Health Insurance Plan HIP HMO 2000
A Health Maintenance Organization
Serving Greater New York City Area
Enrollment in this Plan is limited see page 6 for requirements
Enrollment code
511 Self Only
512 Self and Family
This plan has Commendable Accreditation from the
NCQA See the FEHB 2000 Guide
for more information on NCQA
Visit the OPM Web site at http www opm gov insure
and
Visit this Plan's Web site at http www hipusa com
Authorized for distribution by the
Federal Employees Health Benefits Program
RI 73 001
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Health Insurance Plan HIP HMO 2000
Table of Contents
Page
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6 8
Section 4 What to do if we deny your claim or request for service 9 10
Section 5 Benefits 11 18
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19 20
Section 8 FEHB FACTS 21 23
Inspector General Advisory Stop Healthcare Fraud 24
Summary of Benefits 27
Premiums 28
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Health Insurance Plan HIP HMO 2000
Introduction
Health Insurance Plan HIP HMO
The Health Insurance Plan of Greater New York 7 West 34th Street New York NY 10001
This brochure describes the benefits you can receive from HIP HMO under its contract CS 1040 with the Office of Personnel
Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement
of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are
enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 5 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 HIP HMO as this Plan throughout this brochure even though in other legal documents you will see a plan referred
to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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Health Insurance Plan HIP HMO 2000
How to use this brochure
This brochure has eight 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 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs 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 services 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 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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Health Insurance Plan HIP HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other
providers that contract with us These providers coordinate your health care services The care you receive includes preventive care such
as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or remain
under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes office visits
This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program
See Section 3 How to get benefits for more information
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 Your share of the Non Postal premium will increase by 1.9 for Self Only or 57.5 for Self and Family
Plan See back cover
Under Medical and Surgical Benefits a primary care or specialty care office visit copay increased from nothing to 10 See page 11
Under Prescription Drugs the copay increased from 5 to 10 See page 16
Under Prescription Drugs for mail order service the maximum copay changed See page 16
Under Emergency Benefits emergency room copay increased from nothing to 25 urgent care visits increased from nothing to 10 See page 14
Under Medical and Surgical Benefits chiropractic service is covered See page 11
Thepreventivedentalbenefit hasmoved fromcoverageunderOther BenefitstotheNon FEHBpage See page 18
The HIP VIP Medicare Plan has moved from coverage under Other Benefits to the Non FEHB page See page 18
The Plan has updated language regarding its delivery system See page 6
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Health Insurance Plan HIP HMO 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice Our service area Plan's service is New York City the Boroughs of Manhattan Brooklyn Bronx Queens and Staten Island all of
area Nassau Orange Rockland Suffolk and Westchester Counties
Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care as described on page 14 We will not pay for any other
health care services
If you or a covered family member move outside of our service area you can enroll in another plan If
your dependentsliveoutof the area(forexample,if your childgoes tocollegeinanother state),youshould
consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas
HIP HMO members can receive care from HIP Health Plan of Florida's participating providers within
their respective FEHB approved service areas HIP HMO also participates in two reciprocity programs
The first is with 37 other HMOs through the American Association of Health Plans AAHP the second
is with 23 other plans through TravelCare In this manner HIP ensures that members can obtain
emergency urgent or even routine care in some cases while they are outside the Plan's service area If
you or a family member move you do not have to wait until Open Season to change plans Contact your
employing or retirement office
How much do You must share the cost of some services This is called a copayment a set dollar amount Please I pay for rememberyou mustpaythisamount whenyoureceiveservices Yourout of pocketexpensesforbenefits
services under this Plan are limited to the stated copayments required for a few benefits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit claims who doesn't contract with us If you file a 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
Who provides The Health Insurance Plan of Greater New York HIP HMO was organized over 50 years ago as a my health care
non profit corporation On December 1 1978 HIP HMO became a New York certified Health
Maintenance Organization HMO Responsibility for HIP HMO policy and operations is vested in an
unpaid Board of Directors This Board is composed of distinguished representativesof labor consumers
doctors and the general public The Board selects the principal administrative officer the President and
holds him responsible for the enforcement of Board policy and for the operations of the Plan
HIP HMO is a Mixed Model plan with doctors in both independent and group practice HIP HMO
Participating Physicians practice in independent offices throughout the greater metropolitan area Some
HIP participating physicians also practice in over 40 multi specialty medical centers Members may choose
any of the independent practice or group practice physicians as their source of primary care regardless of
where they live Family members may choose a different primary care doctor and medical group
At the present time there are approximately 12,000 doctors participating in HIP HMO and providing
