Pages 1--45 from Q050553 copy

For changes its
in benef pages
see 4 5

Sponsored by the U S Secret Service Employees Health Association

Who may enroll in this Plan Only employees and retirees of the U S Secret Service are eligible to be enrolled in this Plan

To become a member or associate member To be enrolled you must be or must become a member of the U S Secret Service Employees Health Association
Membership dues There is a one time only fee of 5 New members will be billed dues when the Plan receives notice of enrollment

Enrollment code for this Plan Y71 Self Only
Y72 Self and Family

Visit the OPM website at http www opm gov insure and
our website at http www carefirst com

Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service

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SSEHA Health Benefit Plan 2000
Table of Contents
Page
Introduction 3

Plain Language 3
How To Use This Brochure 3 4
Section 1 Fee For Service Plans 4
Section 2 How We Change For 2000 .4
Section 3 How To Get Benefits 4 8
Section 4 What If We Deny Your Claim Or Request For Pre Authorization 9
Section 5 Benefits 11 22
Section 6 How To File A Claim 23 25
Section 7 General Exclusions Things We Don't Cover 26
Section 8 Limitations Rules That Affect Your Benefits 26 31
Section 9 Fee For Service Facts 31 36
Section 10 FEHB FACTS 37 40
Inspector General Advisory Stop Healthcare Fraud 41
Summary Of Benefits Inside back cover
Premiums Back cover

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SSEHA Health Benefit Plan 2000
Introduction
U S Secret Service Employees Health Association SSEHA Health Benefit Plan 950 H Street NW Washington DC 20001
This brochure describes the benefits you can receive from U S Secret Service Employees Health Association SSEHA Health
Benefit Plan under its contract CS2276 with the Office of Personnel Management OPM as authorized by the Federal Employees
Health Benefits FEHB law This Plan is underwritten by CareFirst BlueCross BlueShield CareFirst

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 page 4 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 Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary
technical terms you and other personal pronouns active voice and short sentences

We refer to SSEHA Health Benefit Plan 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

How To Use This Brochure
This brochure has ten sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons
easier

1 Fee for Service Plan FFS This Plan is a FFS Plan Turn to this section for a brief description of Fee for Service 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 to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not
to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits

6 How to file a claim Look here to find specific information on how to file claims with us
7 General exclusions Things we don't 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

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SSEHA Health Benefit Plan 2000
How To Use This Brochure continued

9 Fee for Service Facts This section contains information about pre certification protection against catastrophic expenses and a
definition section

10 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

Section 1 Fee For Service Plans
Fee for service plans reimburse you or your provider for covered services They do not typically provide or arrange for health care
Fee for service plans let you to 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

Section 2 How We Change For 2000
Program wide changes This year you have a right to more information about this Plan care management our networks facilities and providers

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 10 for Self Only or 10 for Self and Family
The Plan has changed to a new drug vendor Advanced Paradigm Inc API for both the Retail
Pharmacy and Mail Order Program Your benefits have not changed Please see page 31 33 for
more detailed information

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 fee for service plans include two specific provisions in their benefits
packages precertification of all inpatient admissions and flexible benefits option Some
include managed care options such as PPO's 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 hospital days required to treat your condition You are responsible for ensuring that the precertification
requirement is met You or your doctor must check with your Carrier before being admitted to
the hospital If that doesn't happen your Carrier will reduce benefits by 500 Be a responsible

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SSEHA Health Benefit Plan 2000
Section 3 How To Get Benefits continued
How do I keep my health expenses down continued
Precertification continued consumer Be aware of your Carrier's cost containment provisions You can avoid penalties and help keep premiums under control by following the procedures specifies on pages 31 32 of this
brochure
Flexible benefits option Under the flexible benefits option the Carrier has the authority to determine the most effective way to provide services The Carrier may identify medically appropriate alternatives to traditional
care and coordinate the provisions 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 Carrier's
and may be withdrawn at any time It is not subject to OPM review under the disputed claims
process

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 expenses an individual must incur for covered services and supplies before the Carrier starts paying benefits for the expense involved A deductible is not reimbursable
by the Carrier and benefits paid by the Carrier do not count toward a deductible When
a benefit is subject to a deductible only expenses allowable under that benefit count toward the
deductible

Calendar year The calendar year deductible is the amount of expense an individual must incur for covered services and supplies each calendar year before the Carrier pays certain benefits The deductible is
200 per person for Surgical Maternity and Other Medical Benefits and is not reimbursable by
the Carrier Separate deductibles may apply to benefits for mental conditions and substance
abuse and to admissions under Inpatient Hospital Benefits and are not reimbursable by the
Carrier

Other There is a 100 per admission deductible which applies to inpatient hospital expenses and a separate 200 deductible per person per calendar year which applies to all covered inpatient treatment
of mental conditions and substance abuse services
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 plan's
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 year's benefits benefit changes are effective on January 1

Family limit Under family enrollment when the expenses applied to the deductible for all family members reach 400 the family deductible is met and benefits are payable for all family members The
family deductible does not apply to the per admission inpatient hospital deductible
Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductible The Carrier will base this percentage on either the billed charge or the
Carrier allowance whichever is less For instance when a Carrier pays 80 of Carrier allowance
for a covered service you are responsible for the 20 coinsurance In addition you may be
responsible for any excess charge over the Carrier's allowance For example if the provider
ordinarily charges 100 for a service but the Carrier allowance is 95 Carrier will pay 80 of
the allowance 76 You must pay the 20 coinsurance 19 plus the difference between the
actual charge and the Carrier allowance 5 for a total member responsibility of 24 5 5
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SSEHA Health Benefit Plan 2000
Section 3 How To Get Benefits continued
How do I keep my health expenses down continued
Copayments A copayment is the stated amount the Plan may require you to pay for a covered service such as 5 per prescription for generic and 12 per prescription for brand name drug by mail or from a
pharmacy
If provider waives If a provider routinely waives does not require you to pay your share for services rendered the your share Carrier is not obligated to pay the full percentage of the amount of the charge it would otherwise
have paid of the provider's original charge A provider or supplier who routinely waives copayments
or deductibles is misstating the actual charge and when doing so may be in violation of the
law and subjecting you to a benefit calculated from an amount less than the misstated charge the
lesser amount being the actual charge The Carrier will only pay the percentage of the fee actually
charged For example if the provider ordinarily charges 100 for a service but waives the
20 coinsurance the actual charge is 80 The carrier will pay 64 80 of the actual charge
of 80

Lifetime maximums Hospice benefits are limited to 180 days per lifetime with 45 reserve days
Smoking cessation benefits are limited to one program per member per lifetime

Do I have to You usually do not have to submit claims to us if you use participating providers If you file a submit claims claim please send us all of the documents for your claim as soon as possible You must submit
claims by December 31 of the year after the year you received the service Either OPM or we
can extend this deadline if you show that circumstances beyond your control prevented you from
filing on time

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 Fee for Service Plan you may choose any covered facility or provider health care

What is covered Benefits under this Plan are available both in facilities such as hospitals and from providers such as pharmacies doctors and other health care personnel who provide covered services
Covered facilities
Ambulatory A facility accredited by the Joint Commission on Accreditation of Health Care Organizations or surgical facility approved by the Carrier designed for the treatment of minor elective surgical procedures on an
ambulatory basis
Extended care A facility approved by the Carrier or eligible for payment under Medicare possessing an facility organized medical staff providing continuous non custodial inpatient care for convalescent
patients not requiring acute hospital care yet not at a stable stage of illness
Hospice A facility which provides short periods of stay for a terminally ill person in a home like setting for either direct care or respite This facility may be either free standing or affiliated with a
hospital It must operate as an integral part of the hospice care program
Hospital A facility conforming to the standards of and accredited by the Joint Commission on Accreditation of Health Care Organizations providing inpatient diagnosis and therapeutic facilities
for surgical and medical diagnosis treatment and care of injured and sick persons by or
under the supervision of a staff of licensed doctors of medicine M D or licensed doctors of

