Pages 1--28 from Untitled

Kaiser Permanente to be acquired by Capital District Physicians Health Plan Inc
2000

A Health Maintenance Organization

For changes benefits in
page 4 Serving Albany New York and surrounding counties see
Cooperstown New York and surrounding counties Hudson Valley Region of New York

Enrollment in this Plan is limited see page 5 for requirements
Enrollment code PW1 Self Only

PW2 Self and Family
Region I includes the Albany and Cooperstown New York areas
Enrollment code QB1 Self Only

QB2 Self and Family
Region II includes the Hudson Valley of New York area
The NCQA accreditation status for this service area is rated Commendable See the FEHB Guide for more information on NCQA

Special notice The Plan has eliminated a portion of its service area for 2000 If you are enrolled in this
Plan under enrollment code 8M and live in one of the following areas you must select another plan during
the Open Season to continue to receive full benefits Vermont

Visit the OPM website at http www opm gov insure and
the Kaiser Permanente website at http www kaiserpermanente org

Authorized for distribution by the
United States Office of Personnel Management
retirement and insurance service

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Kaiser Permanente 2000
Table of Contents

Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 17
Section 8 FEHB FACTS 19
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits Inside back cover
Premiums Back cover

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Kaiser Permanente 2000
Introduction

Kaiser Permanente 1 CHP Plaza
Latham NY 12110
This brochure describes the benefits you can receive from Community Health Plan Inc d b a Kaiser Permanente Inc to be acquired by Capital District Physicians Health Plan Inc CDPHP under its contract CS1760 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 4 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 Kaiser Permanente to be acquired by CDPHP 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 rewritten the Benefits section of this brochure You will find new benefits language next year

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Kaiser Permanente 2000
How to use this brochure

This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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Kaiser Permanente 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 services from a provider who does not contract with us
you may have to submit a claim
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all changes 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 Your share of the non postal premium for code PW will increase by 21.8 for Self Only or 43.4 for Self and Family
Your share of the non postal premium for code QB will increase by 35.2 for Self Only or 44.6 for Self and Family

Hearing aids are no longer covered See page 11
Coverage for orthopedic and prosthetic devices and durable medical equipment has been changed from a 10 copayment for covered equipment to a 20 copayment subject to a
lifetime maximum of 250,000 See page 11
Kaiser Permanente to be acquired by Capital District Physicians Health Plan Inc CDPHP This change does not effect benefits or rates

Services from other Kaiser Permanente Plans and benefits available while you travel for follow up care and continuing care are no longer available because this Plan will no longer
be affiliated with Kaiser Permanente

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Kaiser Permanente 2000
Section 3 How to get benefits

What is this Plan's To enroll in this Plan you must live or work in our service area This is where our providers service area practice Our service area is

Region I New York Albany County Broome County Chenango County Clinton County Columbia County Delaware County Essex County Fulton County Greene County Hamilton
County Herkimer County Madison County Montgomery County Oneida County Otsego County Rensselaer County Saratoga County Schenectady County Schoharie County Sullivan
County Tioga County Warren County Washington County
Region II Hudson Valley Dutchess County Orange County Putnam County Ulster County
Ordinarily you must receive your care from physicians hospitals and other providers who contract with us We also pay for emergency care obtained from any non Plan provider as
described on page 13 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 permanently reside outside of the area you should consider enrolling
in another plan 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 pay You must share the cost of some services This is called either a copayment a set dollar for services amount or coinsurance a set percentage of charges Please remember you must pay this
amount when you receive services If you do not pay at the time you receive your service you will be billed for the service We also will bill you an additional 10 This charge will be added
to each service for which you did not pay
Your out of pocket expenses for benefits under this Plan are limited to the stated copays required for a few benefits

