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GHI 2000 HealthPlan
A Prepaid Comprehensive Medical Plan with a Point of Service Product

For changes
in benefits 5
see Page
Serving Enrollment in this Plan is limited see page 6 for requirements

Enrollment code
801 Self Only
802 Self and Family

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

Authorized for distribution by the
United States Office of
Personnel Management
Retriement and Insurance Service Federal Employees Health Benefits Program

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GHI Health Plan 2000
Table of Contents

Page
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 A Prepaid Comprehensive Medical Plan with a Point of Service Product 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6 7
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 8 16
Non FEHB Benefits 17
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 18 19
Section 8 FEHB facts 19 22
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits Inside Back Cover
Premiums Back Cover

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GHI Health Plan 2000
Introduction Group Health Incorporated

441 Ninth Avenue
New York NY 10001
This brochure describes the benefits you can receive from Group Health Incorporated under its contract CS1056 GHI Health Plan 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 communications 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 GHI Health Plan or GHI 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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GHI Health Plan 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 A Prepaid Comprehensive Medical Plan with a Point of Service Product This Plan is a Prepaid Comprehensive Medical Plan with a Point of Service Product Turn to this section for a brief description of this Plan and how it works
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 requests 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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GHI Health Plan 2000
Section 1 A Prepaid Comprehensive Medical Plan with a Point of Service Product

This Plan is a prepaid medical plan that offers a point of service or POS product Whenever you need services you may choose to obtain them from your personal doctor within the Plan's provider network or go outside the network for treatment Within the Plan's
network you are encouraged to select a personal doctor who will provide or arrange your care and you will pay minimal amounts for comprehensive benefits When you choose a non Plan doctor or other non Plan provider you will pay a substantial portion of the
charges and the benefits available may be less comprehensive
Because the Plan emphasizes care through participating providers and pays the cost it seeks efficient and effective delivery of health services By controlling unnecessary or inappropriate care it can afford to offer a more comprehensive range of benefits than many

insurance plans In addition to providing comprehensive health services and benefits for accidents illness and injury the Plan emphasizes preventive benefits such as office visits physicals immunizations and well baby care You are encouraged to get medical
attention at the first sign of illness

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
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 Plan 1 Under the Medical and Surgical section the 15 visit per calendar year limitation for chiropractic services has been eliminated
2 Under the Mental Conditions benefits section the 30 visit outpatient care limitation and the 60 days inpatient care limitation have been eliminated

3 Under the Prescription Drug benefits section the following benefits changes are made
a The Retail Drug copays have been increased from 10 for a name brand drug and 5 for a generic drug to 20 for a name brand drug which is not listed on the preferred prescription

drug formulary 15 for a brand name drug when it is listed on the preferred prescription drug formulary and 5 for a generic drug

b The Maintenance Drug copays have been increased from 10 for a name brand drug and 5 for a generic drug to 20 for a name brand drug and 10 for a generic drug
c A Mandatory Mail Program for Maintenance Medication has been implemented You can get your original prescription filled plus two refills of the original prescription at a participating
pharmacy After two refills all fills must be received through the mail service prescription benefits

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GHI Health Plan 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice
service area Our service area is all of New York and the New Jersey counties of Bergen Essex Hudson Middlesex Monmouth Morris Passaic Somerset Sussex and Union
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another

state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until
Open Season to change plans Contact your employing or retirement office

How much do I You must share the cost of some services as defined below
pay for services Copayment A set dollar amount for services rendered by a participating provider Coinsurance A set percentage of GHI's scheduled allowance for services rendered by

a non participating provider An enrollee is responsible for charges in excess of the fee schedule
Deductible An annual fixed dollar amount for nursing appliances oxygen and equipment benefits that must be met before benefits are payable

In the event you receive any of the covered services described below rendered by a nonparticipating provider and incur out of pocket expenses in a calendar year of more than a 5,000
per person catastrophic deductible GHI will then pay catastrophic benefits at 100 of reasonable and customary charges as determined by the Plan Out of pocket expenses are calculated based
upon the reasonable and customary charge for covered catastrophic services
Covered catastrophic services Covered services under catastrophic coverage include
1 Surgery 4 Covered in hospital services and
2 Administration of anesthesia diagnostic services
3 Chemotherapy and radiation therapy 5 Maternity
Non catastrophic services The following services are not covered under catastrophic coverage
1 Home and office visits and related 3 Dental services
diagnostic services 4 Vision services
2 Nursing Appliances Oxygen and Equipment 5 Prescription drugs