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SSEHA Health Benefit Plan 2000
Section 3 How To Get Benefits continued
Covered facilities continued
Hospital continued osteopathy D O The hospital must provide continuous 24 hour a day professional registered nursing R N services and may not be an extended care facility other than an approved ECF a
nursing home a place of rest an institution for exceptional children the aged drug addicts or
alcoholics or custodial or domiciliary institution having the primary purpose of furnishing food
shelter training or non medical personal services This definition includes college infirmaries
and Veterans Administration hospitals

Non participating A hospital not having at the time services are rendered a participating agreement with the Blue hospital Cross Plan in the area where services are rendered College infirmaries and Veterans
Administration hospitals are considered non participating hospitals The Carrier may at its discretion
recognize any institution located outside the 50 States and District of Columbia as a nonparticipating
hospital

Participating A hospital having at the time services are rendered a participating agreement with the Blue hospital Cross Plan in the area where services are rendered and thereby agreeing to complete and file
claims for covered hospital billed services on behalf of covered patients to admit covered
patients without requiring admission deposits and to accept benefit payments directly from the
Blue Cross Plan with which the hospital participates

Cancer research Approved Cancer Research Facility A facility that is facility
1 a National Cooperative Cancer Study Group Institution that is funded by the National Cancer
Institute NCI and has been approved by a Cooperative Group as a bone marrow transplant
center

2 a NCI designated Cancer Center or
3 an Institution that has an NCI funded peer review grant to study allogeneic bone marrow
transplants of autologous bone marrow transplants autologous stem cell support and autologous
peripheral stem cell support

Renal dialysis center A freestanding facility approved by the Carrier and designed specifically for the treatment of chronic renal disease
Covered providers For purposes of this Plan covered providers include
1 a licensed doctor of medicine M D or a licensed doctor of osteopathy D O
2 a licensed or certified chiropractor nurse anesthetist dentist podiatrist occupational therapist
and speech therapist practicing within the scope of their license or certification and

3 other covered providers who may render services without the supervision of an M D but for
whom the Carrier provides benefits include a qualified clinical psychologist clinical social
worker optometrist nurse midwife and nurse practitioner clinical specialist 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 underserved areas be 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

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SSEHA Health Benefit Plan 2000
Section 3 How To Get Benefits continued
Covered facilities continued
What do I do if I'm First call our customer service department at 800 424 7474 extension 6039 or 202 479 6039 in the hospital when If you are new to the FEHB Program we will reimburse your covered expenses If you are
I join this Plan currently in the FEHB Program and are switching to 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 serious illness and to continue seeing your provider for up to 90 days after you receive notice that we are
my provider leaves terminating our contract with the provider unless the termination is for cause If you are in the the Plan or this Plan second or third trimester of pregnancy you may continue to see your OB GYN until the end of
leaves the Program your postpartum care
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
OB GYN care you receive from your current provider until the end of your postpartum care

If you continue seeing your specialist or OB GYN under these conditions your cost will be no
more than you would normally pay for the services covered

How do you decide if A drug device or biological product is experimental or investigational if the drug device or a service is experimental biological product cannot lawfully be marketed without approval of the U S Food and Drug
or investigational Administration FDA and approval for marketing has not been given at the time it is furnished Approval means all forms of acceptance by the FDA

Experimental A medical treatment or procedure or a drug device or biological product is experimental or or Investigational 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 medical treatment or procedure is that further studies or clinical trials are necessary
to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy
as compared with 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 protocol
s 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 or medical treatment or procedure If you desire additional
information concerning the experimental investigational determination process please contact the
Plan

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SSEHA Health Benefit Plan 2000
Section 4 What If We Deny Your Claim Or Request For Pre Authorization
What should I do Before you ask us to reconsider your claim you should first check with your provider or facility before filing a to be sure that the claim was filed correctly For instance did the provider use the correct
disputed claim procedure code for the services performed surgery laboratory test X ray 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 services or won't pay your claim you may ask us to reconsider our decision Your
request must

1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this
time limit if you show that you were unable to make a timely request due to reasons beyond
your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 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 to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service
What if I have a serious Call us 800 424 7474 extension 6039 or 202 479 6039 and we will expedite our review or life threatening condition
and you haven't responded to my request for
pre authorization
What if you have denied If we expedite your review due to a serious medical condition and deny your request we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is serious OPM's health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life threatening or life 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 time limits initial 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

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SSEHA Health Benefit Plan 2000
Section 4 What If We Deny Your Claim Or Request For Pre Authorization continued
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information

1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms

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

If you want OPM to review different claims you must clearly identify which documents apply to
which claim

Who can make 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
person's representative They must send a copy of the person's specific written consent with
the review request

Where should I mail my Send your request for review to Office of Personnel Management disputed claim to OPM Office of Insurance Programs
Contracts Division II
P O Box 436
Washington DC 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision your only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information
to support the disputed claim decision If you file a lawsuit this information will become
part of the court record

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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS
Inpatient Hospital Benefits
What is covered The Plan pays for inpatient hospital services as shown below
After a 100 per admission deductible the Carrier pays 100 of room and board and other covered
charges for covered services and supplies when furnished by a hospital and payable as a
regular hospital service in both Participating and Non Participating hospitals and 100 of the
per diem charge in United States Health Service and Armed Forces hospitals

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 pages 31 32 for details

Wai ve r This precertification requirement 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 pages 27 28
Room and board The Plan provides benefits for charges for a semi private room meals including special diets and general nursing care Charges for a private room are considered only when there are no
semi private accommodations available or when a private room is medically necessary due to isolation
for contagious disease If a private room is chosen based upon medical necessity an
allowance will be paid equal to the hospital's average semi private room rate as determined by
the Carrier If the hospital has private accommodations only the Carrier will pay the lesser of the
private room charge or the semi private room charge of the hospital which the carrier determines
to be the most comparable hospital in the area

Other charges Administration of blood or plasma
Ancillary services such as laboratory tests diagnostic X rays electrocardiograms and
electroencephalograms

Dressings plaster casts and sterile tray service
Drugs and medicines listed in official formularies
Intravenous solutions and injections
Operating recovery intensive care and cystoscopic rooms
Oxygen including the use of equipment and administration
Physical therapy occupational therapy and inhalation therapy
Sera except blood blood plasma and blood expanders which are covered under Other
Medical Benefits

Limited benefits
Pre admission The Plan pays 100 of hospital billed covered charges not subject to the per admission
Testing deductible for tests performed in a hospital outpatient department or emergency room when
related to and within seven days prior to the admission Hospital billed covered charges for tests
performed more than seven days prior to an admission are payable under Other Medical Benefits

Related benefits
Professional charges Doctor's charges are covered under the appropriate benefit provisions such as Other Medical
Benefits

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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Inpatient Hospital Benefits continued
Take home items Take home items such as prescription drugs medical supplies and medical equipment are
covered under Other Medical Benefits

Renal dialysis The Plan pays 100 of covered charges not subject to the per admission deductible for inpatient
renal dialysis outpatient renal dialysis rendered in and billed by a renal dialysis center approved
by the Carrier is paid under Other Medical Benefits

Extended care The Plan pays 100 of facility billed covered room board and hospital services and supplies for facilities up to 365 days per confinement in semi private accommodations Each day a patient receives benefits
in a hospital reduces by two days the number of ECF benefit days available for the confinement
To be covered ECF confinements must follow and be related to a hospital admission therefore
ECF admissions are not subject to the per admission inpatient hospital benefits deductible
ECF benefits are not provided for admissions for mental conditions or substance abuse

What is not covered Hospital room and board and inpatient doctor care when in the Carrier's judgement a hospital admission or portion of an admission is not medically necessary i e the medical services
did not require the acute hospital inpatient overnight setting but could have been provided
in a doctor's office the outpatient department of a hospital or some other setting without
adversely affecting the patient's condition or the quality of medical care rendered

Admissions primarily for physical therapy
Admissions primarily for diagnostic purposes convalescence custodial care rest or rehabilitation
Admissions for dental services covered by dental benefits

Surgical Benefits
What is covered The Plan pays for the following services
After the 200 calendar year deductible has been met the Plan pas 80 of the Carrier allowance
for the following services received in or out of a hospital

Doctors covered surgical services including pre and post operative care
Treatment of fractures and dislocations
Surgical sterilization
Surgical correction of congenital anomalies