medical servicesto more than 750 000 enrollees They provide services in 14 medical specialties ranging
from family practice to urology Super specialty care such as open heart surgery beyond the capacity
of the medical groups is provided by non participating HIP HMO physicians In addition paramedical
services are provided at the group centers including social services nutrition and health education
New members are asked to select a primary care physician PCP when they join HIP HMO The PCP
provides primary medical care and when medically necessary provides referrals for specialty care and
ancillary services such as lab tests and x rays Female members do not need a referral for primary and
preventive obstetric and gynecologic care HIP HMO encourages new members to schedule an
appointment with their PCP for a baseline physical after enrollment becomes effective
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Health Insurance Plan HIP HMO 2000
Section 3 How to get benefits continued
Who provides During the hours when the medical groups and participating physician offices are closed members can my health care call HIP's NurseAdviceLine at 1 800 HIP HELP 1 800 446 4357 7 days aweek 24 hoursa day This
continued line was previously known as the Emergency Services Program or ESP
The first and most important decision each member must make is the selection of a primary care doctor The decision is important since it is through this doctor that all other health services particularly those
of specialists are obtained It is the responsibility of your primary care doctor to obtain any necessary authorizationsfromthe Planbeforereferringyou toaspecialistor makingarrangementsforhospitalization
Services of other providers are covered only when you have been referred by your primary care doctor with the following exceptions primary and preventive obstetric and gynecologic care female members
have direct accessto a qualified Plan participating provider of obstetric and gynecological care for at least two primary and preventive care visits annually for services required as a result of these visits and for
services related to pregnancies and acute gynecological conditions chiropractic care unlimited as medically necessary subject to review routine foot care limited to 4 visits calendar year and routine
eye care visits
The Plan'sproviderdirectorylists primarycaredoctors(family practitioners,pediatriciansandinternists with their locations and phone numbers and notes whether or not the doctor is accepting new patients
Directories are updated a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 1 800 HIP TALK you can also find out if your doctor
participates with this Plan by calling this number If you are interested in receiving care from a specific provider who is listed in the directory call the provider to verify that he or she still participates with the
Plan and is accepting new patients Important note When you enroll in this Plan services except for emergency benefits are provided through the Plan's delivery system the continued availability and or
participation of any one doctor hospital or other provider cannot be guaranteed
What do I do if Call us We will help you select a new one my primary
care physician leaves the Plan
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will I need to go into make the necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our Customer Service Department at 1 800 HIP TALK 1 800 447 8255 If you are new to I'm in the
the FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program hospital when
and are switching to us your former plan will pay for the hospital stay until I join this Plan
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out 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
How do I get Your primary care physician will arrange your referral to a specialist Except in a medical emergency specialty care or when a primary care doctor has designated another doctor to see his or her patients you must receive
a referral from your primary care doctor before seeing any other doctor or obtaining special services Referraltoa participatingspecialist isgivenatthe primary care doctor'sdiscretion;ifnon Planspecialists
or consultants are required the primary care doctor will arrange appropriate referrals
When you receive a referral from your primary care doctor you must return to the primary care doctor after the consultation unlessyour doctor authorizes additional visits All follow up care must beprovided
or authorized by the primary care doctor Do not go to the specialist for a second visit unlessyour primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance
If you needto seea specialist frequently becauseof achronic complex or seriousmedical condition your
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Health Insurance Plan HIP HMO 2000
Section 3 How to get benefits continued
How do I get primary care physician will develop a treatment plan that allows you to see your specialist for a certain specialty care number of visits without additional referrals Your primary care physician will use our criteria when
continued creating your treatment plan
What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with
specialist when us you must receive treatment from a specialist who does Generally we will not pay for you to see a I enroll specialist who does not participate with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I have a Pleasecontact usif you believe your condition is chronic or disabling You may beable to continueseeing serious illness and my your provider for up to 90 days after we notify you that we are terminating our contract with the provider
provider leaves the unless the termination is for cause If you are in the second or third trimester of pregnancy you may Plan or this Plan leaves continue to see your OB GYN until the end of your postpartum care
the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for
up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize medical recommending follow up care Beforegiving approval weconsider if the serviceis medically necessary
services and if it follows generally accepted medical practice
How do you decide EXPERIMENTAL AND INVESTIGATIONAL TREATMENT means any evaluation treatment if a service is therapy or device which involves the application administration or use of procedures techniques