Do I have to You normally won't have to submit claims to us unless you receive emergency services from
submit claims a provider who doesn't contract with us or whenever you use any non participating provider 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 GHI can

extend this deadline if you show that circumstances beyond your control prevented you from filing on time

Who provides my A provider as used in this brochure includes any duly licensed doctor dentist podiatrist
health care qualified clinical psychologist optometrist chiropractor nurse certified midwife nurse practitioner clinical specialist or qualified clinical social worker and any other duly licensed registered or certified practitioner or privately operated facility permitted to perform or render care

or service described in this brochure
A medical surgical provider who participates has agreed to limit fees to the GHI allowance and to await payment from GHI Such a provider must be notified by the subscriber before service is

rendered that GHI is the insurer
A medical surgical provider who does not participate has no agreement with GHI and does not have to accept GHI payments as payment in full Only 50 of GHI's scheduled allowance will

be paid to you if you use the services of a non participating medical surgical provider Services of non participating diagnostic laboratory facilities x ray facilities and anesthesia are
covered at the plan's full medical surgical fee schedule Payment may be less than actual charges In addition you can not transfer your right to collect payment from GHI to another person
corporation or other organization Any assignment by you will be void
If you are newly enrolling in this Plan you will be given a GHI medical surgical hospital identification card and a GHI prescription drug card The medical surgical hospital card is to be

used for all services except drug benefits The medical surgical hospital card contains telephone
What do I do if I need numbers which you are required to call before non emergency hospital confinement or surgery of the type referred to on page 11
to go to the hospital If you need to be hospitalized your physician or specialist will make the necessary hospital arrangements and supervise your care

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GHI Health Plan 2000
Section 3 How to get benefits continued
What do I do if I'm First call our Customer Service Department at 212 501 4444 If you are currently in the FEHB
in the hospital when Program 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
But what if I have a serious illness and my provider leaves the Plan or this Plan leaves the Program

Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your provider for up to 90 days after we notify you that we are terminating our contract with
the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of 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

How do you Your plan requires precertification for certain services such as high tech nursing infusion therapy
authorize medical mental health and substance abuse benefits non emergency hospital admissions and all inpatient hospital admissions for maternity care and skilled nursing facilities In addition although a specific
services service may be listed as a benefit it will not be covered for you unless the Plan itself determines it is medically necessary to prevent diagnose or treat your illness or condition

How do you decide The Plan considers factors which it determines to be most relevant under the circumstances such
if a service is as published reports and articles in the authoritative medical scientific and peer review literature or written protocols used by the treating facility or being used by another facility studying
experimental or substantially the same drug device or medical treatment The Plan also considers Federal and other government agency approval as essential to the treatment of an injury or illness by but not
investigational limited to the following American Medical Association U S Surgeon General U S Department of Public Health the Food and Drug Administration or the National Institutes of Health

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 we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not

receive the requested information within 60 days we will make our decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to 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 Call us at 212 615 4662 and we will expedite our review
serious life threatening
condition and you
haven't responded to
my request for service
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GHI Health Plan 2000
Section 4 What to do if we deny your claim or request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's Health Benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life
care and my condition threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
is serious or life
threatening

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 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
to OPM 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 the Those who have a legal right to file a disputed claim with OPM are 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
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the decision 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file review on the record that was before OPM when OPM made its decision on your claim You may
a lawsuit 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

Section 5 Benefits Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by doctors and other providers This includes all necessary office visits you pay a 10 office visit copay but no
additional copay for laboratory tests and X rays by Participating Providers Within the Service Area house calls will be provided if in the judgment of the Plan such care is necessary and

appropriate you pay a 10 house call copay for a participating doctor's visit and nothing for visits by nurses Participating doctors also provide all necessary medical or surgical care in a hospital
at no additional cost to you

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GHI Health Plan 2000
Section 5 Benefits Medical and Surgical Benefits continued The following services are included

Preventive care including well baby care no copay applies 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 The cost of the immunizing agent is covered for children to age 22

Consultations by specialists upon referral from attending doctors one inpatient per confinement and one outpatient per illness
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 participating doctor 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 Routine 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
Chiropractic services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment which includes the cost of the test and treatment materials such as allergy serum

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Non experimental transplants including cornea human heart heart lung lung pancreas kidney and liver transplants Allogenic donor bone marrow transplants autologous bone

marrow transplants autologous stem cell and peripheral stem cell support for acute lymphocytic leukemia or non lymphatic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's
lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors Additionally autologous bone marrow transplants autologous stem and peripheral
stem cell support and high dose chemotherapy for the following conditions Breast cancer multiple myeloma and epithelia ovarian cancer 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 and radiation therapy
Inhalation therapy
Surgical treatment of morbid obesity
High tech nursing and infusion therapy through GHI's participating provider network for services of I V infusion therapy parenteral and enteral therapy and other home I V therapy