Hospital outpatient The Plan pays 100 of covered charges not subject to the calendar year deductible for hospital surgery billed services and supplies when provided by and in a hospital outpatient department or emergency
room in connection with in and out surgery where minor surgery is performed and the
patient goes home the same day the surgery is performed Also covered under this benefit are
related facility billed services and supplies when performed in a freestanding ambulatory surgical
facility

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 the full allowance for the
primary procedure and one half the allowance for secondary procedures If equal procedures are
performed through different incisions or body openings the Plan pays the full allowance for the
first procedure and one half the allowance for the other procedure

When an office visit is rendered on the same day as a major surgery benefits are provided for the
surgery only When an office visit is rendered on the same day as surgery benefits will be provided
for either the surgery or the visit by the surgeon whichever is the greater fee 12 12
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Surgical Benefits continued
Incidental procedures If primary and incidental procedures are performed the Plan pays the full allowance for the primary procedure only there are no additional benefits for incidental procedures

Assistant surgeon After the 200 calendar year deductible the Plan pays 80 of the Carrier allowance for inpatient inpatient surgery
Anesthesia After the 200 calendar year deductible the Plan pays 80 of the Carrier allowance for anesthesia and its administration including acupuncture
Organ tissue transplants Inpatient hospital surgical and other medical expenses for covered transplants are limited to a and donor expenses maximum of 150,000 for each listed transplant The dollar maximums will be applied to the
portion of an inpatient hospitalization that is for the transplant the surgical fees and all medical
care related to the transplant for a period of up to 42 days after the date of surgery Other services
such as maintenance and prescription drugs will be considered under the Plan's Prescription Drug
Program

What is covered Cornea heart kidney liver pancreas heart lung single lung and double lung transplants in
approved centers for the following end stage pulmonary diseases primary fibrosis primary
pulmonary hypertension and emphysema Double lung transplants for cystic fibrosis

Bone marrow and stem cell support as follows

Allogeneic bone marrow transplants limited to patients with acute leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advance neuroblastoma limited to children over
age one aplastic anemia chronic myelogenous leukemia infantile malignant osteoporosis
severe combined immunodeficiency thalassemia major or Wiskott Aldrich syndrome

Autologous bone marrow transplants autologous stem cell support and autologous peripheral
stem cell support limited to patients with acute lymphocytic or non lymphocytic leukemia
advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma
limited to children over age one testicular mediastinal retroperitoneal and ovarian germ cell
tumors breast cancer multiple myeloma epithelial ovarian cancer

Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be provided in
non randomized clinical trials For the transplants covered through clinical trials the clinical trial
must be approved and funded by the National Cancer Institute NCI and the procedure must be
conducted at an NCI approved Cancer Research Facility see page 8 Eligibility for non randomized
clinical trials will be determined according to NCI approved protocols In the event
non randomized clinical trails are not available for whatever reason the Plan will provide its regular
transplant benefit in a Carrier designated facility using eligibility criteria for NCI sponsored
clinical trails

Related medical and hospital expenses of the donor are covered when the recipient is covered by
the Plan Recipient means an insured person who undergoes an operation to receive an organ
transplant Donor means a person who undergoes an operation for the purpose of donating an
organ for transplant surgery

Prior to approval of the procedure and the facility is required for bone marrow heart heart lung
liver singe or double lung and pancreas transplants see Precertification pages 31 32

What is not covered Autologous bone marrow transplants and associated high dose chemotherapy for the treatment
of transplants not listed as covered

Charges in excess of the dollar limitations noted above

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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Surgical Benefits continued
Oral and maxillofacial The Plan pays 80 of the Carrier allowance not subject to the calendar year deductible for a surgery doctor's non dental oral surgical services for

Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip cleft palate or protruding mandible
Removal of stones from salivary ducts
Excision of tori leukoplakia or malignancies
Excision of cysts and incision of abscesses not involving the teeth
Removal of impacted teeth
Other procedures not involving a tooth structure alveolar process periodontal disease or
disease of gingival tissue

Mastectomy surgery Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Benefits will be provided for breast reconstruction surgery following a mastectomy including
surgery to produce a symmetrical appearance on 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

Pre surgical testing When a covered surgical procedure is performed in an outpatient or inpatient setting the Carrier pays actual charges for laboratory tests pathology radiology and X rays directly related to the
surgery when performed within 10 days prior to the surgery including the day of the surgery
when an outpatient or within 10 days prior to admission for inpatient surgery

What is not covered Cutting or removal of corns callouses or toenails except when necessary because the patient is under active treatment for a peripheral vascular disease

Subluxations of the joint of the foot
Cosmetic surgeries other than those specifically listed as covered
Services or supplies for or related to transplants other than those listed as covered

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 and 96 hours after a caesarean delivery Inpatient stays will be extended
if medically necessary

Inpatient hospital
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 mother's discharge must be precertified If any of the above
are not done the benefits payable will be reduced by 500 See pages 31 32 for details

14 14
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Maternity Benefits continued
Room and board After a 100 per admission deductible 100 of covered charges in both participating and nonparticipating
hospitals and 100 of the per diem charge in United States Health Service and
Armed Forces hospitals

Bassinet or nursery charges for days on which mother and child are both confined are considered
hospital expenses of the mother and not expenses of the child All other expenses of the newborn
child are considered the child's own expenses and are covered only if the child is covered as a
family member Routine newborn care is covered as part of Well Child Care see page 19

Other charges Charges for covered services shown on page 16 when appropriate to maternity care
Obstetrical care After the 200 calendar year deductible the Plan pays
80 of the Carrier allowance for maternity care such as the delivery of a child or miscarriage
80 of the Carrier allowance for prenatal care postnatal care sonograms amniocentesis and
other related tests of the unborn child

80 of the Carrier allowance for services of a licensed midwife when those services are
within the scope of the license and rendered in lieu of doctor's services

80 of the Carrier allowance for Pregnancy Risk Management Programs

Related benefits
Diagnostic and Infertility services including diagnostic testing and treatment are covered under
treatment of Other Medical Benefits see page 17
infertility

Voluntary Voluntary sterilization is covered under surgical benefits see pages 12 14
sterilization

For whom Benefits are payable under Self Only enrollments and for family members under Self and Family
enrollments

What is not covered 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

Services related to conception by artificial means including artificial insemination in vitro
fertilization and embryo transplants

Reversal of voluntary surgical sterilization
Charges incurred after enrollment in this Plan ends
Assisted Reproductive Technology ART procedures such as artificial insemination in vitro
fertilization embryo transfer and Gamete Intrafallopian Transfer GIFT as well as services
and supplies related to ART procedures are not covered

15 15
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Mental Conditions Substance Abuse Benefits
What is covered The Plan pays for the following services
Inpatient Care After a separate inpatient deductible of 200 per person per calendar year for treatment of mental
conditions and substance abuse the Plan pays 80 of inpatient room and board and other inpatient
services and supplies furnished and billed for by a hospital including a mental hospital or
licensed substance abuse facility

Precertification The medical necessity of your admission to a hospital or other 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 pages 31 32 for details

Inpatient visits The Plan pays 80 of the Carrier allowance for non surgical inpatient services rendered during a
covered confinement for treatment of mental conditions or substance abuse

Catastrophic When a member's share of the above covered inpatient charges reaches 4,000 in a calendar year
protection in addition to the separate deductible the Plan pays 100 of covered charges up to 50,000 per
calendar year per person

Outpatient Care After the 200 calendar year deductible the Plan pays 50 of covered charges per person per
calendar year for doctor and hospital outpatient treatment rendered for mental conditions and up
to 2,000 per person per calendar year for doctor and hospital outpatient treatment rendered for
substance abuse Covered services include

Individual and group therapy
Collateral visits
Day night psychiatric services when provided by a doctor clinical psychologist clinical
social worker or psychiatric nurse

Psychological testing

Calendar year There is a 50,000 per calendar year maximum per person for inpatient treatment of substance
maximum abuse

What is not covered Marriage or family counseling and related therapy

Other Medical Benefits
What is covered After the 200 deductible has been met the Plan pays 80 of the Carrier allowance for the following
Allergy tests injections and serum
Artificial limbs or eyes
Blood transfusions including the cost of blood if not donated or replaced blood plasma and
blood plasma expanders