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
we need to respond to your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline
if you show that circumstances beyond your control prevented you from filing on time
Who provides my This Plan offers comprehensive health through a group of medical providers and affiliated health care specialists Plan physicians These medical offices are where your physician and his or her support
services are located Plan physicians arrange any necessary specialty care Other services such as physical therapy and laboratory and X ray are available at Plan facilities and other
designated locations Hospital care is provided through the Plan at several community hospitals
You must receive your health care services at Plan facilities except if you have an emergency
Your primary care physician PCP either a family practitioner pediatrician or internist will coordinate most aspects of your health care including arranging for you to receive services from
a specialist This Plan will cover specialists services only when your primary care physician refers you However a woman may see her gynecologist without having to obtain a referral

Choose your primary care physician at the medical office or an affiliated practice most convenient for you Use this Plan's provider directory in making your choice The directory which is updated
on a regular basis lists the physicians addresses phone numbers and lets you know whether the physician is accepting new patients To get a directory call the Customer Service Department at

New York 888 783 1864 Capital Area 800 292 7598 Plattsburgh 800 507 6635 Bassett 888 783 1864 Glens Falls
888 247 4500 Hudson Valley Region

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Kaiser Permanente 2000
Section 3 How to get benefits continued

If you want to receive care from a specific physician who is listed in the directory call the physician to verify that he or she still participates with the Plan and is accepting new patients

Notify the Plan of the primary care physician you choose Ask the Plan for a primary care physician selection form then complete and return it to the Plan If you need help choosing a primary
care physician call the Plan You may change your primary care physician or your health center by notifying the Plan The change is effective 30 days after we receive your notice

What do I do if Call us We will help you select a new one my primary care
physician leaves the Plan

What do I do if I Your primary care physician or specialist will make the necessary arrangements and continue need to go into the to supervise your care
hospital
What do I do if I'm First call the Customer Service Department at 888 783 1864 Capital Area 800 292 7598 in the hospital when Plattsburgh 800 507 6635 Bassett 888 783 1864 Glens Falls 888 247 4500 Hudson
I join this Plan Valley Region in New York If you are new to the FEHB Program we will arrange for 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 determine if you need care from a specialist He or she will specialty care obtain necessary authorizations from the Plan The referral will describe the services you will
receive You should return to your primary care physician after your consultation with the specialist If your specialist recommends additional visits or services your primary care physician will
review the recommendation and authorize the visits or services as appropriate You should not go to a specialist unless your primary care physician and your Plan has authorized the 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 specified number of visits You will not need to obtain additional referrals Your primary care physician will obtain Plan authorization for these visits

What do I do if I am Your primary care physician will decide what treatment you need If your primary care physician seeing a specialist decides to refer you to a specialist ask if you can see your current specialist If your current
when I enroll specialist does not participate 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 serious illness and continue seeing your physician for up to 90 days after we notify you that we are terminating

my provider leaves our contract with the provider unless the termination is for cause If you are in the second the Plan or this Plan or third trimester of pregnancy you may continue to see your OB GYN until the end of your
leaves the Program postpartum care

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Kaiser Permanente 2000
Section 3 How to get benefits continued

You may also be able to continue seeing your physician if this 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 physician until the end of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist authorize medical or recommending follow up care Before giving approval we consider if the service is
services medically necessary to prevent diagnose or treat an illness or condition We follow generally accepted medical practice in providing services to you

How do you decide When the service or supply including a drug 1 has not been approved by the FDA or 2 it if a service is is the subject of a new drug or new device application on file with the FDA or 3 is part of a
experimental or Phase I or Phase II clinical trial as the experimental or research arm of a Phase III clinical trial investigational or is intended to evaluate the safety toxicity or efficacy of the service or 4 is available as the
result of a written protocol that evaluates the service's safety toxicity or efficacy or 5 is subject to the approval or review of an Institutional Review Board or 6 requires an informed

consent that describes the service as experimental or investigational then this Plan considers that service supply or drug to be experimental and not covered by the Plan This Plan and its
Medical Group carefully evaluate whether a particular therapy is safe and effective or offers a degree of promise with respect to improving health outcomes The primary source of evidence
about health outcomes of any intervention is peer reviewed medical literature