Participating providers must be used for these services Contact GHI at 212 615 4662 prior to receiving services to ensure coverage

Intermittent home nursing service The Plan pays full charges when billed by a home nursing service for services of a Registered Nurse or if not available a Licensed Practical Nurse
provided that the service is authorized and supervised by a doctor subject to the same limitations as those imposed for other providers rendering the same type of covered service The Plan covers
only intermittent visits generally for less than two 2 hours per day
Plan provides payment in full for medical surgical benefits shown above by Participating Providers Only 50 of the Plan's fee schedule will be paid unless otherwise stated for services

of a non participating medical surgical provider Failure to precertify nonemergency hospital confinements and certain surgical procedures will result in benefit reductions See Page 11

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GHI Health Plan 2000
Section 5 Benefits Medical and Surgical Benefits continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for 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 the removal of impacted teeth the treatment of fractures and the excision of tumors and cysts All other

procedures involving the teeth or intra oral areas surrounding the teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction
syndrome
Podiatric services including the routine treatment of corns calluses and bunions and the partial removal of toenails are limited to 4 visits per calendar year

Diagnosis and treatment of infertility is covered as well as associated prescription drugs which are covered under the Prescription Drug Benefits The cost of donor sperm is not covered Other
assistive reproductive technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant through other artificial conception procedures such as in
vitro fertilization limited to three transfers per lifetime and embryo transfer and artificial insemination are covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided you pay a 10 copay per session
Reconstructive surgery will be provided to correct a condition resulting from a functional defector from an injury or surgery which has resulted from accidental injury or from surgery if the
accident or injury has produced a major effect on the member's appearance and the condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may
decide whether to have breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

Multiple surgery The allowances for multiple surgery when one incision is made are limited to the highest payment for a single procedure involved When two or more surgical procedures
requiring more than one incision are performed at the same time the allowance is limited to the highest payment plus one half of each of the lesser payments

Short term rehabilitative therapy physical speech and occupational in a general hospital or approved facility is provided on an inpatient or outpatient basis for up to 60 visits per condition if
significant improvement can be expected within two months you pay a 10 copay 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

Nursing appliances oxygen and equipment For nursing services you pay the annual deductible of 150 per individual or family When you use a GHI Participating Provider for nursing services
no further out of pocket expenses would be incurred by you When you use a non participating provider you are responsible for 50 of the Plan's fee schedule after you have satisfied your
deductible plus any charges that exceed the fee schedule For appliances oxygen and equipment you pay the annual deductible of 100 per individual or family When you use a GHI Participating
Provider for appliances oxygen and equipment you are responsible for 20 of the Plan's fee schedule after you have satisfied your deductible When you use a non participating provider you
are responsible for 50 of the Plan's fee schedule after you have satisfied your deductible plus any charges that exceed the fee schedule There is a maximum Plan payment for these combined
benefits of 25,000 per member per calendar year The following services are covered when prescribed by a medical doctor

Active private duty nursing service rendered at home or in the hospital by a registered nurse R N or when an R N is not available by a licensed practical nurse L P N
Durable medical equipment as defined by Medicare such as wheelchairs hospital beds and oxygen for home use
Artificial eyes limbs lenses following cataract removal or prosthetic appliances to replace internal body organs
Breast prostheses and surgical bras in connection with covered breast reconstructive surgery
Orthopedic devices such as braces
Ostomy supplies

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 or
governmental licensing
Elective cosmetic surgery
Cost of donor sperm
Reversal of voluntary surgically induced sterility
Custodial care
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GHI Health Plan 2000
Section 5 Benefits Medical and Surgical Benefits continued
Hearing aids
Homemaker services
Services furnished or billed for by an extended care facility nursing home or other noncovered facility

Blood and blood derivatives received on an outpatient basis no charge if replacement is arranged by member
Air purifying devices
Long term rehabilitative therapy
Orthotic devices for the feet
Stand by services
Alarm and Alert services

TO RECEIVE FULL BENEFITS CARE MUST BE OBTAINED FROM PLAN DOCTORS

Section 5 Benefits Hospital Home Health Care
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a doctor You pay nothing for services billed by the admitting
hospital All necessary services are covered including
Semiprivate room accommodations when medically necessary the doctor may prescribe private accommodations

Specialized care units such as intensive care or cardiac care units
Facility charges for the following outpatient services
Ambulatory surgery
Pre admission testing Surgery must actually take place within 7 days after tests are performed