Casts splints braces except corrective shoes and related devices crutches and trusses
Chiropractic services
Dental care dental surgery or dental appliances required as a result of and directly related to
an accidental bodily injury occurring while the participant was covered by a FEHB Plan

Diagnostic laboratory test and x rays

16 16
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Other Medical Benefits continued
What is covered Doctor's office home and hospital visits continued
Doctor billed services for a medical emergency or accidental injury other than initial care
rendered within 72 hours

Dressings
Group B streptococcus screening for pregnant women
Growth hormone therapy
Infertility services including diagnostic testing and treatment
Pre admission testing performed more than seven days prior to admission
Occupational therapy when rendered by a registered or licensed professional occupational
therapist

Oxygen and equipment for its administration
Physical therapy rendered by a registered or licensed professional therapist
Professional ambulance services within the subscriber's local area for medical emergencies
Radiation therapy chemotherapy respiration therapy and speech therapy
Renal dialysis treatment on an outpatient basis
Rental or at the Carrier's option purchase of durable medical equipment
Take home items billed by a hospital

Limited benefits
Cardiac The Plan provides benefits subject to the 200 calendar year deductible and 20 coinsurance
rehabilitation for up to 90 outpatient visits during the course of a cardiac rehabilitative treatment plan when
program those visits consist of outpatient cardiac rehabilitation exercise education and counseling

Members must be diagnosed as having angina pectoris chest pain or must have hospitalized for
a diagnosed myocardial infarction heart attack or coronary surgery to be eligible for cardiac
rehabilitation benefits

Services must be provided by an approved hospital based or hospital coordinated cardiac rehabilitation
program Cardiac rehabilitation benefits are renewed after subsequent hospital admissions
for a diagnosed myocardial infarction or coronary surgery

Smoking cessation After satisfaction of the 200 calendar year deductible the Plan will pay up to 100 for
benefit enrollment on one smoking cessation program per member per lifetime

Other One pair of eyeglasses or contact lenses and examinations therefor if required to correct an impairment directly caused by accidental ocular injury or intraocular surgery

Private duty nursing care by a registered private duty nurse R N or a licensed practical
nurse L P N rendered to a subscriber who is not confined in the hospital Plan payment is
limited to 10,000 per person per calendar year

Up to 6 per day toward the cost of a private room above the average semi private room rate
when a private room is medically necessary

17 17
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Other Medical Benefits continued
What is not covered Air conditioners humidifiers dehumidifiers and purifiers
Hearing aids unless required because of an accidental injury
Medical examinations or tests not incidental or necessary to the diagnosis or treatment of an
illness injury or condition

Nutritional supplements and vitamins except injectable B 12 for treatment of pernicious
anemia

Routine physical exams and all related expenses and immunizations beyond those covered
under the Well Child Care provision and childhood immunization provision

Private duty nursing care when requested by or for the convenience of the patient or
patient's family or when it consists primarily of custodial care see Definitions

Acupuncture except when used as an anesthetic agent for covered surgery
Orthotics orthopedic shoes arch supports and other devices to support the feet

Additional Benefits
Accidental injury and The Plan pays 100 of covered charges for the initial care other than surgery rendered for and medical emergency within 72 hours of an accidental injury of the onset of a medical emergency by a doctor and by
the outpatient department of a hospital Other Medical Benefits are available for covered services
and supplies provided for follow up care provided after 72 hours Surgery required in the
event of an accidental injury is covered under Surgical Benefits

Ambulance service The Plan pays a maximum of 50 per illness for professional ambulance services for medical special benefit emergencies outside of the subscriber's local area

Home health care The Plan pays 100 of covered charges for up to 90 visits by members of an approved home health care team during the course of a home health care treatment plan A visit is any continuous
care rendered by a member of a home health care team for up to four continuous hours or
any portion of four continuous hours Benefits are renewed when the patient receives no home
health care for 60 consecutive days of following readmission to a hospital

Hospice Care
What is covered The Plan Pays 100 of covered charges for services provided to terminally ill patients with a life
expectancy of 6 months or less for whom no further curative therapy is indicated

Benefits are provided for condition management services rendered at home or as an inpatient
Benefits are provided for palliative care delivered by a team of hospice professionals and volunteers
with family members participating as active members of that team Inpatient hospice care
is covered when the patient requires 24 hour a day care or when the proper care cannot be provided
in the home

The Plan pays for up to 180 day per lifetime 60 of which can be used for inpatient hospital care
If a patient requires hospice care benefits beyond the six month life expectancy period and has
exhausted 180 hospice benefit days 45 reserve days are available

What is not covered Bereavement benefits and remission benefits
Benefits provided in excess of the limitations list above

18 18
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Additional Benefits continued
Flexible benefits option Flexible benefits option is part of the Plan's cost containment program with CareFirst BlueCross BlueShield Flexible benefits option is a health care service that identifies patients with potentially
high cost illnesses as early as possible and is designed to both contain costs and to help
patients their families and their providers to cope with the difficult financial issues involved in
caring for the chronically ill Flexible benefits option helps to identify medically appropriate
alternatives to traditional care and coordinates the provision of the Plan's benefits for that care in
place of the more costly benefits of the Plan

International medical The Plan pays 100 of the charges for medically necessary transportation rendered overseas transportation including medical transportation back to the U S when such medical transportation is coordinated
and arranged for by World Access Inc If such service is needed contact World Access Inc
with the assistance of the international operator when overseas either by calling 202 861 3800
collect or via telex by using the telex number 706305

Routine services The Plan pays 100 of the following routing screening services as preventive care
Colorectal cancer Annual coverage of one fecal occult blood test for member age 40 and older
screening

Prostate cancer Annual coverage of one PSA prostate Specific Antigen test for men age 40 and older
screening

Breast cancer Mammograms are covered for women age 35 and older as follows
screening
From age 35 through 39 one mammogram screening during this five year period

From age 40 through 49 one mammogram screening every one or two consecutive calendar
years

From age 50 through 64 one mammogram screening every calendar year
At age 65 or over one mammogram screening every two consecutive calendar years

Cervical cancer Annual coverage of one pap smear and related office visit for women age 18 and older
screening

Lead screening One routine annual lead screening for children up to age 12
Well child care The Plan pays 100 of covered charges for routine newborn care routine physical examinations
and immunizations for babies up to one year of age who are covered subscribers under a Self
and Family enrollment in this Plan

Childhood Childhood immunizations recommended by the American Academy of Pediatrics are covered at
immunizations 100 of covered charges not subject to the deductible or coinsurance for dependent children
under age 22 Benefits for associated office visits are subject to the deductible and coinsurance
under Other Medical Benefits

Prescription Drug Benefits
What is covered This program enables you to purchase medication prescribed for immediate use that requires a prescription by Federal law and is prescribed by your doctor and obtained from a local pharmacy
for the initial 30 day supply and one refill only You may receive up to a 90 day supply of maintenance
medication through the Advanced Paradigm Inc API Mail Order Service Prescription
drugs are not subject to the calendar deductible and any coinsurance or copays by you do not
count toward the catastrophic protection benefit

19 19
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Prescription Drug Benefits continued
What is covered Covered medications and accessories include continued
Drugs for which a prescription is required by Federal law
FDA approved prescription drugs and devices for birth control
Insulin and the following injectables Heparin Glucagon Initrex EpiPen and Anakit
Disposable needles and syringes needed to inject covered prescribed medication
Smoking deterrents limited to one series per member per lifetime
Diabetic supplies including insulin syringes needles glucose test strips lancets and alcohol
swabs

Implantable drugs such as Norplant some injectable drugs such as Depo Provera and
IUDs are covered under Medical and Surgical Benefits

Drugs to treat sexual dysfunctions are limited to drugs for male impotence i e viagra viagra
limited to 6 pills per 30 days

Allergy serum and intravenous fluids and medication for home use under Other Medical
Benefits

What is not covered Drugs to aid in smoking cessation except those limited to 100 lifetime maximum as part of the smoking cessation benefit see page 17

Nutritional supplements and vitamins except injectable B 12 for treatment of pernicious
anemia

