any benefits payable
according to all of the terms of this brochure will be reduced by 500 for failing to have the admission
precertified
If the admission is determined to be medically necessary but part of the length of stay was found not
to be medically necessary inpatient hospital benefits will not be paid for the portion of the
confinement that was not medically necessary However medical services and supplies otherwise
payable on an outpatient basis will be paid
Protection against catastrophic costs
Catastrophic For those services with coinsurance the Plan pays 100 of reasonable and customary charges for protection
the remainder of the calendar year after outofpocket expenses for coinsurance exceed
3000 for Self and Family and 2500 for Self Only if you use PPO providers
4000 for Self and Family and 3500 for Self Only if you use nonPPO providers Any of the above expenses for PPO providers also count toward this limit Therefore your eligible out of
pocket expenses will not exceed this amount whether or not you use PPO providers
Outofpocket expenses for purposes of this benefit are
The 10 you pay for PPO charges under Inpatient Hospital Other Charges Outpatient Hospital Charges and Other Medical and Surgical Benefits
The 25 you pay for NonPPO charges under Inpatient Hospital Other Charges Outpatient Hospital Charges Other Medical Surgical and Maternity Benefits
The following cannot be counted toward outofpocket expenses
The 300 calendar year deductible
The 15 copayment for doctors office visits
The 75 copayment for hospital emergency room expenses
Expenses in excess of reasonable and customary charges or maximum benefit limitations
Expenses for well child care and immunization
Expenses for mental conditions substance abuse dental and chiropractic care
Any amounts you pay because benefits have been reduced for noncompliance with this Plans cost containment requirements see pages 7 and 39
Expenses for prescription drugs purchased through retail or Mail Order Drug Program
Mental conditions The Plan pays 100 of reasonable and customary charges for the remainder of the calendar year up and outpatient
to the calendar year day or visit maximum after the 500 deductible is met if outofpocket expenses for substance abuse
inpatient or outpatient mental conditions and outpatient substance abuse treatment total 8000 for all benefits
family members combined in that calendar year
Outofpocket expenses for purposes of this benefit are
500 deductible for Inpatient Hospital and Intensive Day Treatment under the Mental Conditions Substance Abuse Benefit
The 50 you pay for inpatient hospital and intensive day treatment expenses
The 50 you pay for inpatient visits
The 50 you pay for outpatient care
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GEHA Health Plan 2000
Section 9 FeeForService Facts continued
The following cannot be included in the accumulation of outofpocket expenses
Expenses in excess of reasonable and customary charges or maximum benefit limitations
Expenses for outpatient psychotherapy sessions in excess of 30 sessions per year
Expenses for inpatient care in excess of 100 days per year
Expenses for inpatient provider visits in excess of 100 visits per year
Expenses for Intensive Day Treatment in excess of 60 days per year
Any amounts you pay because benefits have been reduced for noncompliance with this Plans cost containment requirements see page 39
Expenses for prescription drugs purchased through retail or Mail Order Drug Program
Expenses in excess of the 50 of reasonable and customary charges for inpatient substance abuse charges
Carryover If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1 any expenses that would have applied to that
plans catastrophic protection benefit during the prior year will be covered by your old plan if they are
for care you got in January before the effective date of your coverage in this Plan If you already met
the covered outofpocket maximum expense level in full your old plans catastrophic protection
benefit will continue to apply until the effective date If you have not met this expense level in full
your old plan will first apply your covered outofpocket expenses until the prior years catastrophic
level is reached and then apply the catastrophic protection benefit to covered outofpocket expenses
incurred from that point until the effective date The old plan will pay these covered expenses
according to this years benefits benefit changes are effective on January 1
Definitions
Accidental injury An injury caused by an external force or element such as a blow or fall that requires immediate medical attention Also included are animal bites poisonings and dental care required to repair injuries to
sound natural teeth as a result of an accidental injury not from biting or chewing
Admission The period from entry admission into a hospital or other covered facility until discharge In counting days of inpatient care the date of entry and the date of discharge are counted as the same day