Renal dialysis
Mammography and pap smear screenings
Chemotherapy and radiation therapy
Emergency room treatment 25 co payment per emergency room visit
Ambulatory laboratory test and diagnostic X rays when referred and rendered
subject to a 25 deductible per referral
Precertification of Nonemergency admissions must be precertified prior to admission All inpatient hospital

hospital confinement admissions for maternity care and skilled nursing facility must be approved by the Plan whether or not the case is an emergency Maternity admissions should be precertified no later

than the second trimester In case of emergency GHI should be notified within 48 hours 72 hours if confined on a weekend Responsibility for informing GHI rests with you the

subscriber Urge your doctor to contact GHI as soon as possible You or your doctor must call the Plan at 212 615 4662 in New York City or 1 800 223 9870 outside New York City If
precertification is not obtained benefits will be reduced by 125 per day to a maximum of 250
Large case The Plan provides a large case management program which seeks to provide alternatives for management improving the quality and cost effectiveness of care The large case management program focuses

on catastrophic illnesses for example major head injury high risk infancy stroke and severe amputations The large case management process begins when GHI is notified that an enrollee or
covered family member has experienced a specific illness or injury with potential long term effects or changes in lifestyle Case Managers assess individual needs and the full range of treatment and
financial exposures from the onset of a condition or illness to recovery or stabilization They review the efforts of the health care team and family with the goal of helping the patient return to
pre illness injury functioning or of lessening the burden of a chronic or terminal condition Case Managers provide the family with support and advice ranging from referral to family counseling

If it is determined that involvement of a Case Manager would be both care and cost effective GHI will obtain the necessary authorization from the patient to proceed Throughout the process GHI
will maintain strict confidentiality

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GHI Health Plan 2000
Section 5 Benefits Hospital Home Health Care Benefits continued
Skilled nursing Within 14 days following discharge from a hospital after a covered admission of at least 3 days the care facility Plan will cover up to 30 days per calendar year of full time skilled nursing care for confinements
in a participating skilled nursing facility which are in lieu of hospitalization Participating Providers must be used for these services Contact GHI at 212 615 4662 prior to receiving services

to ensure coverage The following services are covered
Bed board and general nursing services in a semi private room
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility as governed by Medicare guidelines

Your condition must require skilled nursing that can only be provided in a skilled nursing facility and the skilled care must be based on a doctor's order

Home health care Following discharge from a hospital after a covered admission benefits are provided for the benefits covered home health care service stated below if 1 services rendered are billed by a certified
home health agency which has an agreement with GHI to provide home health care services and 2 the subscriber remains under the care of a medical doctor and 3 the services are provided

according to a plan of treatment approved by the attending medical doctor and 4 medical evidence substantiates that the subscriber would have required further inpatient care had the home
health care not been available and 5 the home health care begins within 5 days after the discharge from the hospital Participating Providers must be used for these services Contact GHI
at 212 615 4662 to pre certify and ensure coverage
What is covered Part time or intermittent nursing care by a registered professional nurse R N or a home health aide under the supervision of a registered professional nurse

Physical therapy
Respiration or inhalation therapy
Prescription drugs
Medical supplies which serve a specific therapeutic or diagnostic purpose
Other medically necessary services or supplies that would have been provided by a hospital if the subscriber were still hospitalized

What is not covered Homemaking services including housekeeping preparing meals or acting as a companion or sitter
Services and supplies related to normal maternity care
Services and supplies provided following a noncovered hospital admission or admission to a facility that is not a participating facility

Services and supplies provided when the subscriber would not have required continued inpatient care
Services and supplies provided by a non participating facility
High tech nursing and infusion therapy

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less An eligible hospice

organization is one which has an agreement with GHI and or is recognized as a hospice by Medicare

Ambulance services The Plan pays up to 100 for an ambulance service for each trip to or from a hospital in connection with the types of services covered by the contract This includes the use of an ambulance for
emergency outpatient care and maternity care to the nearest facility You pay all charges above Plan payment

Organ transplants Hospital benefits for the organ transplant procedures described on Page 9 will apply only to covered patients and will include
All medically necessary inpatient and outpatient hospital charges of the recipient patient
All medically necessary medical surgical and hospital costs of the donor patient when the recipient is covered by the Plan related to the donation of the organ used in the transplant

procedure such as the surgical procedure necessary to procure the organ storage expenses and organ transportation costs up to a maximum of 10,000 per transplant

Travel expenses up to a maximum of 150 per person per day and 10,000 per lifetime of the recipient if the recipient patient lives more than 75 miles from the transplant center including
food and lodging for the recipient patient and one adult family member two if the recipient is a minor to the city where the transplant takes place