Drugs available without a prescription

From a pharmacy You will be provided with an AdvanceRx Prescription identification card In most cases you simply present the card together with the prescription to the pharmacist Under the Prescription
Drug Card Program you may only obtain a 30 day supply and one refill For the initial 30 day
supply and the one refill you pay 12 for brand name and 5 for generic drugs You may fill
your prescription at a participating pharmacy You may obtain the names of participating pharmacies
by calling API Member Services at 1 800 241 3371

If a participating pharmacy is not available where you reside or you do not use your identification
card you must submit your claim to
Advance Paradigm Inc
P O Box 853901
Richardson TX 75085 3901

Your claim will be reimbursed subject to the copayment level shown above and based on
SSEHA's cost for the drug had a participating pharmacy been used

Claims must be filed within 12 months of the date of service
Drug Formularies Medications that are not on the formulary are still covered through the prescription
drug program and members do not have to pay any additional copayments Enrollees
are not held accountable for departures from formulary prescriptions

To claim benefits Use a claim form to claim benefits for prescription drugs and supplies you purchased without your AdvanceRx drug card You may obtain these forms by calling 1 800 241 3371 Follow
instructions on the form and mail it to the address referenced on this page

20 20
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Prescription Drug Benefits continued
By mail Through the API Mail Order Service you may receive up to a 90 day supply of maintenance medications for drugs which require a prescription diabetic supplies and insulin including
syringes and oral contraceptives You may receive refills of the original prescription for up to
one year You must pay a copayment of 12 for brand name drugs and 5 for generic drugs

Each enrollee will receive an enrollment kit which includes a brochure describing the Mail Order
Service including a Mail OrderForm and a pre addressed reply envelope

Wai ve r If you are enrolled in a Medicare Part B the Plan will waive the 5 or 12 copayment ONLY through the Mail Order Program The copayment WILL NOT be waived under the Prescription
Drug Card Program Any copayment or coinsurance for drugs purchased at retail are not waived
The Carrier will send you information on the Mail Order Program To use the Program
1 Complete the Mail Order Form Complete the information on the back of the pre addressed
envelope

2 Enclose your prescription and your 12 or 5 copayment
3 Mail your order in the pre addressed envelope to Advance Paradigm Inc P O Box 660783
Dallas TX 75266 0783

4 Allow approximately two weeks for delivery

You will receive forms for refills and future prescription orders each time you receive drugs or
supplies under this Program In the meantime if you have any questions about a particular drug
or a prescription and to request your first order forms you may call toll free 1 800 241 3371
form 8 a m to 11 p m Monday through Friday 8 a m to 7 p m on Saturday and 8 a m to 5 30
p m on Sunday EST Emergency consultation is available seven days a week 24 hours per day

Purchasing drugs When purchasing mail order drugs while you are overseas you must provide an APO address when you are overseas The mail order company is unable to mail prescription drugs if you do not have an APO address
If you do not have an APO address you may request that the drugs be sent to a friend with an
APO address who can then ensure that you get them

For the prescription card benefit short term medications or the first two times you fill a long
term medication or if you don't have an APO address you should have the pharmacist complete
the blue portions of the claim form as completely as possible and sign it in the bottom right corner
you may have to translate it for him her You should complete the white areas Attach the
bill and include a short note notifying the Plan that you are overseas Also please have the total
on the bill converted to U S dollars or if that is not possible indicate what currency the bill is in

As with all claims keep a copy of your documents Send the originals to
Advance Paradigm Inc
P O Box 853901
Richardson TX 75085 3901
ATTN Correspondence

You will be reimbursed the average wholesale price of the drug minus your copayment 5 for
generic and 12 for brand name

21 21
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SSEHA Health Benefit Plan 2000
Section 5 BENEFITS continued
Dental Benefits
What is covered The Plan pays 100 of the Carrier's allowance up to 1,000 per person per calendar year for covered dental services and supplies when provided by a licensed dentist Services and supplies
covered under dental benefits are not covered under any other provision of this Plan The following
is a complete list of covered services

Routine cleaning including scaling and polishing twice in a calendar year
Two oral examinations per person per calendar year
Two topical fluoride applications per calendar year for children under age 16
Regular X rays
Palliative emergency services
Space maintainers for maintenance of space created by premature loss of deciduous teeth
from cuspid to posterior

Diagnostic models
Panoramic X rays in lieu of full mouth X rays not to exceed one in three consecutive calendar
years

Pulp vitality tests
One consultation by any dental consultant per calendar year Such consultation must be
requested by the attending dentist rendered to a subscriber and supported by a written report
from the consultant

Related benefits
Oral surgery For covered oral surgery see page 14
What is not covered Charges for services or supplies not meeting accepted standards of dental practice as determined by the Plan

Dental preventive counseling including plaque control
Endodontic services
Orthodontic treatment and appliances
Periodontic services
Prosthodontic services
Restorative services
Sealants
Service or supplies to diagnose or treat conditions or dysfunctions of the temporomandibular
joint

Services treatments or supplies provided by a non covered dental provider except for prophylaxis
performed by a licensed dental hygienist working under the supervision of a dentist

22 22
22 Page 23 24
SSEHA Health Benefit Plan 2000
Section 6 How To File A Claim
Claim forms If you do not receive your identification card s within 60 days after the effective date of your identification enrollment you may call the Carrier at 1 800 424 7474 extension 6039 toll free outside the
cards and questions Washington D C area 202 479 6039 in the Washington D C area or 1 202 479 3546 TDD Telecommunications Device for the Deaf to report the delay In the meantime use your copy of
the 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 1 800 424 7474 extension
6039 or 202 479 6039 or you may write to the Carrier at CareFirst BlueCross BlueShield 550
12th St S W Washington D C 20065 You may also contact the Carrier by fax at 202 479
1544 at its web site at http www carefirst com

Claim forms and detailed instructions for filing claims will be furnished with your identification
card You may obtain additional claim forms duplicate identification cards and information
about benefits from CareFirst BlueCross BlueShield

When writing CareFirst BlueCross BlueShield
SSEHA Health Benefit Plan
550 12th Street SW
Washington D C 20065

In all correspondence please include your full name address and identification number including
the three letter prefix SSA

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 the 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 such as Medicare
must be sent with your claim

If benefits are assigned directly to the provider of care the bill must show the provider's Tax
ID Number

Bills for psychotherapy must show length and type of each session
Bills for private duty nursing must show that the nurse is a registered or licensed practical
nurse

23 23
23 Page 24 25
SSEHA Health Benefit Plan 2000
Section 6 How To File A Claim continued
How to file claims continued
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

Dental claims must be submitted with a Dental Health Plan Claim Form Complete and sign
the top portion of the form and either have the dentist fill out the bottom portion or attach
the itemized bill including the tooth number treated to the claim form

Claims for surgical benefits other medical benefits and additional benefits must be submitted
with a SSEHA Health Plan Claim Form

Claims for overseas foreign services should include an English translation Charges should
be converted to U S dollars using the exchange rate applicable at the time the expense was
incurred

Canceled checks cash register receipts or balance due statements are not acceptable
After completing a claim form and attaching proper documentation send claims to
CareFirst BlueCross BlueShield
SSEHA Health Benefit Plan
550 12th Street SW
Washington D C 20065

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 all copies of 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 promptly You are strongly encouraged to file your claims within 12 months of the date the service was rendered All claims must be received by the Carrier no later than 24 months after the services were
provided No claims will be considered if received more than 24 months after the date of service
unless timely filing was prevented by administrative operations of government or legal incapacitation
provided the claim was submitted as soon as reasonably possible Once benefits have
been paid there is a three year limitation on the reissuance of uncashed checks

If the Carrier returns a claim or part of a claim for additional information it must be resubmitted
within 90 days or before the timely filing period expires whichever is later