experimental or equipment supplies products remedies vaccines biological products drugs pharmaceuticals or investigational chemical compounds if as determined solely by the Plan
1 Such evaluation treatment therapy or device cannot be lawfully marketed without approval of the
United States Food and Drug Administration or the New York Department of Health and Rehabilitative
Services and approval for marketing has not in fact been given at the time such is furnished to the
2 Reliableevidence,asdetermined bythePlan,shows thatsuchevaluation,treatment
therapy or device a is the subject of an ongoing Phase I or II clinical investigation or experimental or
research arm of a Phase III clinical investigation or under study to determine maximum tolerated
dosage s toxicity safety efficacy or efficacy as compared with the standard means for treatment or
diagnosis of the condition in question or b has not been proven safe and effective for the treatment of
the condition in question as evidenced in the most recently published medical literature in the United
States Canada or Great Britain using generally accepted scientific medical or public health methodologies
or statistical practices or c is not the standard evaluation treatment therapy or device utilized
by practicing physicians in treating other patients with the same or similar condition or 3 There is no
consensus among practicing physicians that the evaluation treatment therapy or device is safe or
effective for the treatment in question or 4 The consensus of opinion among experts is that further
studies reach or clinical investigations are necessary to determine maximum tolerated dosage s
toxicity safety efficacy or efficacy as compared with the standard means for treatment or diagnosis of
the condition in question
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Health Insurance Plan HIP HMO 2000
Section 4 What to do if we deny your claim or request for service
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 Arrange for a health care provider to give you the service or
4 Ask for more information
If weaskyour medical provider for moreinformation,we willsend youacopyof our request Wemust 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will OPM to review determine if we correctly applied the terms of our contract when we denied your claim or request for service
a denial What if I have a serious or life threatening condition and youhaven't responded to my request for service
Call us 1 800 HIP TALK 1 800 447 8255 and we will expedite our review
What if you have denied my request for care and my condition is serious or life threatening
If we expedite your review due to serious medical condition and deny your claim we will inform OPM so that they can give your claim expedited treatment too Alternatively you may call OPM's health
benefit Contracts Division III at 1 202 606 0755 between 8 a m and 5 p m Serious 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 initial time limits denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within
120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send Your request must be complete or OPM will return it to you You must send the following information to OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this
brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which
claim
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Health Insurance Plan HIP HMO 2000
Section 4 What to do if we deny your claim or request for service continued
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 acopy ofthe person'sspecific written consent with the reviewrequest
Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs mail my disputed Contract Division III P O Box 436 Washington D C 20044
claim
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision upholds the your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year
after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us the Privacy Act to determine if our denial of your claim is correct The information OPM collects during the review
process becomes a permanent part of your disputed claims file and is subject to the provisions of the
Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay 10 Within the service area
house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay 10 for a doctor's house call and you pay nothing for home visits by nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women age 50
through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms are covered when prescribed by the doctor as
medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care The mother at her option may remain
in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Nonexperimental transplants including heart heart lung kidney liver lung single or double pancreas and corneal transplants allogeneic donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors and aplastic anemia Related medical and
hospital expenses of the donor are covered when the recipient is covered by this Plan
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
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Chiropractic Services
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits continued
What is covered Prosthetic devices such as artificial limbs breast prostheses or surgical bras and their replacements and continued lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness
as needed
Insulin
Diabetic supplies including glucose test tablets and test tape acetone test tablets
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
Blood and blood derivatives charges in connection with storing your own blood in advance of an elective surgical procedure
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Limited Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for benefits congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding the
teeth are not covered including shortening of the mandible or maxillae for cosmetic purposes correction of malocclusion and any dental care involved in the treatment of temporomandibular joint TMJ pain
dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the condition
can reasonably be expected to be corrected by such surgery A patient and her attending physician will decide whether or not to have breast reconstruction surgery following a mastectomy including whether
or not to have surgery on the other breast in order to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected within
two months you pay nothing per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member
to achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 10 The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine
insemination IUI you pay 10 cost of donor sperm is not covered Oral and injectable fertility drugs are covered you pay a 10 copay per prescription unit or refill In vitro fertilization and embryo transfer
are not covered
Podiatric services are provided for four 4 visits per calendar year for routine foot care you pay 10
copay However this limit does not apply if foot care services are required due to a medical condition
such as diabetes
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits continued
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Long term rehabilitative therapy
Homemaker services
Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized Hospital care under the care of a Plan doctor You pay nothing All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility for a total of up to 210 days Services include inpatient and outpatient care and family counseling these
services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need
procedures for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization
but not the cost of the professional dental services Conditions for which hospitalization would be covered
include hemophilia and heart disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate See page 16 for
non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become more
serious examples include deep cuts and broken bones Others are emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if you the service area
are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are
a Plan member so they can notify the Plan You or a family member should notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in non Plan facilities and a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition Plan doctors
are available 24 hours a day 7 days a week After regular hours call the toll free number located on the back of your HIP ID Card If you are not sure who to contact you may call 1 800 HIP HELP 447 4357
or 1 888 HIP 4TDD 447 4833 the telephone number for the hearing impaired
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit you pay 10 per urgent care center visit for emergency services that are covered benefits of this Plan
Emergencies Benefits are available for any medically necessary health service that is immediately required because of outside the
injury or unforeseen illness service area
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time If a
Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit you pay 10 per urgent care center visit for emergency services that are covered benefits of this Plan
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits continued
Emergency Benefits continued
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or non emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon non Plan providers receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are
required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions
of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on pages 9 and 10
Mental Conditions Substance Abuse Benefits
Mental Conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care All necessary visits to Plan mental health facilities You pay nothing
Inpatient care Up to 30 days to hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined
by a Plan doctor to be necessary and appropriate Psychological testing that is not medically necessary to
determine the appropriate treatment of a short term psychiatric condition
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits continued
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any
other illness or condition and to the extent shown below the services necessary for diagnosis and
treatment
Outpatient care All necessary visits to Plan providers for treatment each calendar year You pay nothing
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the benefit period
all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan local pharmacy will be
dispensed for up to a 30 day supply You pay a 10 copay per prescription unit or refill
HIP Mail Order Service Members may obtain generic drugs through the Mail Order Service You pay 5 copay per prescription
unit or refill up to a 90 day supply For further information contact ValueRX the Plan's Mail Order
vendor at 1 800 224 5502 or Customer Service Department at 1 800 HIP TALK 1 800 447 8255
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Nonformulary drugs will be covered when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by law
Implanted time release medications such as Norplant you pay 10 of the cost of the prescription per prescription For other internally implanted time release medications you pay 10 of the cost of the
prescription per prescription There is no charge when the device is implanted during a covered hospitalization
Oral and injectable contraceptive drugs and devices
Smoking cessation drugs and medication including nicotine patches
Insulin a copay charge applies to each vial
Disposable needles and syringes needed to inject covered prescribed medication
Nutritional supplements for the treatment of phenylketonuria branched chain ketonuria galactosemia and homocystinuria
Fertility drugs oral and injectable
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are
covered under Medical and Surgical Benefits
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits continued
Limited Benefits Sexual dysfunction drugs have dispensing limitations Contact the Plan for details
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Other Benefits
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result from an accidental injury you pay nothing
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription for eyeglasses may be obtained from
Plan providers You pay nothing
What is not covered Corrective eyeglasses and frames or contact lenses including the fitting of the lenses
Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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Health Insurance Plan HIP HMO 2000
Section 5 Benefits continued
Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB
Program but are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not
count toward any FEHB deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure
HIP VIP Medicare HMO Benefits
Who may enroll You may enroll in the HIP VIP Medicare Plan 1 if you have FEHB coverage 2 if you are enrolled in Medicare Parts A and B Note If you meet the above mentioned criteria you do not need to be retired