The benefit period begins five 5 days prior to surgery and extends for a period of up to one year from the date of surgery There is a separate lifetime maximum benefit up to 1,000,000
per recipient for each type of covered transplant 12 12
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GHI Health Plan 2000
Section 5 Benefits Hospital Home Health Care Benefits continued
Limited benefits Hospitalization for certain dental procedures is covered when a doctor determines there is a need inpatient dental for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
procedures hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia impacted teeth 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 14 for nonmedical Substance Abuse Benefits

What is not covered To avoid possible reduction in benefits you must precertify all non emergency hospital confinements See Page 11
Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
Extended care
Blood and blood derivatives received on an outpatient basis no charge if replacement is arranged by member

Long term rehabilitation
Air ambulance and Ambulette service
Transplants not listed as covered

Section 5 Benefits Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies

because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that 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 doctor In extreme emergencies if you are the service area unable to contact your doctor contact the local emergency system e g the 911 telephone system
or go to the nearest hospital emergency room It is your responsibility to ensure that the Plan has been timely notified

Benefits within the Benefits are available for care from non Plan providers in a medical emergency only if delay in service area reaching a Plan provider would result in death disability or significant jeopardy to your condition

Plan pays Emergency fee schedule for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or urgent care center visit for emergency services which are covered benefits of this Plan You also pay charges which exceed the Plan's emergency fee
schedule If the emergency care is provided by private physicians who are not hospital employees you may receive a separate bill for these services which will be processed as a medical benefit

Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforeseen illness
Plan pays Full emergency fee schedule for emergency care services to the extent the services would have been covered if received from Plan providers 80 of charges from a non participating hospital
You pay 25 plus 20 of charges per hospital emergency room visit or urgent care center visit for nonparticipating facilities and nothing for emergency services billed for by a doctor except charges
which exceed the Plan's emergency fee schedule for services which are covered benefits of this Plan If the emergency care is provided by private physicians who are not hospital employees you

may receive a separate bill for these services which will be processed as a medical benefit

What is covered Emergency care at a doctor's office or an urgent care center Ambulance service see page 12
Emergency care as an outpatient or inpatient at a hospital including doctors services
If the medical surgical care received from non participating providers is not due to a medical emergency as defined above the Plan will pay 50 of its fee schedule Follow up care after an

emergency is covered in full only if received from participating providers

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GHI Health Plan 2000
Section 5 Benefits Mental Conditions Benefits
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 treatment of mental illness or disorders Only
services rendered by a Participating Provider are covered You must pre certify before you receive benefits by calling GHI at 1 800 692 7311

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Life Management Services telephone consultation services for a finance credit b childcare c eldercare d legal problem e organizing life's affairs f taxes and pre retirement questions

These services are not subject to the outpatient and inpatient limits
Outpatient care You are covered for outpatient care subject to a 10 copay when you use a Participating Provider when the diagnosis is listed in the Diagnostic and Statistical Manual Fourth Edition DSM IV
Revised as a mental disorder and there is impairment in one or more important areas of functioning

Inpatient care You are covered in a participating general hospital or participating private facility All inpatient admissions for mental conditions must be precertified by the Plan prior to admission You must
contact GHI at 1 800 692 7311 for precertification prior to admission and to determine the hospital's current eligibility status or facility's current participating status in order to ensure

coverage In case of emergency GHI should be notified within 48 hours 72 hours if confined on a weekend You pay nothing for medically necessary covered services

What is not covered Care for psychiatric conditions that in the professional judgment of the Plan 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 the Plan to be necessary and appropriate

Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Benefits are payable only when personally rendered by doctors who confine their practices to psychiatry by a licensed and registered psychologist or a certified and qualified psychiatric
social worker
The following diagnoses are not payable in that they are defined in the DSM IV Revised Manual as conditions not attributable to a mental disorder malingering borderline intellectual

functioning adult antisocial behavior childhood or adolescent antisocial behavior academic problem occupational problem uncomplicated bereavement noncompliance with medical
treatment phase of life problem or other life circumstance problem marital problem parentchild problem

Facility charges of a non participating general hospital or facility
Treatment by a non participating provider

Section 5 Benefits Substance Abuse Benefits
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 Only services rendered by a Participating Provider are covered You

must pre certify before you receive benefits by calling GHI at 1 800 692 7311
Outpatient care Up to 60 outpatient visits to the outpatient department of a participating hospital or certified approved participating facility for follow up care and counseling;You pay nothing for each covered
visit all charges thereafter