Direct payment to hospital or provider of care

Bills from a If you are admitted to or receive services in a participating hospital your claim will be filed for participating hospital you however you must show your identification card when you are admitted to assure that the
hospital files its charges with the Blue Cross Plan with which it participates
The three letter prefix SSA with your identification number identifies you as an SSEHA
Health Benefit Plan subscriber and advises the Blue Cross Plan in your area to contact CareFirst
BlueCross BlueShield to determine what benefits should be provided The hospital must include
the three letter prefix with you identification number when filing claims If the services are for
pre admission testing or are related to outpatient surgery an accidental injury or a medical emergency
please advise the hospital to include that information on the bill so that you can receive
the benefits to which you are entitled If the services rendered are in relation to mental conditions
or substance abuse an SSEHA Health Benefit Plan Claim Form must be filed as described
under How to File Claims see pages 23 24 24 24
24 Page 25 26
SSEHA Health Benefit Plan 2000
Section 6 How To File A Claim continued
Direct payment to hospital or provider of care continued
Bills from a If you are admitted to a non participating hospital or receive services for per admission testing non participating or services related to outpatient surgery an accidental injury or a medical emergency in a nonhospital
participating hospital you must complete and file a claim form Complete a SSEHA claim form
and send it to CareFirst see address on the back of the claim form with the itemized bill It is
good practice to keep a copy of the itemized bill for your records You should arrange to pay the
hospital and then file a claim with the Blue Cross Plan for reimbursement Payments will usually
be made directly to you

Other facilities For the following charges hospice care home health care ambulatory surgical facility extended care facility overseas facilities or renal dialysis center if the organization participates with the
Blue Cross Plan in the area where the services were rendered the organization completes and
files your claim for you If the organization does not participate you must complete and file a
claim form as described above for obtaining benefits from a non participating hospital

When more information Reply promptly when the Carrier requests information in connection with a claim If you do not is needed respond the Carrier may delay processing or limit the benefits available

Section 7 General Exclusions Things We Don't Cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
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 Services drugs or supplies that are not medically necessary the following
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

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 and supplies furnished without charge except as described on page 29 30 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 and supplies furnished by immediate relatives or household members such as
spouse parents children brothers or sisters by blood marriage or adoption

Services and supplies furnished or billed by a noncovered facility except that medically necessary
prescription drugs are covered

Services and supplies not specifically listed as covered
Any portion of a provider's fee or charge that is ordinarily due from the enrollee but has been
waived If a provider routinely waives does not require the enrollee to pay a deductible or
coinsurance the Carrier will calculate the actual provider fee or charge by reducing the fee
or charge by the amount waived 25 25
25 Page 26 27
SSEHA Health Benefit Plan 2000
Section 7 General Exclusions Things We Don't Cover continued
We do not cover the following continued

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 and or B see pages 27 29
doctor charges exceeding the amount specified by the Department of Health and Human
Services when benefits are payable under Medicare limiting charge see page 30 or State
premium taxes however applied

Personal comfort items
Convalescent or custodial care
Rest institutional or rehabilitation care not specifically stated as covered
Treatment of obesity weight reduction except surgery for morbid obesity
Acupuncture except when used as an anesthesia for covered surgery
Biofeedback
Charges for stand by services
Any portion of a charge which is determined by the Carrier to be in excess of the carrier
allowance

Charges for completion of claim forms or similar charges
Claims for services and supplies which are filed later than two years following the date services
were rendered or the supplies were provided

Claims for services and supplies which are filed later than two years following the date services
were rendered or the supplies were provided

Charges for services rendered to a patient after the date of death and
Travel even if prescribed by a doctor

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 Medicare Choice plan and also remain
enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration
SSA office or call SSA at 1 800 638 6833

26 26
26 Page 27 28
SSEHA Health Benefit Plan 2000
Section 8 Limitations Rules That Affect Your Benefits continued
Coordinating benefits The following information applies only to enrollees and covered members entitled to 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
the primary secondary status of this plan and Medicare see pages 27 29

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 an FEHB plan and Medicare

This Plan is primary if 1 You are age 65 or over have Medicare Part A or Parts A and B and are employed by the Federal Government

2 Your covered spouse is age 64 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 patient's primary payer on the day before he or
she become 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 primary if 1 You are an annuitant age 65 or over covered by Medicare Part A or Parts A and B and are not 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 U S C b
you are a Tax Court judge who retired under Section 7447 of title 26 U S C 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
6 You are age 65 or over and employed by the Federal Government in an appointment that
excludes similarly appointed non retired employees from FEHB coverage and have
Medicare Part A or Parts A and B

7 You are a former Federal employee receiving worker's compensation and the Office of
Worker's Compensation has determined that you are unable to return to duty

8 The patient you or a covered family member has completed the 30 month 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 status for the patient under rules 1 to 6 above

27 27
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SSEHA Health Benefit Plan 2000
Section 8 Limitations Rules That Affect Your Benefits continued
When Medicare When Medicare is primary all or part of your Plan deductibles and coinsurance will be waived is primary as follows

Inpatient hospital benefits If you are enrolled in Medicare Part A the Plan will waive the
deductible applicable to the impatient hospital care covered by Medicare Part A and this Plan

Surgical benefits If you are enrolled in Medicare Part B medical insurance and Medicare is
primary payer you do not have to meet the Plan's calendar deductible and all of your balances for
covered services are paid up to 100 of the Carrier's Plan allowance

Maternity benefits If you are enrolled in Medicare Part A inpatient hospital and Medicare is
the primary payer this Plan will waive the deductible applicable to inpatient maternity benefits
If you are enrolled in Medicare Part B medical insurance and Medicare is the primary payer
you do not have to meet this Plan's calendar year deductible and all of your balances are paid up
to 100 of the Carrier's Plan allowance This provision applies solely to services covered by
both Medicare and the Plan

Mental conditions substance abuse benefits If you are enrolled in Medicare Part A inpatient
hospital expenses for covered hospital inpatient care for the treatment of mental conditions and
substance abuse are paid at 100 up to the calendar year maximum

Other medical benefits If you are enrolled in Medicare Part B medical insurance and
Medicare is the primary payer you do not have to meet this Plan's calendar year deductible and
all of your balances are up to 100 of the Carrier's Plan allowance This provision applies solely
to services and supplies covered by both Medicare Part B and the Plan Note prescription drugs
are not covered by Medicare therefore the coinsurance for prescription for drugs is not waived
except for as noted below

Additional Benefits Prescription Drugs If you are enrolled in Medicare Part B the Plan
will waive the 5 or 12 copayment ONLY through the Mail Order Drug Program The copayment
WILL NOT be waived under Prescription Drug Card Program Any copayment or coinsurance
for the drugs purchased at retail are not waived

Dental Benefits If you are enrolled in Medicare Part A inpatient hospital or Medicare Part B
medical insurance and Medicare is the primary payer this Plan will continue to provide benefits
for covered dental care up to the annual maximum benefit

` When Medicare is the primary payer this Plan will limit its payment to an amount that supplements
the benefits 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 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 enroll in When you are enrolled in a Medicare prepaid plan while you are a member of this Plan you may a Medicare prepaid plan continue to obtain benefits form this Plan If you submit claims for services covered by this Plan
that you receive from providers that are not in the Medicare plan's network the Plan will not
waive any deductibles or coinsurance when paying these claims

28 28
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SSEHA Health Benefit Plan 2000
Section 8 Limitations Rules That Affect Your Benefits continued
Medicare's payment If you are covered by Medicare Part B and it is primary you should be aware that your out ofand this Plan pocket cost for services covered by both this Plan and Medicare Part B will depend on whether
your doctor accepts Medicare assignment for the claim
Doctors who participate with Medicare accept assignment that is they have agreed not to bill
you for more than the Medicare 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 doctors is permitted to bill you after the Plan has paid
only when the Medicare and Plan payments combined do not total the Medicare approved
amount

Doctors who do not participate with Medicare are not required to accept assignment form
Medicare Although they can bill you for more than the amount Medicare would pay Medicare
law the Social Security Act 42 U S C sets a limit on how much you are obligated to pay This
amount called the limiting charge is 115 percent of the Medicare approved amount Under this
law if you use a doctor who does not accept assignment for the claim the doctors 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 Medicare
limiting charge for charges of a doctor who does not participate with Medicare The Medicare
Explanation of Benefits EOB form will have more information about this limit

If your doctor does not participate with Medicare charges you 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 EOB form In any case a doctor who does not participate with Medicare is not entitled
to payment of more than 115 percent of the Medicare approved amount

