For changes
in benefits 4 5 Serving Greater Minneapolis St Paul St Cloud West Central Wisconsin
see pages
Enrollment Codes 531 High Option Self Only 532 High Option Self and Family
534 Standard Option Self Only 535 Standard Option Self and Family
Enrollment in this Plan is limited see page 5 for requirements
This plan has Commendable accreditation from the NCQA See the FEHB Guide
for more information on NCQA
Special Notice This Plan has significantly reduced
its service area See page 4 for more information
Visit the OPM website at http www opm gov insure
RI 73 009
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HealthPartners Classic 2000
Table of Contents
Page
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4 5
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 9 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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HealthPartners Classic 2000
Introduction
Group Health Inc dba HealthPartners Classic 8100 34th Avenue South
Minneapolis Minnesota 55440
This brochure describes the benefits you can receive from HealthPartners Classic under its contract CS1048 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 pages 4 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 HealthPartners Classic 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
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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HealthPartners Classic 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 preventative
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 changes To keep your premiums as low as possible OPM has set a minimum copay of 10 for all primary care 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 Plan The Plan has reduced it's service area by no longer serving the following partial counties in Minnesota Crow Wing County including the townships of Crow Wing Daggett Brook Fort
Ripley Long Lake Maple Lake Nokay Lake Oak Lawn Platte Lake and St Mathias Todd County including the townships and cities of Bruce Burnhamville Clarissa Clotho Fawn
Lake Gray Eagle Hartford Little Elk Little Sauk Long Prairie Reynolods Round Prairie Turtle Creek and West Union Douglas County including the townships and cities of
Alexandria Belleriver Carlos and Osakis Kandiyohi County including the townships and cities of Hawick New London and Regal and Pope County including the townships and
cities of Glenwood Sedan Villard and Westport
Your share of the non postal standard option premium will increase by 14 for Self Only and for Self and Family
Your share of the non postal high option premium will increase by 22.5 for Self Only or 19.7 for Self and Family
A mail order drug benefit has been added which provides a 90 day supply for two prescription drug copays 16 for the High Option plan and 20 for the Standard Option plan
Orthognathic surgery coverage has been added under the oral and maxillofacial surgery benefit with 25 of charges coinsurance Coverage for the treatment of temporomandibular joint
TMJ has increased to include the related dental appliance See page 10
Coverage for transplants has increased to remove certain limits for kidney pancreas transplants and autologous bone marrow transplants for neuroblastoma See page 9
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HealthPartners Classic 2000
Section 2 How we change for 2000 continued
Changes to this Plan Benefits for the treatment of infertility does not include the cost of donor sperm or ova or continued storage of donor sperm ova or embryo See page 10
Hospice care has been clarified to indicate that the five day limit for respite care applies per episode The member must pay all charges thereafter See page 12
Short term rehabilitative therapy has been clarified to show that respiratory therapy is also covered along with physical speech and occupational and there is a 10 copay per outpatient
session for High Option and a 15 copay per outpatient session for Standard Option See page 10
Inpatient substance abuse care in an alcohol detoxification or rehabilitation center will no longer be limited to emergency care detoxification and treatment planning
Durable medical equipment has been clarified to indicate that glucose monitors and insulin pumps are covered if deemed medically necessary See page 11
The office visit copay for group therapy mental conditions visits have decreased from 10 for high option and 15 for standard option to 5 for high option and 7.50 for standard option
See page 15
Medically necessary care as determined by the Plan Medical Director for procedures services and supplies related to sex transformations are covered in full
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
The following counties in Minnesota Anoka Benton Carver Chisago Dakota Hennepin Morrison Ramsey Rice Scott Sherburne Stearns Washington and Wright
The following partial county in Minnesota Mille Lacs and Isanti
The following counties in Wisconsin Pierce Polk and St Croix
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 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 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 This is called either a copayment a set dollar amount pay for services or coinsurance a set percentage of charges
After you pay 3,000 in copayments or coinsurance for one family member or 5,000 for two or more family members you do not have to make any further payments for certain services for the
rest of the calendar year This is called a catastrophic limit