Assignment An authorization by an enrollee or spouse for the Carrier to issue payment of benefits directly to the provider The Carrier reserves the right to pay the member directly for all covered services
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
Congenital A condition existing at or from birth which is a significant deviation from the common form or norm anomaly For purposes of this Plan congenital anomalies include cleft lips cleft palates birthmarks webbed
fingers or toes and other conditions that the Carrier may determine to be congenital anomalies In no
event will the term congenital anomaly include conditions relating to teeth or intraoral structures
supporting the teeth
Cosmetic procedure Any procedure or any portion of a procedure performed primarily to improve physical appearance and or treat a mental condition through change in bodily form
Custodial care Treatment or services regardless of who recommends them or where they are provided that could be rendered safely and reasonably by a person not medically skilled or that are designed mainly to help
the patient with daily living activities These activities include but are not limited to
1 personal care such as help in walking getting in and out of bed bathing eating by spoon tube
or gastrostomy exercising dressing
2 homemaking such as preparing meals or special diets
3 moving the patient 41
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GEHA Health Plan 2000
Section 9 FeeForService Facts continued
4 acting as companion or sitter
5 supervising medication that can usually be self administered or
6 treatment or services that any person may be able to perform with minimal instruction including
but not limited to recording temperature pulse and respirations or administration and monitoring
of feeding systems
The Carrier determines which services are custodial care
Durable medical Equipment and supplies that equipment
1 are prescribed by your attending doctor
2 are medically necessary
3 are primarily and customarily used only for a medical purpose
4 are generally useful only to a person with an illness or injury
5 are designed for prolonged use and
6 serve a specific therapeutic purpose in the treatment of an illness or injury
Effective date The date the benefits described in this brochure are effective
1 January 1 for continuing enrollments and for all annuitant enrollments
2 the first day of the first full pay period of the new year for enrollees who change plans or options
or elect FEHB coverage during the open season for the first time or
3 for new enrollees during the calendar year but not during the open season the effective date of
enrollment as determined by the employing office or retirement system
Elective surgery Any nonemergency surgical procedure that may be scheduled at the patients convenience without jeopardizing the patients life or causing serious impairment to the patients bodily functions
Experimental or See page 10 Investigational
Expense An expense is incurred on the date the service or supply is rendered
Group health Health care coverage that a member or covered dependent is eligible for because of employment by coverage membership in or connection with a particular organization or group that provides payment for
hospital medical dental or other health care services or supplies including extension of any of these
benefits through COBRA
Hospice care A coordinated program of home and inpatient palliative and supporting care for the terminally ill program patient and the patients family that is provided by a medically supervised team under the direction of
a Plan approved independent Hospice Administration
Hospice care agency an agency or organization which meets all of the following
1 provides hospice care 24 hours a day
2 is certified by Medicare as such or is licensed or accredited as such by the jurisdiction it is in
3 is staffed by at least one doctor MD DO one RN one licensed or certified social worker and
has a fulltime administrator
4 provides for skilled nursing services medical social services psychological counseling dietary
counseling and
5 provides an ongoing quality assurance program
Infertility The inability to conceive after a year of unprotected intercourse or the inability to carry a pregnancy to term
Intensive Outpatient treatment of mental condition or substance abuse rendered at and billed by a facility that day treatment meets the definition of a hospital Treatment program must be established which consists of
individual or group psychotherapy andor psychological testing
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GEHA Health Plan 2000
Section 9 FeeForService Facts continued
Medically Services drugs supplies or equipment provided by a hospital or covered provider of the health care necessary services that the Carrier determines
1 are appropriate to diagnose or treat the patients condition illness or injury