How to claim benefits In most cases when services are covered by both Medicare and this Plan Medicare is the primary payer if you are an annuitant and this Plan is the primary payer if you are an employee
When Medicare is the primary payer your claims should first be submitted to Medicare The
Carrier has contracted with some Medicare Part B carriers to receive electronic copies of your
claims after Medicare has paid their benefits This eliminates the need for you to submit your
Part B claims to this Carrier You may call the Carrier at 1 800 638 8432 to find out if your
claims are being electronically filed If they are not you should initially submit your claims to
Medicare and after Medicare has paid its benefits this Plan will consider the balance of any covered
expenses upon receipt of the itemized bill and Medicare EOB statement This Carrier will
not process your claim without knowing whether you have Medicare and if you do without
receiving the Medicare EOB Once benefits have been paid there is a three year limitation on
the reissurance of uncashed checks

Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage 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

If we pay second we will determine how much of the charge we will pay for After the first plan
pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge

Remember Even if you do not file a claim with your other plan you must still tell us that you
have double coverage

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SSEHA Health Benefit Plan 2000
Section 8 Limitations Rules That Affect Your Benefits continued
When others are Subrogation applies when you are sick or injured as a result of the act or omission of another responsible for injuries person or party Subrogation means the Plan's right to recover any payments made to you or your
dependent by a third party's insurer because of an injury or illness caused by a third party Third
party means another person or organization If you need more information about subrogation
the Plan will provide you with its subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage

Worker's compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide

OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency Agencies directly or indirectly pays for

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 if The information in these following paragraphs applies to you when 1 you are not covered by you're 65 or older and either Medicare Part A hospital insurance or Part B medical insurance or both 2 you are
don't have Medicare enrolled in this Plan as an annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse and 3 you are not employed in a position which
confers FEHB coverage
Inpatient hospital care If you are not covered by Medicare Part A are age 65 or older or become age 65 while receiving inpatient hospital services and you receive care in a Medicare participating hospital the law 5
U S C 8904 b requires the Carrier 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 Carrier's 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 refund call the Plan at 1 800 424 7474 extension 6039 for assistance

30 30
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SSEHA Health Benefit Plan 2000
Section 8 Limitations Rules That Affect Your Benefits continued
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 U S C 8904 b 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 Carrier is required to base its payment on the Medicare approved amount which is the
Medicare fee schedule for the service or the actual charge whichever is lower The carrier will
base its payment on the lower of these two amounts and you are responsible only for any
deductible and copayment or coinsurance

If you go to a doctor who does not participate with Medicare you are responsible for any
deductible and the copayment or coinsurance In addition unless the doctor's agreement with the
Carrier specifies otherwise you must pay the difference between the Medicare approved amount
and the limiting charge 115 of the Medicare approved amount

If your physician is not a Carrier doctor but participates with Medicare the Carrier will base its
regular benefit payment on the Medicare approved amount For instance under this Plan's benefit
the Carrier will pay 80 of the Medicare approved amount You will only be responsible for
any deductible and coinsurance equal to 20 of the Medicare approved amount

If your physician does not participate with Medicare the Carrier will still base its payment on the
Medicare approved 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 amount 115
of the Medicare approved amount

Since a physician who participate 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 participate with Medicare

The Carrier's explanation of benefits EOB will tell you how much the physician can charge you
in addition to what 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 Carrier at 1 800 424 7474 extension 6039 for assistance

Section 9 FFS Facts
Precertification Precertify before admission
Precertification is not a guarantee of benefit payments Precertification of an inpatient
admission is a predetermination that based on the information given verbally the admission
must meet the medical necessity requirements of the Plan It is your responsibility to ensure
that precertification is obtained If 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 CareFirst BlueCross
BlueShield for medical admissions at least two days prior to admission The toll fre
number is 1 800 999 8849 or 202 479 6718 in the Washington D C area For mental health
and substance abuse admissions call Health Management Strategies International Inc
HMS at 1 800 553 8700 or 703 836 6365

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SSEHA Health Benefit Plan 2000
Section 9 FFS Facts continued
Precertification continued
Provide the following information enrollee's name and Plan Identification number patient's
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

HMS will then tell the doctor and hospital the number of approved days of confinement for the
care of the patient's condition Written confirmation 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 days A review coordinator will contact your doctor before the certified length of stay ends to determine if you will be discharged on time or if additional impatient days are medically necessary
If the admission is precertified but you remain 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 don't need to certify an admission when
Medicare Part A or another group health insurance policy is the primary payer for the hospital
confinement see page 27 Precertification is required however when Medicare hospital
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 emergency admissions that puts the patient's life in danger or could cause serious damage to bodily function you your
representative the doctor or the hospital must telephone 1 800 999 9849 or 202 479 6718 in the
Washington D C area within two business days following the day of admission even if the
patient has been discharged from the hospital Otherwise impatient benefits otherwise payable
for the admission will be reduced by 500

Newborn confinements that extend beyond the mother's discharge date must also be certified
You your representative the doctor or hospital must request certification for the newborn's continued
confinement within two business days following the day of the mother's discharge

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 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 maternity or emergency admission or in the case of a newborn the mother's
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

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 benefits will not be paid for the portion of the confinement
that was not medically necessary However medical services and supplies otherwise
payable will be paid

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SSEHA Health Benefit Plan 2000
Section 9 FFS Facts continued
Protection Against Catastrophic Costs
Catastrophic protection For those services with coinsurance the Plan pays 100 of the Carrier allowance charges for the remainder of the calendar year after the calendar year deductible is met if out of pocket expenses
for the deductible and coinsurance in that calendar year exceed 1,000 per member or 2,000 per
family enrollment

Out of pocket expenses for the purposes of this benefit are
The calendar year deductible
The 20 you pay for Surgical Benefits
The 20 you pay for Maternity Benefits and
The 20 you pay for Other Medical Benefits

The following cannot be counted toward out of pocket expenses
Expenses for Inpatient Hospital Benefits
Expenses in excess of the Carrier allowance or maximum benefit limitations
Expenses for mental conditions substance abuse or dental care
Any amounts you pay if benefits have been reduced because of non compliance with this
Plan's cost containment requirements see pages 4 and 31 32

Expenses for prescription drugs purchase through retail or mail order program

Mental conditions The Plan pays 100 of the Carriers allowance for inpatient hospital care up to 50,000 per substance abuse calendar year per person after the separate 200 deductible is met if out of pocket expenses for
your 20 of covered inpatient charges for mental conditions substance abuse treatment total
4,000 for the covered person in that calendar year

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
the plan's catastrophic protection benefit during the prior year will be covered by your old plan if
they are for care you received in January before the effective date of your coverage in this Plan
If you have already met the covered out of pocket maximum expense level in full your old plan's
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 out of pocket expense until
the prior year's catastrophic level is reached and then apply the catastrophic benefit to covered outof
pocket expenses incurred from that point until the effective date The old plan will pay these
covered expenses according to this year's benefits benefit changes are effective on January 1

Definitions
Accidental injury An injury caused by an external force such as a blow or fall and which requires immediate medical attention Also included are animal bites poisonings and dental care required as a result of
an accidental injury to sound natural teeth An injury to the teeth while eating is not considered
an accidental injury

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

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SSEHA Health Benefit Plan 2000
Section 9 FFS Facts continued
Definitions continued
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
Confinement The period of time beginning when a subscriber is admitted into a hospital or extended care facility as an inpatient and ending when the subscriber has been out of a hospital or extended care
facility for 60 consecutive days
Congenital anomaly A condition existing at or from birth which is a significant deviation from the common form or norm For purposes of this Plan congenital anomalies include protruding ear deformities 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 intra oral strictures supporting the teeth

Cosmetic surgery Any operative procedure or any portion of a procedure performed primarily to improve physical appearance and or treat a mental condition through change in bodily form

Covered charges The actual charges or expenses allowed by the Carrier for medically necessary covered services and supplies
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
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 are supplies that equipment
1 are prescribed by your attending doctor
2 are medically necessary
3 are primarily and customarily use 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

34 34
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SSEHA Health Benefit Plan 2000
Section 9 FFS Facts continued
Definitions continued
Effective Date Benefits described in this brochure are effective January 1 for continuing enrollments For new enrollees in this Plan the effective date of enrollment in determined by the employing office or
retirement system or the enrollee
Experimental or A drug device or biological product is experimental or investigational if the drug device or investigational biological product cannot be lawfully marketed without approval of the U S food and Drug
Administration FDA and approval for marketing has not been given at the time it is furnished
Approval means all 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 medical treatment or procedure is that further studies or clinical trials are
necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy
as compared with 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 protocol
s 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 procedure If you desire additional
information concerning the experimental investigational determination process please contact
the Plan