Inpatient care Up to a maximum of 30 days per calendar year for substance abuse rehabilitation intermediate care programs in a participating general hospital or Participating Private Facility All inpatient
admissions for substance abuse must be precertified by the Plan prior to admission You must contact GHI at 1 800 692 7311 for precertification prior to admission and to determine the

hospital's current eligibility status or facility's current participation status in order to ensure coverage In case of emergency GHI should be notified within 48 hours 72 hours if confined on a
weekend You pay nothing for medically necessary covered services during the benefit period all charges thereafter

What is not covered Treatment that is not authorized by a doctor Facility charges of a non participating general hospital or facility
Treatment by a non participating provider
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GHI Health Plan 2000
Section 5 Benefits Prescription Drug Benefits
What is covered Prescription drugs prescribed by a doctor and obtained at a pharmacy that participates under the program through PAID Prescriptions Inc Coordinated Care Network III will be dispensed for up
to a 31 day supply Drugs are prescribed by doctors and dispensed in accordance with the Plan's drug formulary You pay a 5 copay for a generic drug a 15 copay per prescription unit or refill

for a name brand drug listed on the preferred prescriptions drug formulary and a 20 copay per prescription unit or refill for a name brand drug not listed on the preferred prescription drug
formulary
Covered medications and accessories include
Drugs for which a prescription is required by law
FDA approved prescription drugs and devices for birth control
Fertility Drugs
Drugs to treat sexual dysfunction Viagra is limited to six tablets per every thirty one days
Diabetic supplies including insulin syringes needles glucose test tablets and test tape
Disposable needles and syringes needed for injection of covered prescribed medication
Allergy serum
Smoking cessation drugs and medication including nicotine patches up to 90 day supply
Intravenous fluids and medications for home use through GHI's Participating Provider network for home infusion therapy

In addition to covered prescription drugs you are covered for enteral formulas if each of the criteria set forth below are met
A covered Provider has given a written order and or a prescription
It must be proven effective as a disease specific treatment regimen for persons who are or will become malnourished or suffer from disorders which if left untreated cause chronic physical

disability mental retardation or death
You are also covered for these modified food products that are low in protein or contain modified protein if each of the criteria set forth below are met

An authorized Provider has given a written order and or a prescription
It must be for the treatment of certain inherited diseases of amino acid and organic acid metabolism

You are covered for these modified food products up to a maximum of 2,500 per calendar year or any continuous twelve 12 month period You must submit your written order or prescription and
store receipt for modified food products along with a completed claim form to GHI P O Box 2868 New York New York 10116 2868

Mandatory Mail Your prescription coverage also includes a mandatory mail program All maintenance medications must be sent to Merck Medco Rx Services Two refills per prescription will
be allowed at any local preferred TelePAID pharmacy When a new maintenance medication is prescribed the patient should request 2 prescriptions The initial for a 31 day supply to be filled at a
retail pharmacy and the second for up to a 90 day supply to be submitted using the enclosed envelope to Merck Medco Rx Services For all existing maintenance medications at a retail
pharmacy the patient is required to obtain a new prescription for up to a 90 day supply to be sent to Merck Medco Rx Services

Maintenance Drug Program The maintenance drug program permits long term prescriptions to be filled for up to a 90 day supply You pay a 10 copay for a generic drug a 20 copay per
prescription unit for a name brand
What is not covered Drugs available without a prescription or for which there is a non prescription equivalent available
Drugs obtained at a non participating pharmacy except for 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

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GHI Health Plan 2000
Section 5 Benefits Other Benefits
Dental Care This Plan provides the following program of dental coverage The emphasis is on prevention with preventive and diagnostic dental services covered with no copayments through Participating Plan
What is covered Dentists Services by non participating dentists are covered in accordance with the fees listed below
This Plan provides the following program of dental coverage
Plan Pays
Examinations maximum 2 per calendar year 10.00 each
Prophylaxes under 12 years maximum 2 per calendar year 7.00 each
Prophylaxes over 12 years maximum 2 per calendar year 10.00 each
Emergency visits for relief of pain 1 per calendar year 10.00
X rays
Full mouth series 1 every 3 years 20.00
Bitewings 4 per calendar year 2.50 each
Space maintainers 65.00 maximum
Fluoride treatments dependent children to age 22 5.00

Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth benefits are covered The need for these services must result from an accidental injury caused by external
means and services must be completed within one year It must occur while the member is covered under the FEHB Program You pay the difference between the fee schedule and the actual charges

What is not covered Therapeutic service Other dental services not shown as covered
Charges which exceed the Plan's fee schedule
Vision Care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye this Plan provides certain vision care benefits You pay nothing for covered benefits
What is covered provided by participating opticians optometrists and vision centers Services by non participating providers are paid in accordance with the Plan's fee schedule