2 are consistent with standards of good medical practice in the United States
3 are not primarily for the personal comfort or convenience of the patient the family or the
provider
4 are not a part of or associated with the scholastic education or vocational training of the patient
and
5 in the case of inpatient care cannot be provided safely on an outpatient basis
The fact that a covered provider has prescribed recommended or approved a service supply drug or
equipment does not in itself make it medically necessary
Mental conditions Conditions and diseases listed in the most recent edition of the International Classification of substance abuse Diseases ICD as psychoses neurotic disorders or personality disorders other nonpsychotic mental
disorders listed in the ICD to be determined by the Carrier or disorders listed in the ICD requiring
treatment for abuse of or dependence upon substances such as alcohol narcotics or hallucinogens
Prompt repair The Carrier considers prompt repair of an accidental injury to be services rendered within the consecutive 90day period following the date of an accidental injury or as soon as the members
medical condition permits
Reasonable and The Carrier allows benefits unless otherwise indicated to the extent that they are reasonable and customary customary The reasonable and customary charge for any service or supply is the usual charge for the
service or supply in the absence of insurance The usual charge may not be more than the general
level of reasonable and customary charges for illness or injury of comparable severity and nature made
by other providers within the geographic area in which the service or supply is provided This is
generally determined by the use of prevailing health care charges guides such as that prepared by the
Health Insurance Association of American HIAA and is updated at least annually HIAA guides are
applied at the 80 th percentile to surgery doctors services therapy physical speech and
occupational Xray and lab expenses The Carrier may apply charge guides for other services such
as anesthesiology or outpatient facility charges as such data become available When there are
exceptions to this general method of determining the reasonable and customary charge such as when
HIAA data is unavailable or services occur infrequently the Carrier may determine the reasonable and
customary charge based on other credible data sources available such as charge guides prepared by
Medical Data Research MDR applied at a comparable percentile level and statistically derived
charges developed by the Carrier or by MediRisk Inc The Carrier may also conduct independent
geographic surveys to determine the usual cost of a service or supply in the area If the Carrier
negotiates a reduced fee amount on an individual claim for services or supplies which is lower than the
reasonable and customary amount covered benefits will be limited to the negotiated amount Your
coinsurance will be based on the reduced fee amount When a PPO provider is used or when the Plan
negotiates with a nonPPO provider a reduced fee amount on an individual claim the fee that has been
negotiated is considered the reasonable and customary charge
Sound natural Sound and Natural Tooth is a whole or properly restored tooth that has no condition that would tooth weaken the tooth or predispose it to injury prior to the accident such as decay periodontal disease
or other impairments For purposes of the Plan damage to a restoration such as a prosthetic crown or
prosthetic dental appliances ie bridgework would not be covered as there is no injury to the natural
tooth structure
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GEHA Health Plan 2000
Section 10 FEHB Facts
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to to the following information about your health plan its networks providers and facilities You can also find out about
information care management which includes medical practice guidelines disease management programs and how
we determine if procedures are experimental or investigational OPMs website wwwopmgov lists
the specific types of information that we must make available to you
If you want specific information about us call 8008216136 or write to GEHA PO Box 4665
Independence Missouri 640514665 You may also contact us by fax at 8162573233 or visit our
website at wwwgehacom
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We dont determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled when I retire in the FEHB Program for the last five years of your Federal service If you do not meet this
requirement you may be eligible for other forms of coverage such as Temporary Continuation of
Coverage which is described later in this section
What types of SelfOnly coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for me retirement office authorizes coverage for Under certain circumstances you may also get coverage for and my family
a disabled child 22 years of age or older who became incapable of selfsupport before 22