Group health coverage Health care coverage that a member is eligible for because of employment membership in or connection with a particular organization or group that provides payment for hospital medical
or other health care services or supplies including extension of any of these benefits through
COBRA Group health coverage also includes coverage that pays a specific amount for each day
or period of hospitalization if the specified amount exceeds 100 per day The Carrier will coordinate
benefits against the amount that exceeds 100 per day

Home health care An agency that provides care that is ordered and supervised by a doctor of medicine M D or a agency doctor osteopathy D O rendered in the patient's place of residence on a visiting or part time
basis by a home health care agency providing skilled and non skilled personal care to the patient
including assisting with self administered medication caring for the nutritional needs of the
patient and helping with exercise and other personal needs

Hospice care Professional care rendered by a licensed or certified hospice to terminally ill patients for the program personal care and relief of pain using technical and related medical procedures

Maternity care Care rendered resulting in childbirth or miscarriage
Medical emergency The sudden and unexpected onset of a condition requiring immediate non surgical medical care which the covered person secures within 72 hours of the onset The severity of the condition as
revealed by the doctor's diagnosis must be such as would normally require emergency care
Medical emergencies include heart attacks cardiovascular accidents poisonings loss of consciousness
or respiration convulsions and such other acute conditions as may be determined by
the Carrier to be medical emergencies

35 35
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SSEHA Health Benefit Plan 2000
Section 9 FFS Facts continued
Definitions continued
Medically necessary Services supplies or equipment provided by a hospital or covered provider of the health care services that the Carrier determines

1 are appropriate to diagnose or treat the patient's 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 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 or
equipment does not in itself make it medically necessary

Mental conditions Conditions and diseases listed in the most recent edition of International Classification of substance abuse Diseases ICD as psychoses neurotic disorders listed in the ICD to be determined by the
Carrier or disorders in the ICD requiring treatment for abuse of or dependence upon substances
such as alcohol narcotics or hallucinogens

Morbid obesity A condition in which an individual 1 is the greater of 100 pounds or 100 over his or her normal weight in accordance with the Carrier's Medical policy and 2 has been so for at least five
years despite documented unsuccessful attempts to reduce weight under a doctor monitored diet
and exercise program

Reasonable and The basis the Carrier uses to determine your claim payment customary
In developing its customary charge the Carrier sets aside those charges at the high end of the
scale by setting a point it considers acceptable or customary This cutoff point in known as a
percentile For example if the Carrier uses the 90th percentile it bases its payments on a charge
at or below ninety percent of local providers claims for the particular service or supply
Payments for this Carrier are generally based on the 90th percentile or higher

A charge is reasonable if it is customary or if in the opinion of the Carrier it is justified because
of unusual circumstances such as medical complications

The Carrier applies its coinsurance percentage to the provider's charge up to the reasonable and
customary R C amount For example the Carrier will pay 80 percent of your surgeon's charge
or 80 percent of the R C amount whichever is less

The R C allowances are adjusted upwards or downwards as appropriate to reflect charge patterns
in the provider's area

Resource Based Relative For claims from the Washington D C area Resource Based Relative Value Scale RBRVS is the Value Scale methodology use for paying physicians based on a schedule of relative procedure values which
reflect the resource costs and effort used to perform each procedure
For service rendered outside the United States RBRVS is determined based upon the charges and
services and supplies in Washington D C Any difference between the actual charges and
RBRVS is not covered

36 36
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SSEHA Health Benefit Plan 2000
Section 10 FEHB FACTS
You have a right to the OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the following information right to information about your health plan its networks providers and facilities You can also
find out about care management which includes medical practice guidelines disease management
programs and how we determine if procedures are experimental or investigational OPM's
website www opm gov lists the specific types of information that we must make available to you

If you want specific information about us call 202 479 6039 or write to CareFirst BlueCross
BlueShield 550 12th St S W Washington D C 20065 You may also contact us by fax at
202 479 1544 or visit our website at http www carefirst com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the make an 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 don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your and premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for me unmarried dependent children under age 22 including any foster or step children your employing
and my family or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who became incapable of self support before 22

If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

37 37
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SSEHA Health Benefit Plan 2000
Section 10 FEHB FACTS continued
Are my medical and claims We will keep your medical and claims information confidential Only the following will have records confidential access to it

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
Worker's Compensation Programs OWCP when coordinating benefit payments and subrogating
claims

Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or

OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan

Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this Plan
ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your spouse's enrollment But you may be eligible for your own FEHB coverage under
the spouse equity law If you are recently divorced or are anticipating a divorce contact your exspouse's
employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example
you can receive TCC if you are not able to continue your FEHB enrollment after you retire You
may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

38 38
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SSEHA Health Benefit Plan 2000
Section 10 FEHB FACTS continued
When you lose benefits continued

What is TCC continued 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 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll in TCC If you are leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
did not pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if
you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage

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SSEHA Health Benefit Plan 2000
Section 10 FEHB FACTS continued
How can I convert to individual coverage continued

Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Certificate of Coverage that indicates how long you have been enrolled with us You can use this certificate
Group Health when getting health insurance or other health care coverage You must arrange for the othe PlanCoverage 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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SSEHA Health Benefit Plan 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services
you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 202 479 3708 or 800 680 9495 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate
anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

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SSEHA Health Benefit Plan 2000
Summary of Benefits for SSEHA Health 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
with an asterisk are subject to the 200 calendar year deductible

Benefits Plan pays provides Page
Inpatient care Hospital 100 of covered services and supplies subject to a 100 admission deductible 11 12

Surgical 80 of covered charges 12 14
Medical 80 of covered charges .16 18
Maternity Same as for illness or injury 14 15
Mental Conditions After the separate 200 deductible per person per calendar year
Substance Abuse 80 of covered charges after certain out of pocket costs for covered
expenses reach 4,000 additional covered charges are paid at 100 for
the remainder of the calendar year inpatient benefits for substance abuse
are subject to a 50,000 per calendar year per person maximum .16

Outpatient care Hospital 100 of covered services and supplies for accidental injury initial care same day surgery and pre admission testing 80 of other covered
hospital billed services and supplies 11 12
Surgical 80 of covered charges 12 14
Medical 80 of covered charges 16 17
Maternity Same as for illness or injury 14 15
Home Health Care 100 of covered charges for up to 90 visits benefits renew after
60 consecutive days without home health care or following readmission
to a hospital 18

Mental Conditions 50 of covered charges per person per calendar year up to 2,000
Substance Abuse per person per calendar year for substance abuse 16

Emergency care 100 of covered charges for initial care rendered within 72 hours accidental injury see page 25 for coverage of follow up care 35

Prescription drugs Retail Card Program Member pays 5 for generic drugs 12 for brand name drugs for
initial prescription and one refill 19 21
Mail Order Service Member pays 5 for generic 12 for brand name drugs up
to a 90 day supply 21

Dental care 100 of covered preventative and diagnostic services up to 1,000 per person per calendar year 22

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SSEHA Health Benefit Plan 2000
Summary of Benefits for SSEHA Health Benefit Plan 2000 continued

Benefits Plan pays provides Page
Additional benefits Ambulance service special benefit home health care hospice care well child care flexible benefits option and international medical
transportation 18 19
Protection against 100 of covered surgical maternity and other medical benefits catastrophic costs charges after a subscriber's cumulative coinsurance
inclusive of the deductible reaches 1,000 per person or
2,000 per family for a calendar year .33

100 of additional covered inpatient services for mental
conditions substance abuse after covered charges other than
separate deductible reach 4,000 in the same calendar year
subject to 50,000 per calendar year per person maximum 33

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SSEHA Health Benefit Plan 2000
2000 Rate Information for
U S Secret Service Employees Health Association

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member
of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans
for United States Postal Service Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members
of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Type of Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share
Share Share Share Share Share Share Share

Self Only Y71 72.94 24.31 158.03 52.68 N A N A N A N A
Self and Family Y72 172.85 57.62 374.51 124.84 N A N A N A N A

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SSEHA Health Benefit Plan 2000
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