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider 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
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HealthPartners Classic 2000
Section 3 How to get benefits continued
Who provides my Health Partners Classic is a group practice prepayment plan that allows members to receive health health care services at over 70 medical mental health and dental facilities and 25 contracting hospitals
throughout the Twin Cities and surrounding areas including St Cloud HealthPartners Classic medical providers include 575 primary care doctors and over 1,100 community specialists to
whom patients are referred Members may choose any medical center in the Plan's network for their primary care Each covered person in a family may select a different medical center
What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or to go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm in First call our customer service department at 612 883 5000 or 1 800 883 2177 hearing impaired the hospital when I individuals should call 612 883 5127 If you are new to the FEHB Program we will arrange for
join this Plan you to receive care If you are currently in the FEHB Program and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
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 with the following exception specialty care a woman may see a plan gynecologist associated with her clinic for her annual wellness exam
without a referral
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves receive services from your current specialist until we can make arrangements for you to see
the Plan someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract
provider leaves the with the provider unless the termination is for cause If you are in the second or third trimester Plan or this Plan of pregnancy you may continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or
provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care
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HealthPartners Classic 2000
Section 3 How to get benefits continued
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a medical services specialist or recommending follow up care
You should check with your Plan physician to determine if a service requires a referral or authorization before you obtain services
Plan medical directors or their designees make coverage determinations and make final authorization for certain covered services Coverage determinations are based on established
medical policies which are subject to periodic review and modification by the medical or dental directors Call the Plan for more information on referral and authorization requirements
How do you decide if a The plan determines if a treatment or procedure is experimental investigational or unproven if it is service is experimental
Not approved by the U S Food and Drug Administration FDA to be lawfully marketed for the or investigational proposed use or
If reliable evidence shows that the drug device or medical treatment or procedure is the subject of ongoing Phase I II or III Clinical Trials or
If reliable evidence shows that the drug device or medical treatment or procedure is under study to determine its maximum tolerated dose its toxicity its safety and its efficacy as compared with the
standard means of treatment or diagnosis
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 serious or Call us at 612 883 5000 or 1 800 883 2177 hearing impaired individuals should call life threatening condition 612 883 5127 and we will expedite our review
and you haven't responded to my request for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious or health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening life threatening conditions are ones that may cause permanent loss of bodily functions or death if they
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HealthPartners Classic 2000
Section 4 What to do if we deny your claim or request for service continued
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 Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with
the review request
What address should I send Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contract Division IV P O Box 436 Washington D C 20044
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will base a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record
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HealthPartners Classic 2000
Section 5 BENEFITS
Medical and A comprehensive range of preventive diagnostic and treatment services is provided by Plan Surgical Benefits doctors and other Plan providers This includes all necessary office visits
What is covered High Option Standard Option
You pay a 10 copay per office visit and You pay a 15 copay per office visit and per house call by a doctor but no additional per house call by a doctor but no additional
copay for laboratory tests and X rays copay for laboratory tests and X rays
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups routine screening for cancer routine eye and hearing exams and voluntary family planning services You pay nothing
Routine immunizations and boosters You pay nothing
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 age 64 one mammogram every year and for women age 65 and above one mammogram every two years You pay nothing for routine mammograms In
addition to routine screening mammograms are covered when prescribed by a Plan doctor as medically necessary to diagnose or treat your illness