If you have a SelfOnly enrollment you may change to a Self and Family enrollment if you marry give
birth or add a child to your family You may change your enrollment 31 days before to 60 days after
you give birth or add the child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or becomes an eligible
family member
Your employing or retirement office will not notify you when a family member is no longer eligible to
receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
Are my medical We will keep your medical and claims information confidential Only the following will have access to and claims records it
confidential OPM this Plan and our subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and subrogating claims
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GEHA Health Plan 2000
Section 10 FEHB Facts continued
Law enforcement officials when investigating andor prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
As part of its administration of the prescription drug benefits the Plan may disclose information about
the members prescription drug utilization including the names of prescribing physicians to any
treating physicians or dispensing pharmacies
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF cards 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an
Employee Express confirmation letter
What if I paid a Your old plans deductible continues until our coverage begins deductible under
my old plan
Preexisting We will not refuse to cover the treatment of a condition that you or a family member had before you conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in
Your enrollment ends unless you cancel your enrollment or this Plan ends
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage your spouses enrollment But you may be eligible for your own FEHB coverage under the spouse
equity law If you are recently divorced or are anticipating a divorce contact your exspouses
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can receive TCC if
you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired
from your Federal job due to gross misconduct
Get the RI 7927 which describes TCC and the RI 705 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
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GEHA Health Plan 2000
Section 10 FEHB Facts continued
You pay the total premium and generally a 2percent administrative charge The government does not share your costs
You receive another 31day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC in TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60
days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in
TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60day deadline
How can I convert You may convert to an individual policy if to individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage
due to preexisting conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of
leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for
health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well
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GEHA Health Plan 2000
Department of DefenseFEHB Demonstration Project
What is the The National Defense Authorization Act for 1999 Public Law 105261 established the DoDFEHBP Department of Demonstration Project It allows some active and retired uniformed service members and their
Defense DoD and dependents to enroll in the FEHB Program The demonstration will last for three years beginning with FEHB Program
the 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000 Demonstration
DoD and OPM have setup some special procedures to successfully implement the Demonstration Project
Project noted below Otherwise the provisions described in this brochure apply
Who is Eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for Medicare
You are a qualified former spouse of an active or retired uniformed service member and you have not remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you
are not eligible to enroll under the DoDFEHBP Demonstration Project
Where are the Dover AFB DE demonstration
Commonwealth of Puerto Rico areas
Fort Knox KY
GreensboroWinston SalemHigh Point NC
Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA
When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through
December 13 1999 Your coverage will begin January 1 2000 DoD has setup an Information
Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff will
verify your eligibility and provide you with FEHB Program information plan brochures enrollment
instructions and forms The tollfree phone number for the IPC is 877DODFEHB 8773633342
You may select coverage for yourself SelfOnly or for you and your family Self and Family during
the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following the
Open Season that you enrolled
If you become eligible for the DoDFEHBP Demonstration Project outside of Open Season contact the