to enroll in this program If you are eligible to enroll in the HIP VIP Medicare Plan you will continue to remain enrolled in the FEHB Program
The HIP VIP Medicare Plan is available at no additional cost to you
HIP VIP Medicare Plan has continuous open enrollment so you may join any time during the year Except for emergency care or urgently needed care HIP VIP Medicare Plan members must use the Plan's
participating providers for all their health care needs As a member of the HIP VIP Medicare Plan all your medical and hospital services must be provided or authorized by HIP
What is covered You are entitled to all benefits under the FEHB One pair of free eyeglasses every 12 months Program
You are entitled to coverage for everything that 500 towards the purchase of a hearing aid every Medicare covers 36 months
You will have no copays for covered services Worldwide emergency and urgently needed care
Fitness Program HIP HMO Members receive a 100 reduction on the annual membership at all participating YMCA
Discount locations in the metropolitan New York area
NEW for January 1 2000
Alternative Medicine We are pleased to introduce an Alternative Medicine Program effective 1 1 2000 It provides you with Program access to discounted Acupuncture Massage Therapy and Yoga Therapy services through an agreement
with Consensus Health a leading national alternative medicine services organization
Should you choose to seek such services you'll have access to the large Consensus network of quality screened providers at discount rates You pay no additional plan premiums The fees you are charged will
be at a discount off of the provider's usual rates Present your HIP ID card to the Consensus network provider in order to obtain the discounted rate
After 1 1 2000 call 1 888 HIP ALMD 1 888 447 2563 for a list of Consensus network providers
Dental care What is covered The following diagnostic and preventive services are covered when provided by participating HIP
General Dentists
One examination comprehensive or periodic every six months 5 visit
One prophylaxis cleaning every six months 10 visit
One topical application of fluoride for children age 16 and under every six months 5 visit
If you require other additional services such as x rays fillings crowns or dentures your participating HIP General Dentist will provide them at a discounted rate Please contact HIP's Dental Provider Careington
International at 1 800 290 0523 for a complete schedule of current reduced member fees
All member fees must be paid directly to participating HIP Dentists Members must use participating HIP Dentists in order to take advantage of the reduced member fee schedule Members may select any
participating HIP Dentist and may change their choice of provider at any time
How To Obtain Benefits Questions If you have a question concerning Plan benefits or how to arrange for care contact the Plan's Customer
Service Department or you may write to the Plan at HIP HMO 7 West 34th Street New York NY 10001 A special number 1 888 HIP 4TDD 447 4833 is available for use by the hearing impaired You may also
contact us at our Web site at www hipusa com or call us at 1 800 HIP TALK
Through HIP's agreement with Consensus Health Corporation this program provides HIP members with discounts on services provided by Consensus alternative
medicine providers Consensus is responsible for credentialing and managing all program practitioners This program is not a covered benefit and HIP makes no
representations or guarantees regarding the efficacy or appropriateness of the services made available Use of these services is strictly the member's decision and HIP
is not responsible for any acts or omissions of any Consensus alternative medicine provider
Benefits on this page are not part of the FEHB contract
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Health Insurance Plan HIP HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your
Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the Services drugs or supplies that are not medically necessary
following Services not required according to accepted standards of medical dental or psychiatric practice Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits or eligible self referred services
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an act
of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 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 Choiceplan 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 request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan
offered by this Plan see page 18
Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance 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 what the reasonable charge for the benefit should be After the first plan pays wewill payeither whatis left of the reasonablecharge or ourregular benefit whichever
is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure 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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Health Insurance Plan HIP HMO 2000
Section 7 Limitations Rules that affect your benefits continued
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to provide
our control them In that case we will make all reasonable efforts to provide you with necessary care
When others are When youreceivemoneyto compensateyouformedical orhospitalcarefor injuriesor illnessthatanother responsible for injuries person caused you must reimburse us for whatever services we paid for We will cover the cost of
treatment that exceeds the amount you received in the settlement If you do not seek damages you must
agreetolet ustry This iscalledsubrogation Ifyou needmore information contactusfor our 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
Workers Compensation
We do not cover You need because of a workplace related disease or injury that the Office of Workers Compensation services that
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 theOWCPorsimilar agencyhaspaid itsmaximumbenefitsfor your treatment,wewill provideyour
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 directly or Agencies
indirectly pays for
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Health Insurance Plan HIP HMO 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about
information about your health plan its networks providers and facilities You can also find out about care your HMO
management which includes medical practice guidelines disease management programs and how we