Consultations by specialists
Diagnostic procedures including laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan 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 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 the infant requiring definitive treatment will be covered only if the infant is covered under a
Self and Family enrollment You pay nothing for prenatal and postnatal care
Voluntary sterilizations and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum You pay nothing for allergy injections
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung or single and double lung for primary pulmonary hypertension Eisenmenger's syndrome end stage pulmonary fibrosis alpha 1 antitrypsin disease cystic
fibrosis and emphysema kidney pancreas for diabetes kidney liver transplants for bilary atresia in children primary bilary cirrhosis post acute viral infection including hepatitis A
hepatitis B antigen e negative and hepatitis C causing acute atrophy or post necrotic cirrhosis primary sclerosing cholangitis and alcoholic cirrhosis allogenic donor bone marrow
transplants or peripheral stem cell support associated with high dose chemotherapy for acute myelogenous leukemia acute lymphocytic leukemia chronic myelogenous leukemia severe
combined immunodeficiency disease Wiscott Aldrich syndrome and aplastic anemia autologous bone marrow transplants or peripheral stem cell support for acute lymphocytic and nonlymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma neuroblastoma breast cancer multiple myloma epithelial ovarian cancer and testicular
mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Medical Director 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
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HealthPartners Classic 2000
Section 5 BENEFITS continued
Medical and Chiropractic services Chiropractic therapy does not include ongoing maintenance therapy or Surgical Benefits therapy other than for treatment of acute musculoskeletal conditions
What is covered Breast reduction surgery if approved by the Plan Medical Director
continued Surgical treatment of morbid obesity if approved by the Plan Medical Director 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 and need You pay the office visit copay shown above per visit for health aides
physical therapists occupational therapists respiratory therapists and speech therapists You pay nothing for all other covered home health services
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
Non Plan services for voluntary family planning the diagnosis of infertility testing and treatment of sexually transmitted diseases and testing for HIV and HIV related conditions You pay
the same as you would for the applicable service provided by a Plan provider
Limited benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical and surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures treatment of temporomandibular joint TMJ pain dysfunction syndrome
including the related dental appliance and excision of tumors and cysts Treatment of cleft lip and cleft palate including orthodontia and oral surgery is limited to dependent children to age 18
Orthognathic surgery is covered for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non surgical treatment alone and a demonstrable functional
impairment exists Functional impairments include but are not limited to difficulties in chewing breathing or swallowing You pay 25 of charges Associated orthodontic services pre or post
operative is not covered
All other procedures involving the teeth and intra oral areas surrounding the teeth are not covered
Diagnosis and treatment of infertility is covered you pay 20 of the cost of injectable prescription drugs for infertility therapy if there is prior authorization by a Plan doctor before therapy
begins Artificial insemination is covered you pay 20 of the charges Cost of donor sperm or ova or cost of storage of donor sperm ova or embryo is not covered Fertility drugs are covered
Other assisted reproductive technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant through other artificial procedures such as in vitro
fertilization and embryo transfer are not covered
Short term rehabilitative therapy physical speech respiratory 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 a 10 copay High Option or 15 Standard Option per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic
origin or to correct the effects of illness or injury 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
Habilitative care is speech physical or occupational therapy which is provided for congenital developmental or medical conditions which have significantly limited the successful initiation of
normal speech and motor development To be considered habilitative significant functional improvement and measurable progress must be made toward achieving functional goals within a
predictable period of time toward an enrollee's maximum potential ability The Plan will supplement and coordinate such services with similar benefits made available by other agencies including
the public school system The determination of whether such measurable progress has been made is within the sole discretion of the Plan Medical Director based on objective documentation
Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction is provided for Phase I Phase II is provided if the Plan determines it is medically necessary Phase
III is not covered You pay nothing
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HealthPartners Classic 2000