IPC to find out how to enroll and when your coverage will begin
DoD has a web site devoted to the Demonstration Project You can view information such as their
MarketingBeneficiary Education Plan Frequently Asked Questions demonstration area locations and
zip code lists at wwwtricareosdmilfehbp You can also view information about the demonstration
project including The 2000 Guide to Federal Employees Health Benefits Plans Participating in the
DoDFEHBP Demonstration Project on the OPM web site at wwwopmgov
Am I eligible for See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the only Temporary
individual eligible for TCC is one who ceases to be eligible as a member of family under your Self Continuation of
and Family enrollment This occurs when a child turns 22 for example or if you divorce and your Coverage TCC
spouse does not qualify to enroll as an unremarried former spouse under title 10 United States Code
For these individuals TCC begins the day after their enrollment in the DoDFEHBP Demonstration
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GEHA Health Plan 2000
Department of DefenseFEHB Demonstration Project continued
Project ends TCC enrollment terminates after 36 months or the end of the Demonstration Project
whichever occurs first You your child or another person must notify the IPC when a family member
loses eligibility for coverage under the DoDFEHBP Demonstration Project
TCC is not available if you move out of a DoDFEHBP Demonstration Project area you cancel your
coverage or your coverage is terminated for any reason TCC is not available when the demonstration
project ends
Do I have the 31day These provisions do not apply to the DoDFEHBP Demonstration Project extension and
right to convert
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 8008216136 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
2024183300
US Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington DC 20415
Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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GEHA Health Plan 2000
Index
A Environmental medicine 33 Oral surgery 17 29
ABMTBreast cancer 16 17 Exclusions 32 33 Organtissue transplant 15 16
Abortion 19 32 Experimental 10 32 42 Outofpocket 40
Accidental injury benefits 17 24 41 Eye examglasses 24 30 Oxygen 13 21
Allergy tests 20 22 F P
Ambulance 21
Ambulatory surgical center 9 Family limit 8 Physical therapy 24 31
Anesthesia 15 20 Fecal occult blood test 22 Physician services 20 38
Artificial insemination 19 Flexible benefits option 7 Point of Service POS 7
Assignment 31 32 41 Freestanding ambulatory facility 9 Precertification 5 7 13 19 39
Assistant surgeon 15 Preferred providers 5 6 7
Assisted reproductive technology 19 G Prescription drugs 25 26 27 28
Gamete intrafallopian transfer GIFT 19 Private room 13 B Psychotherapy 20 41
Blood 13 21 H
Bone marrow transplant 15 16 R Home uterine devices 19
Breast cancer screening 22 Hospice 9 23 42 Radiation therapy 21
Breast prosthesis 15 21 Hospital 9 10 13 14 Reasonable and
customary 14 18 19 20 33 40 43
C I Registered nurse 24 31 33
Calendar year deductible 8 40 41 Renal dialysis 21 Impacted teeth 17 Routine services 22 25
Carryover 8 41 Incidental procedures 14
Casting 21 Infertility 18 19 25 42 S
Catastrophic protection 20 40 Inpatient hospital 13 14 38
Chiropractic 22 40 Intensive day treatment 20 41 42 Sigmoidoscopy 6 22
Coinsurance 6 8 Skilled nursing care 24 31 33
Congenital anomaly 15 41 L Skilled nursing facility 9 10
Contact lenses 21 24 30 Smoking cessation benefit 9 24 25
Contraceptives 18 26 Laboratory and pathological Speech therapy 23 31
Conversion 46 services 20 21 Sterilization 15 17 18
Coordination of Licensed practical nurse 24 31 33 Subrogation 37
benefits 27 28 34 35 36 Lifetime maximums 9 19 23 Substance Abuse 9 19 35 40 41 43
Cosmetic surgery 17 33 41 Surgery 14 15 16 17
Cost containment 7 M
Covered facility 9 10 Mail order drugs 26 27 28 T
Covered provider 10 Mammograms 22 Temporomandibular joints 17 24
Crutches 23 Maternity benefits 17 18 19 39 40 Transplant 15 16
Custodial care 14 24 41 Medicaid 37
Medically necessary 43 V
D Medicare 26 27 33 34 35 36 39
Mental conditions Vision therapy 9 24 Days certified 39
benefit 19 20 40 41 43 Vitamins 25 30 Deductible 6 7
Midwife 10 18 Dental 14 24 29 30 40 43
Multiple surgical procedures 14 W Department of Defense DoD
Well child care 18 25 40 Demonstration Project 47 48
N Wheelchair 23 Diabetic supplies 25 26
Workers compensation 37 Disputed claims 11 12 13 NoFault 37
Donor expense 15 16 NonFEHB benefits 30 X
Drugs 25 26 27 28 30 31 32 40 41 Nursing 24 31 33
Durable medical Xray 13 20 21
equipment 9 23 31 42 O
Obstetrical care 10 18 E
Occupational therapy 23 31 Emergency admission 39
Oral contraceptives 18 26 49
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GEHA Health Plan 2000
Summary of Benefits for GEHA Benefit Plan 2000
Do not rely on this chart alone All benefits are subject to the definitions limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in this Plan