determine if procedures are experimental or investigational OPM's Web site www opm gov lists the
specific types of information that we must make available to you
If you want specific information about us call 1 800 HIP TALK 1 800 447 8255 or write to 7 West
34 th Street New York NY 10001 You may also contact us by fax at 1 212 630 0089 or visit our Web
site at www hipusa 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 make an
enrolling in the informed decision about FEHB Program
When you may change your enrollment How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment
We 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 coverage and and premiums effective
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 When you retire you can usually stay in the FEHB Program Generally you must have been enrolled I retire in the FEHB Program for the last five years of your Federal service If you do not meet this requirement
you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which
is described later in this section
What types of coverage SelfOnlycoverage isforyoualone SelfandFamilycoverage isforyou,your spouse,andyourunmarried are available for my
dependentchildrenunderage 22,includinganyfoster orstepchildrenyour employingorretirementoffice family and me
authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22
years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give
birth or add a child to your family You may change your enrollment 31 days before to 60 days after 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
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Health Insurance Plan HIP HMO 2000
Section 8 FEHB FACTS continued
Are my medical We will keep your medical and claims information confidential Only the following will have and claims records
access to it confidential
OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit payments and subrogating claims
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 We will send you an Identification ID card Use your copy of the Health Benefits Election Form cards 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 Your old plan's deductible continues until our coverage begins a deductible
under my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in
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 employeeor annuitant you may not continue to get benefits under your spouse coverage former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse
equity law If you arerecently divorced or are anticipating a divorce,contact your ex spouse'semploying
or retirement office to get more information about your coverage choices
What is TCC Temporary Continuationof Coverage(TCC If you leaveFederalserviceor if youlosecoveragebecause 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
Key points about TCC You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receiveanother 31 day extension of coveragewhen your TCC enrollment ends unless youcancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
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Health Insurance Plan HIP HMO 2000
Section 8 FEHB FACTS continued
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC You in TCC
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 You may convert to an individual policy if to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a family
member who is losing coverage the employing or retirement office will not notify you You must apply
in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage due
to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of
indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of Plan Coverage
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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Health Insurance Plan HIP HMO 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 1 877 TELL HIP 1 877 835 5447 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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Health Insurance Plan HIP HMO 2000
Summary of Benefits for HIP HEALTH INSURANCE PLAN 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the 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 SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED
ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care private room
and private nursing care if medically necessary diagnostic tests drugs and medical
supplies use of operating room intensive care and complete maternity care
You pay nothing 13
Extended care All necessary services no dollar or day limit You pay nothing 13
Mental Diagnosis and treatment of acute psychiatric conditions for 30 days of inpatient care
conditions per year You pay nothing 15
Substance abuse All necessary services for up to 30 days per year in a substance abuse treatment
program You pay nothing 16
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury
including specialist's care preventive care including well baby care periodic
check ups and routine immunizations laboratory tests and X rays complete
maternity care You pay 10 per office visit nothing per house call by a doctor
copay is waived for maternity visits 13
Home health All necessary visits by nurses and health aides
care You pay nothing 12
Mental All necessary outpatient visits per year
conditions You pay nothing 15 16
Substance abuse All necessary outpatient visits per year You pay nothing 16
Emergency care Reasonable charges for services and supplies required because of a medical emergency
You pay 10 copay for urgent care visits you pay 25 to the hospital for each
emergency room visit and any charges for services that are not covered by this Plan 14 15
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay 10 copay
per prescription unit or refill for generic or brand name drugs 16 17
Dental care Accidental injury benefit you pay nothing 17
Vision care One refraction annually You pay nothing 17
Out of pocket Your out of pocket expenses for benefits under this Plan are limited to the stated
maximum co payments that are required for a few benefits 6
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2000 Rate Information for Health Insurance Plan of Greater New York HIP HMO
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 Gov't Your Gov't Your USPS Your USPS Your Enrollment Code Share Share Share Share Share Share Share Share
Self Only 511 64.25 21.41 139.20 46.40 76.02 9.64 76.02 9.64
Self and Family 512 175.97 81.02 381.27 175.54 207.74 49.25 201.02 55.97
28 28