Section 5 BENEFITS continued
Medical and Reconstructive surgery will be provided to correct a condition which has resulted in a functional Surgical Benefits defect or that has resulted from injury or surgery that has produced a major affect on the member's
appearance and the condition can reasonably be expected to be corrected by such surgery A Limited benefits patient and her attending physician may decide whether to have breast reconstruction surgery following
continued a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance
Hair prostheses when required because of hair loss due to alopecia areata are covered at 80 up to a maximum benefit of 350 per year you pay 20 of the charges and all charges after the Plan
pays 350
Orthopedic devices such as braces or foot orthotics prosthetic devices such as artificial limbs breast prostheses surgical bras and external lenses following cataract surgery and durable medical
equipment such as wheel chairs and hospital beds glucose monitors and insulin pumps deemed medically necessary are covered You pay 20 of the charges Rental of durable medical equipment
is covered for up to one month while the enrollee's own equipment is being repaired The Plan will determine whether an item is approved for purchase or rental Durable medical equipment
and supplies must be obtained from approved vendors
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 including related treatment for infertility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood and blood derivatives no charge if replacement is arranged by member
Long term rehabilitation therapy
Speech therapy services to correct development delays
Genetic counseling and studies not required for diagnosis and treatment
Artificial insemination for surrogate pregnancy
Homemaker services
Hearing aids
Rental of medically necessary durable medical equipment while enrollee's own equipment is being repaired that is beyond one month rental
Over the counter foot orthotics
Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits limit when you are hospitalized under the
Hospital care care of a Plan doctor 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
High Option Standard Option
You pay nothing You pay the first 200 per admission plus 20 of the next 3,500 of charges per
calendar year A separate copay applies to each person including a newborn child
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HealthPartners Classic 2000
Section 5 BENEFITS continued
Extended care The Plan provides a comprehensive range of benefits for up to 180 days per period of confinement when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
High Option Standard Option
You pay nothing You pay the first 200 per admission plus 20 of the next 3,500 of charges per
calendar year
Period of confinement means 1 continuous inpatient stay in a hospital or skilled nursing facility or 2 a series of two or more inpatient stays in a hospital or skilled nursing facility for the same
condition in which the end of each inpatient stay is separated from the beginning of the next one by less than 90 days Same condition means illness or injury related to a former illness or injury in
that it is a within the same ascertainable diagnosis or b within the scope of complications or related conditions
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 family counseling and respite and
continuous care Coverage for respite care is limited to five days per episode you pay all charges thereafter Periods of respite care and continuous care combined are limited to thirty days 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
High Option Standard Option
You pay nothing for part time and intermittent You pay a 10 copay per office or home care provided in the home inpatient visit by a doctor nurse or other provider
services medications for pain and including continuous care For inpatient symptom management and durable medical care you pay the first 200 per admission
equipment and continuous care You plus 20 of the next 3,500 of pay 20 of charges for periods of respite charges You pay 20 of charges for
care periods of respite care
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay 20 of charges Transfers between hospitals for treatment by Plan doctors are covered at
100 if initiated by a Plan doctor You pay nothing for transfers
Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons totally unrelated to the dental procedure This is limited to
Inpatient dental charges incurred by a covered person who 1 is a child under age 5 2 is severely disabled or procedures
3 has a medical condition and requires hospitalization or general anesthesia for dental care treatment The Plan will cover the hospitalization and anesthesia charges see High and Standard benefits
on page 11 but not the cost of the professional dental services
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 15 for nonmedical Substance Abuse Benefits
What is not covered Personal comfort items such as telephone and television
Blood and blood derivatives no charge if replacement is arranged by member
12 Custodial care rest cures domiciliary or convalescent care
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HealthPartners Classic 2000
Section 5 BENEFITS continued
Emergency Benefits A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires immediate
What is a medical medical or surgical care Some problems are emergencies because if not treated promptly they emergency