Examination of the eyes to determine if glasses are required once each calendar year
One set of single vision or bifocal lenses toric kryptok or flat top 22mm once each calendar year

One pair of basic frames from available styles one every two years
Contact lenses for certain unusual medical conditions such as post cataract surgery or keratoconus treatment

Replacement of broken lenses with lenses of the same prescription and material originally supplied

What is not covered Frames at any time unless lenses are also provided Replacement or repair of frames
Certain bifocals and trifocals tinted plastic and oversized lenses and sunglasses and frames other than basic frames contact lenses for cosmetic purposes
Charges in excess of the maximum GHI allowance
Catastrophic medical In the event you receive any of the covered services described below rendered by a nonparticipating coverage provider and incur out of pocket expenses in a calendar year of more than a 5,000
per person catastrophic deductible GHI will then pay catastrophic benefits at 100 of reasonable and customary charges as determined by the Plan Out of pocket expenses are calculated based

upon the reasonable and customary charge for covered catastrophic services
What is covered Covered catastrophic services Covered services under catastrophic coverage include

1 Surgery 4 Covered in hospital services and
2 Administration of Anesthesia diagnostic services
3 Chemotherapy and radiation therapy 5 Maternity

What is not covered Non catastrophic services The following services are not covered under catastrophic coverage

1 Home and office visits and related 3 Dental services
diagnostic services 4 Vision services
2 Nursing Appliances Oxygen 5 Prescription drugs
and Equipment

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GHI Health Plan 2000
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 by GHI 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
Dental services If you should require additional dental services a GHI dental provider participating in the benefit are available at offer will provide these services at reduced fees All reduced fees for dental services must be paid

reduced fees directly to the participating dental provider You must verify that your provider is still participating in the program
Dental services available in the reduced fee program include
DOWNSTATE UPSTATE
DIAGNOSTIC You Pay You Pay
RESTORATIVE Fillings
Resin anterior 1 surface 52.00 38.00
Resin anterior 2 surface 69.00 48.00
Resin anterior 3 surface 86.00 59.00

PROSTHODONTICS REMOVAL
Complete denture upper or lower 660.00 441.00
Partial denture resin base Bilateral Chrome 664.00 453.00
Add tooth to existing partial 65.00 54.00
Add clasp to existing partial 73.00 59.00

PROSTHODONTICS FIXED
Bridge pontic cast mental 520.00 409.00
Porcelain fused to metal 510.00 399.00
Full cast crown with porcelain veneer backing 552.00 432.00

ORAL SURGERY
Extraction completely covered by bone 269.00 210.00
Soft tissue extraction 172.00 118.00

PERIODONTICS Gum Treatment
Gingivectomy per quadrant 200.00 169.00
Osseous Surgery per quadrant 470.00 382.00

ENDODONTICS Root Canal
Therapeutic pulpotomy 82.00 50.00
Root canals 3 canals 466.00 466.00
Apicoectomy first root 306.00 314.00

ORTHODONTICS Braces
Diagnostic and planning fee 912.00 686.00
Active Treatment Maximum 2,220.00 1,680.00
Benefits on this page are not part of the FEHB contract

Downstate includes New York Bronx Kings Queens Richmond Nassau Suffolk Putnam Orange Rockland and Westchester Counties and New Jersey
Upstate includes Eastern Central and Western New York Counties

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GHI Health Plan 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 itself determines it is medically necessary to prevent

diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Procedures treatments drugs or devices that are experimental or investigational Subscribers are not covered for expenses for expenses that GHI determines to be related to

a experimental treatment or
b investigational treatment or
c clinical trials
Experimental treatment is a treatment that has not been tested in human beings or that is being tested but has not yet been approved for general use or that is subject to review or approval by an

Institutional Review Board
Investigational treatment includes but is not limited to services or supplies which are under study or in a clinical trial to evaluate their toxicity safety and efficiency for a particular diagnosis or set

of indications
Clinical trials include but are not limited to controlled experiments having a clinical event as an outcome measurement involving persons having a specific disease or health condition or involve

the administration of different study treatments in a parallel treatment design done to evaluate the efficacy and safety of a test treatment Clinical trials include Phase I Phase II and Phase III Studies
Clinical trials also include randomized trials or studies
Procedures services drugs and supplies related to sex transformations
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
Experimental or investigational procedures treatments drugs or devices
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 Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to the 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 re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6855

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GHI Health Plan 2000
Section 7 Limitations Rules that affect your benefits continued
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 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 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

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contract us for 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 We do not cover services that compensation 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 determines 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 directly Agencies or indirectly pays for