be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure All items below with an asterisk are subject to the 300 calendar year deductible When Medicare A B is primary refer to This Plan and Medi
care section on page 34 for description of waiver of deductible coinsurance and reduced copayments
Benefits Plan paysprovides Page
Inpatient Hospital PPO benefit 100 room and board 90 of other hospital charges
NonPPO benefit 100 room and board 75 of other hospital charges 1314
Surgical PPO benefit 90 of covered surgical charges
NonPPO benefit 75 of covered surgical charges including oral surgery 1417
Medical PPO benefit 90 of covered professional services
NonPPO benefit 75 of covered professional services 2023
Maternity PPO benefit 100 of covered services
NonPPO benefit Same benefits as for illness or injury 1719
Mental 50 of covered hospital charges after a separate 500 deductible has been met
Conditions For professional services the Plan pays 50 of the reasonable and customary charge of
covered providers for hospital visits including psychotherapy sessions Inpatient days and
provider inpatient visits are limited to 100 per calendar year 1920
Substance One inpatient substance abuse treatment program 30 day maximum per member per lifetime
Abuse The Plan pays 50 of the reasonable and customary charges subject to the 500 hospital
inpatient and intensive day treatment deductible 19
Outpatient Hospital PPO benefit 90 of covered hospital charges
NonPPO benefit 75 of covered hospital charges 2122
Surgical PPO benefit 90 of covered surgical charges
NonPPO benefit 75 of covered surgical charges including oral surgery 1417
Medical PPO benefit 15 copay per covered office visits and 90 of other covered professional
services including Xray and lab
NonPPO benefit 75 of other covered professional services 2023
Maternity PPO benefit 100 of covered services
NonPPO benefit Same benefits as for illness or injury 1719
Skilled Nursing PPO benefit 90 limited to two hours per day for 25 visits in a calendar year
Care NonPPO benefit 75 limited to two hours per day for 25 visits in a calendar year 24
Mental For professional services the Plan pays covered providers for home and office visits for
Conditions psychotherapy sessions including group sessions up to a maximum of 30 sessions per
Substance calendar year and up to a maximum payable of 50 of the reasonable and customary charge
Abuse per session The Plan pays 50 for Intensive Day Treatment up to 60 visits per year subject
to the inpatient and intensive day treatment 500 deductible 1920
Emergency Accidental Injury 100 of covered charges no deductible incurred within 72 hours of an accident 24
Care Illness 75 copayment for outpatient hospital emergency room charges 21
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GEHA Health Plan 2000
Summary of Benefits for GEHA Benefit Plan 2000 continued
Prescription From a Member pays 5 for generic drugs or 15 for brand name for 30day supply for initial prescription
drugs pharmacy and one refill Subsequent refills are paid at 50 26
By mail Member pays 10 for generic drugs 30 for brand name for 90day supply of maintenance
medications and oral contraceptives 2627
Dental care Routine preventive dental care and accidental injury to sound natural teeth 29
Additional Accidental injury Well Child Care 24Hour nurse phone service 2425
Protection against 100 after applicable coinsurance reaches 3000 Self and Family or 2500 Self Only
catastrophic costs for PPO providers 4000 Self and Family or 3500 Self Only for nonPPO providers 40
100 for Mental Conditions and Outpatient Substance Abuse Benefits after applicable
coinsurances and deductible reach 8000 for all covered family members combined No benefits
are payable for inpatient days and visits in excess of 100 or Intensive Day Treatment in excess
of 60 days per calendar year 4041
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Page 52
2000 Rate Information for
Government Employees Hospital Association Inc GEHA
Benefit Plan
NonPostal rates apply to most nonPostal enrollees If you are in a special enrollment category refer to the FEHB Guide for
that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career US Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a
member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health
Benefits Plans for United States Postal Service Employees RI 702 to determine which rate applies to you
Postal rates do not apply to noncareer postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to
Federal Employees Health Benefits Plans
NonPostal Premium Postal Premium A Postal Premium B
B iweekly Monthly Biweekly Biweekly
Type of Govt Y our Govt Y our USPS Y our USPS Y our
Enrollment Code Share Share Share Share Share Share Share Share
Self Only 311 7883 4572 17080 9906 9306 3149 9326 3129
Self and Family 312 17597 9267 38127 20078 20774 6090 20102 6762
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