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 the Plan network if you 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 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
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 Charges for emergency care services to the extent the services would have been covered if received from Plan providers
High Option Standard Option
All but 10 per visit in Plan urgent care All but 15 per visit in Plan urgent care clinics All but 40 for authorized outpatient clinics All but 40 for authorized outpatient
care in a Plan hospital This 40 care in a Plan hospital This 40 emergency room copay is waived if the emergency room copay is waived if the
condition requiring outpatient care results condition requiring outpatient care results in an authorized admission to the hospital in an authorized admission to the hospital
within the next 24 hours Authorized within the next 24 hours 80 of charges inpatient hospital emergency care is for ambulance service ordered or authorized
covered in full 80 of charges for by a Plan doctor ambulance service ordered or authorized
by a Plan doctor Authorized inpatient hospital emergency
care is covered after a 200 deductible at 80 of the next 3,500 per calendar year
and 100 thereafter of charges 100 of physician charges for in hospital care
You pay High Option Standard Option
10 copayment per visit for care provided 15 copayment per visit for care provided in Plan urgent care clinics 40 per outpatient in Plan urgent care clinics 40 per outpatient
hospital visit This 40 emergency hospital visit This 40 emergency room copay is waived if the condition room copay is waived if the condition
requiring out patient care results in requiring outpatient care results in an an authorized admission to the hospital authorized admission to the hospital within
within the next 24 hours 20 of charges the next 24 hours 20 of the charges for authorized ambulance service for authorized ambulance services
Nothing for authorized inpatient hospital For services in the hospital the first 200 care Any charges which are not a per admission plus 20 of the next
covered benefit of this Plan 3,500 per calendar year
13
13
13
Page 14
15
HealthPartners Classic 2000
Section 5 BENEFITS continued
Emergency Benefits Benefits are available for any medically necessary health service that is immediately required continued because of injury or unforeseen illness 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 Emergencies outside in full To be covered by this Plan any follow up care recommended by non Plan providers
the Plan network must be approved by the Plan or provided by Plan providers
Plan pays Charges for emergency care services to the extent the services would have been covered if received from Plan providers
High Option Standard Option
80 of the first 2,500 and 100 thereafter 80 of the first 2,500 and 100 thereafter of charges per calendar year for of charges per calendar year for
inpatient and outpatient hospital medical doctor services in or outside of the hospital and surgical benefits outpatient hospital services and other
covered non hospital services
For inpatient services after a 200 deductible per admission 80 of the
next 3,500 per calendar year and 100 thereafter of charges
You pay High Option Standard Option
20 of the first 2,500 of charges per 20 of the first 2,500 per calendar year calendar year nothing thereafter for of charges for doctor services in or outside
covered services of the hospital outpatient hospital services and other covered non hospital
services
For inpatient services the first 200 per admission plus 20 of the next 3,500 of
charges per calendar year
What is covered Emergency care at a doctor's office or urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services if approved by the Plan
Ambulance service if approved by the Plan
Emergency dental care from non Plan dentists see page 17
What is not covered Elective care or nonemergency care
Emergency care provided outside the Service Area if the need for care could have been foreseen before departing 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 emergency benefits directly to the providers of your non Plan providers emergency care upon receipt of their claims 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 A 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 You may request reconsideration in accordance with the disputed claims procedure set forth on the inside back cover of this brochure
14
14
14
Page 15
16
HealthPartners Classic 2000
Section 5 BENEFITS continued
Mental Conditions Substance Abuse Benefits
Mental Conditions The medical management of mental conditions will be covered under this Plan's medical and
What is covered Surgical Benefits provisions Related drug costs will be covered under this Plan's Prescription Drug Benefits and any costs for psychological testing or psychotherapy will be covered under this
Plan's Mental Conditions Benefits
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
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care All necessary outpatient care from Plan doctors consultants or other psychiatric personnel each calendar year
High Option Standard Option
You pay a 10 copay per office visit and You pay a 15 copay per office visit and a 5 copay per group therapy visit a 7.50 copay per group therapy visit
Inpatient care All necessary hospitalization and inpatient psychiatric medical care each calendar year
High Option Standard Option
You pay nothing You pay first 200 per admission plus 20 of the next 3,500 of charges per