Liability insurance If a covered person is sick or injured as a result of the act or omission of another person or party and third party the Plan requires that it be reimbursed for the benefits provided in a amount not to exceed the
actions amount of the recovery or that it be subrogated to the person's rights to the extent of the benefits received under this Plan including the right to bring suit in the person's name If you need more information about subrogation the Plan will provide you with its subrogation procedures

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 information about right to information about your health plan its networks providers and facilities You can also find
your Plan 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 have a question concerning Plan benefits or how to arrange for care contact the Plan's Subscriber Relations Department at 212 501 4GHI 4444 or 212 721 4962 Hearing impaired
TDD or you may write to them at Post Office Box 1701 New York NY 10023 9476 or contact the GHI office nearest you You may also contact the Plan at its website at http www ghi com If
you have a question concerning a hospital claim contact GHI's Hospital Service Department at 212 615 0500

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
enrolling in the an informed decision about FEHB Program When you may change your enrollment
How you can cover your family members 19 19
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GHI Health Plan 2000
Section 8 FEHB facts continued
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 premiums and premiums begin on the first day of your first pay period that starts on or after January 1
effective Annuitants premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are available unmarried dependent children under age 22 including any foster or step children your employing
for me and my or retirement office authorizes coverage for Under certain circumstances you may also get family 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

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 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 We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in Your enrollment ends unless you cancel your enrollment or
the Plan ends You or a family member is no longer eligible for coverage
20 You may be eligible for former spouse coverage or Temporary Continuation of Coverage 20
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GHI Health Plan 2000
When you lose benefits continued
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former 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 ex spouse's employing or retirement office to get more information about your coverage choices

What is TCC
Temporary If you leave Federal service or if you lose coverage because you no longer qualify as a family Continuation of member you may be eligible for TCC For example you can receive TCC if you are not able to
Coverage TCC 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 You can pick a new plan TCC 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 If you leave Federal service your employing office will notify you of your right to enroll under
in TCC 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

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

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GHI Health Plan 2000
What is TCC continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan Coverage health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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 888 456 3728 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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GHI Health Plan 2000
Summary of Benefits for GHI Health Plan 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated 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
NOTE If you use a medical surgical provider who does not participate you will receive only 50 of the GHI fee schedule

BENEFITS PLAN PAY S P ROVIDES 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 if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive
care and complete maternity care You pay nothing 11

Extended Care All necessary services for up to 30 days per year You pay nothing 12
Mental Conditions Diagnosis and treatment of acute psychiatric conditions You pay nothing 14

Substance Abuse Up to 30 days of substance abuse treatment per year You pay nothing 14
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 a 10 copay per office visit or house call by a doctor copay does not apply to well baby care 14

Home Health Care All necessary visits by nurses and health aides You pay nothing 12
Mental Conditions Diagnosis and treatment of active psychiatric conditions visits for outpatient treatment per year You pay a 10 copay per visit 14

Substance Abuse Up to 60 visits per year You pay nothing 14
Emergency care Services and supplies required because of a medical emergency 80 of charges from a non participating hospital outside the
Service Area You pay a 25 per emergency room visit and charges in excess of the Plan's emergency fee schedule and charges for
services which are not covered benefits of this Plan and 20 of charges from a non participating hospital outside the Service Area 13

Prescription drugs Drugs prescribed by a doctor and obtained at a participating pharmacy You pay a 5 copay for generic drugs a 15 copay per
prescription unit or refill for name brand drugs listed on the preferred prescriptions drug formulary and a 20 copay per
prescription unit or refill for a name brand drug not listed on the preferred presciption drug formulary For mail order maintenance
drugs you pay a 10 copay for generics a 20 copay for name brand 15

Mandatory Mail Your prescription coverage also includes a mandatory mail program All maintenance medications must be sent to Merck Medco Rx
Services Two refills per prescription will be allowed at any local preferred TelePAID pharmacy 15

Dental care Accidental injury benefit You pay in excess of fee schedule Preventive and diagnostic dental care 16
Vision care One refraction annually Lenses annually and frames every two years You pay nothing to participating vision centers 16
Out of pocket limit Your out of pocket expenses for benefits covered under this plan are limited to the stated payments which are required for a few benefits
and or to the difference between the Plan's payment for nonparticipating providers and the provider's charges 6 7

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GHI Health Plan 2000
2000 Rate Information for GHI Health Plan

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 are 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 Services 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 801 78.65 26.21 170.40 56.80 93.06 11.80 93.06 11.80
Self and Family 802 175.97 86.18 381.27 186.72 207.74 54.41 201.02 61.13

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