calendar year
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject covered 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
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
Outpatient care All necessary outpatient care
High Option Standard Option
You pay a 10 copay per office visit You pay a 15 copay per office visit
Inpatient care Treatment in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan
High Option Standard Option
You pay nothing You pay first 200 per admission plus 20 of the next 3,500 of charges per
calendar year
What is not covered Treatment that is not authorized by a Plan doctor 15
15
15
Page 16
17
HealthPartners Classic 2000
Section 5 BENEFITS continued
Prescription Drug Benefits Prescription drugs must be prescribed by a Plan or referral doctor obtained at a Plan pharmacy and dispensed in accordance with the Plan's formulary If you are requesting a brand name drug
What is covered and there is a generic equivalent the brand name drug will only be covered up to the charge that would apply to the generic drug minus any required copayment If your Plan doctor has indicated
on the prescription that the brand name drug should be dispensed as written the brand name drug will be covered in full minus any required copayment
The Plan's formulary is a list of drugs chosen for coverage by the Plan's Pharmacy and Therapeutics P T Committee based on a drug's safety effectiveness and cost The Plan's P T
Committee evaluates any needed changes to the formulary on a quarterly basis
Non formulary drugs will be covered when prescribed by a Plan doctor It is the Plan doctor's responsibility to obtain authorization for non formulary drugs before they are dispensed
The Plan's formulary will be covered Non formulary drugs will be covered when prescribed by a Plan doctor It is the prescribing doctor's responsibility to obtain authorization for non formulary
drugs before they are dispensed
High Option Standard Option
You pay up to an 8 copay per You pay up to a 10 copay per prescription unit or refill for each prescription unit or refill for each
30 day supply or portion thereof 30 day supply or portion thereof
Covered medications and accessories include
Drugs for which a prescription is required by law and that are obtained at participating pharmacies
Oral contraceptive drugs and contraceptive barrier devices a single copay charge will apply for 3 cycles of oral contraceptive drugs or for each barrier device
Insulin with a copay charge applied to each vial
Diabetic testing supplies
Disposable needles and syringes needed to inject covered prescribed medication including insulin
Intravenous fluids and medications for home use are covered under medical and Surgical Benefits
Tobacco cessation products as determined by the Plan limited to a 60 consecutive day supply per calendar year Benefits are limited to one product at a time and no more than a 30 day
supply will be covered and dispensed at a time
Mail order benefit You may also get outpatient prescription drugs which can be self administered through HealthPartners mail order service For information on how to obtain drugs through HealthPartners
mail order service please call our Member Services Department at 800 883 2177 This benefit does not apply to drugs covered under the Limited benefits shown below
High Option Standard Option
You pay a 16 copay for each prescription You pay a 20 copay for each prescription unit or refill for each 90 day supply unit or refill for each 90 day supply
or portion thereof or portion thereof
Limited benefits Injectable and implantable contraceptive drugs or devices such as Depo Provera Norplant IUD's You pay 20 of charges
Growth hormones You pay 20 of charges Injectable drugs for the treatment of infertility You pay 20 of charges
Special dietary treatment for phenylketonuria PKU is covered You pay 20 of charges Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits
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
Contraceptive devices except as listed above 16 Drugs for cosmetic purposes
Drugs to enhance athletic performance
16
16
Page 17
18
HealthPartners Classic 2000
Section 5 BENEFITS continued
Other Benefits
Dental care The following preventive and diagnostic dental services are covered for all members when provided
What is covered by participating Plan dentists Benefit limitations are noted where they apply High Option High Option members pay nothing no benefits are provided for preventive dental under the Standard Option
Routine dental examinations per Plan dentist's recommendation
Teeth cleaning prophylaxis or periodontal maintenance recall limited to twice per year
Topical application of fluoride per Plan dentist's recommendation
Oral hygiene instruction per Plan dentist's recommendation
Bitewing x rays limited to once per year
Full mouth panoramic x rays limited to once every three years
Accidental injury benefit Services of Plan dentists necessary to promptly repair or replace sound natural teeth limited to restorative services and supplies plus prescription and installation of necessary dental prosthetic
items or devices The need for these services must directly result from an accidental injury not including injury from biting or chewing and treatment and repair must be completed within
twelve months of the date of injury You pay dental laboratory's actual charge for prescription dental prosthetic items and devices related to the accident plus any dental services rendered in connection
with previously missing teeth or for teeth not injured in the accident
Emergency dental services for accidental injury as described above are covered when they are provided by non Plan dentists if the services require immediate treatment After a 50 calendar
year deductible you pay 20 of the charges up to a maximum Plan benefit of 300 per calendar year and any charges thereafter
What is not covered Other dental services not shown as covered
Vision care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions including lens prescriptions are covered You pay nothing
What is covered
What is not covered Corrective eyeglasses frames and contact lenses
Eye exercises
Radial keratotomy
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 who are members of this Plan The cost of the benefits described on this page is not included in the FEHB premium any charges for these services do not count toward any FEHB deductibles
out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedure
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare without payment of an FEHB premium As indicated on page 18 certain annuitants and former spouses who are
covered by both Medicare Parts A and B and FEHB may elect to drop their FEHB coverage and later reenroll in FEHB Contact your retirement system for information on changing your FEHB enrollment Contact us at 883 5601 for information
on the Medicare prepaid plan and the cost of that enrollment
Benefits in this box are not part of the FEHB Contract
17
17
17
Page 18
19
HealthPartners Classic 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 following
Services drugs or supplies that are not medically necessary
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
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 unless determined medically necessary by the Plan Medical Director
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 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 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 6833 For information on the Medicare Choice
plan offered by this Plan see page 17
Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine 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
Circumstancs beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary care
18
18
18
Page 19
20
HealthPartners Classic 2000
Section 7 Limitations Rules that affect your benefits continued
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for injuries another 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 agree to let us try This is called subrogation If you need more information
contact 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 compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly Agencies or indirectly pays for
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
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 612 883 5000 or 1 800 883 2177 hearing impaired individuals should call 612 883 5127 or write to HealthPartners Member Services
Department 8100 34th Avenue South P O Box 1309 Minneapolis MN 55440 1309
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
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 and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1
Annuitants premiums begin January 1 19
19
19
Page 20
21
HealthPartners Classic 2000
Section 8 FEHB FACTS continued
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 coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for me unmarried dependent children under age 22 including any foster or step children your employing
and my family or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who 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 and claims We will keep your medical and claims information confidential Only the following will have records confidential access to it
OPM this Plan and 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 payment and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also
use an Employee Express confirmation letter
What if I paid a deductible Your old plan's deductible continues until our coverage begins under my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
20
20
20
Page 21
22
HealthPartners Classic 2000
Section 8 FEHB FACTS continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Your enrollment ends unless you cancel your enrollment or Plan ends
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits 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 Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example
you can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling
in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
21
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Page 22
23
HealthPartners Classic 2000
Section 8 FEHB FACTS continued
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
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 at 612 883 5000 or 1 800 2177 hearing impaired individuals should call 612 883 5127 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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Page 23
24
Summary
of
Benefits
for
HealthPartners
Classic
2000
Do
not
rely
on
this
chart
alone
All
benefits
are
provided
in
full
unless
otherwise
wish
to
enroll
or
change
your
enrollment
in
this
Plan
be
sure
to
indicate
the
correct
indicated
subject
to
the
definitions
limitations
and
exclusions
set
forth
in
the
brochure
enrollment
code
on
your
enrollment
form
codes
appear
on
the
cover
of
this
brochure
This
chart
merely
summarizes
certain
important
expenses
covered
by
the
Plan
If
you
ALL
SERVICES
COVERED
UNDER
THIS
PLAN
WITH
THE
EXCEPTION
OF
EMERGENCY
CARE
ARE
COVERED
ONLY
WHEN
PROVIDED
OR
ARRANGED
BY
PLAN
DOCTORS
Benefits
High
Option
pays provides
Page
Standard
Option
pays provides
Page
Inpatient
care
Comprehensive
range
of
medical
and
surgical
services
with
no
dollar
Comprehensive
range
of
medical
and
surgical
services
with
no
dollar
or
day
Hospital
or
day
limit
Includes
in hospital
doctor
care
room
and
board
general
nursing
limit
Includes
in patient
doctor
care
room
and
board
general
nursing
care
care
private
room
and
private
nursing
care
if
medically
necessary
diagnostic
private
room
and
private
nursing
care
if
medically
necessary
diagnostic
tests
tests
drugs
and
medical
supplies
use
of
operating
room
intensive
care
and
drugs
and
medical
supplies
use
of
operating
room
intensive
care
and
complete
complete
maternity
care
You
pay
nothing
11
maternity
care
You
pay
200
per
admission
plus
20
of
the
next
3,500
of
charges
per
calendar
year
11
Extended
All
necessary
services
for
up
to
180
days
per
period
of
All
necessary
services
for
up
to
180
days
per
period
of
confinement
You
pay
care
confinement
You
pay
nothing
12
200
per
admission
plus
20
of
the
next
3,500
of
charges
per
calendar
year
12
Mental
Diagnosis
and
treatment
of
acute
psychiatric
Diagnosis
and
treatment
of
acute
psychiatric
conditions
You
pay
200
per
conditions
conditions
You
pay
nothing
15
admission
plus
20
of
the
next
3,500
of
charges
days
per
calendar
year
15
Substance
Each
member
is
entitled
to
all
necessary
treatment
for
substance
Each
member
is
entitled
to
all
necessary
treatment
for
substance
abuse
abuse
abuse
programs
You
pay
nothing 15
programs
You
pay
first
200
per
admission
plus
20
of
the
next
3,500
of
charges
per
calendar
year
15
Outpatient
Comprehensive
range
of
services
such
as
diagnosis
and
treatment
of
illness
or
Comprehensive
range
of
services
such
as
diagnosis
and
treatment
of
illness
or
care
injury
including
specialist's
care
preventive
care
including
well baby
care
injury
including
specialist's
care
preventive
care
including
well baby
care
periodic
check ups
and
routine
immunizations
laboratory
tests
and
X rays
periodic
check ups
and
routine
immunizations
laboratory
tests
and
X rays
complete
maternity
care
You
pay
10
per
visit
You
pay
nothing
for
preventive
complete
maternity
care
You
pay
15
per
visit
You
pay
nothing
for
preventive
care
including
well
baby
care
periodic
check
ups
and
routine
immunizations
9
care
including
well
baby
care
periodic
check
ups
and
routine
immunizations
9
Home
All
necessary
visits
by
nurses
and
health
aides
You
pay
10
per
visit
for
All
necessary
visits
by
nurses
and
health
aides
You
pay
15
per
visit
for
physi
health
physical
therapy
occupational
therapy
speech
therapy
respiratory
therapy
cal
therapy
occupational
therapy
speech
therapy
respiratory
therapy
and
home
care
and
home
health
aide
services
and
nothing
for
all
other
services
10
health
aide
services
and
nothing
for
all
other
services
10
Mental
All
necessary
outpatient
visits
All
necessary
outpatient
visits
conditions
You
pay
10
per
visit
15
You
pay
15
per
visit 15
Substance
All
necessary
outpatient
visits
All
necessary
outpatient
visits
abuse
You
pay
10
per
visit
15
You
pay
15
per
visit 15
Emergency
care
Charges
for
services
and
supplies
required
because
of
a
medical
emergency
You
You
pay
15
per
visit
at
Plan
medical
centers
40
per
authorized
outpatient
pay
10
at
Plan
medical
centers
40
per
authorized
outpatient
Plan
hospital
Plan
hospital
visit
20
of
the
first
2,500
of
authorized
charges
at
non Plan
visit
20
of
the
first
2,500
of
authorized
charges
at
non Plan
facilities
20
of
facilities
20
of
authorized
ambulance
expense 13
14
authorized
ambulance
expense 13
14
Prescription
Drugs
prescribed
by
a
Plan
doctor
and
obtained
at
participating
pharmacies
Drugs
prescribed
by
a
Plan
doctor
and
obtained
at
participating
pharmacies
drugs
You
pay
up
to
8
per
prescription
unit
or
refill
mail
order
benefit
is
two
copays
You
pay
up
to
10
per
prescription
unit
or
refill
mail
order
benefit
is
two
per
90 day
supply 16
copays
per
90 day
supply
16
Dental
care
Accidental
injury
benefit
and
preventive
dental
care
You
pay
no
copayment
for
Accidental
injury
benefit
preventive
care
or
for
services
of
Plan
dentists
for
accidental
injury
You
pay
You
pay
dental
laboratory
charges
17
dental
laboratory
charges
for
accidental
injury
17
Vision
care
Eye
refractions
including
lens
prescriptions
you
pay
nothing
17
Eye
refractions
including
lens
prescriptions
you
pay
nothing 17
Out of
pocket
Copayments
are
required
for
a
few
benefits
however
after
your
out of
pocket
Copayments
are
required
for
a
few
benefits
however
after
your
out of
pocket
limit
expenses
reach
a
maximum
of
3,000
per
Self
Only
or
5,000
per
Self
and
Family
expenses
reach
a
maximum
of
3,000
per
Self
Only
or
5,000
per
Self
and
Family
enrollment
per
calendar
year
covered
benefits
will
be
provided
at
100
5
enrollment
per
calendar
year
covered
benefits
will
be
provided
at
100
5
23
23
Page 24
HealthPartners Classic 2000
2000 Rate Information for HealthPartners Classic
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member of a special
postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share Share Share Share Share Share Share Share
High Option 531 78.83 32.14 170.80 69.64 93.06 17.91 93.26 17.71 Self Only
High Option 532 175.97 90.33 381.27 195.71 207.74 58.56 201.02 65.28 Self and Family
Standard Option 534 71.14 23.71 154.13 51.38 84.18 10.67 84.18 10.67 Self Only
Standard Option 535 170.70 56.90 369.85 123.28 202.00 25.60 201.02 26.58 Self and Family
24 24