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 in 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review refusal OPM will determine if we correctly applied the terms of our contract when we denied

a denial your claim or request for service
What if I have a Call us at 888 783 1864 Capital Area 800 292 7598 Plattsburgh 800 507 6635 Bassett serious or life 888 783 1864 Glens Falls 888 247 4500 Hudson Valley Region in New York

threatening condition and you haven't
responded to my request for service
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Kaiser Permanente 2000
Section 4 What to do if we deny your claim or request for service continued

What if you have If we expedite your review due to a serious medical condition and deny your claim we will denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can
for care and my call OPM's health benefits Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or condition is serious life threatening conditions are ones that may cause permanent loss of bodily functions or death
or life threatening if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold time limits our 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
Where should I Send your request for review to Office of Personnel Management Office of Insurance mail my disputed Programs Contracts Division 3 P O Box 436 Washington D C 20044

claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
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 if I file a lawsuit base 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

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Kaiser Permanente 2000
Section 4 What to do if we deny your claim or request for service continued

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from the Privacy Act you 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 Plan physicians and dentists This includes all necessary office visits you pay a 10 office visit
copay but no additional copay for laboratory tests and X rays Within the Service Area house calls will be provided if in the judgement of the Plan physician such care is necessary and
appropriate you pay a 10 house call copay for a physician's visit a 10 copay for visits by nurses and health aides

The following services are included
Preventive care and periodic check ups
Well baby care visits up to age 19 you pay nothing
Mammograms are covered as follows for women age 35 through 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 physician as medically necessary to diagnose or treat your illness

Routine immunizations and boosters
Visits to Primary Care physicians non physicians and consultations with specialists
Diagnostic procedures such as laboratory tests and X rays you pay nothing
Complete obstetrical maternity care for covered females including all prenatal delivery and postnatal care by a Plan physician 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 a newborn who requires definitive treatment will be covered only if the infant is covered
under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including materials
The insertion of internal prosthetic devices such as pacemakers and artificial joints

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued

What is covered Cornea heart heart lung kidney simultaneous pancreas kidney liver and lung single and double transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma and testicular mediastinal retroperitoneal and ovarian germ cell tumors 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 respiratory therapy
Surgical treatment of morbid obesity
Home health services of physicians nurses and health aides including intravenous fluids and medications when prescribed and directed by your Plan physician who will periodically

review the program for continuing appropriateness and need
Services of physicians and other health professionals in the hospital or extended care facility
Medical management of mental health conditions including drug therapy evaluation and maintenance

Visits to receive injections
Hearing tests
Cardiac rehabilitation following heart transplant bypass surgery or a myocardial infarction
Office visit and related diagnostic tests in connection with a second medical opinion concerning a positive or negative diagnosis of cancer or a recurrence of cancer or any recommendation of

a course of treatment for cancer The specialist rendering the second medical opinion must be a Kaiser Permanente affiliated specialist to whom the member received a referral from
a Plan primary care physician unless the member receives an approved referral to a nonparticipating specialist from a Plan primary care physician Any further care rendered beyond
or as a result of the second opinion must be arranged by Plan physicians
If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge

of 10 for each service for which a bill is sent
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 no limited to treatment of fractures and excision of tumors and cysts All other procedures involving the
teeth or the intra oral areas surrounding the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition that has resulted from functional defect or from an injury or surgery that has produced a major effect on the member's
appearance and if the condition can reasonably be expected to be corrected by such surgery A patient and their 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued

Limited benefits Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can
be expected within two months You pay nothing per inpatient session and 10 per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic orgin
Occupational therapy is limited to services that assist the member to achieve self care and improved functioning in other activities of daily living

Diagnosis and treatment of infertility is covered You pay 50 of covered charges The following types of artificial insemination are covered intravaginal insemination IVI intracervical
insemination ICI and intrauterine insemination IUI you pay 50 of covered charges Cost of donor sperm and donor eggs and services related to their procurement and storage
is not covered Other assisted reproductive technology ART procedures such as in vitro fertilization gamete and zygote intrafallopian transfers and embryo transfers are not covered
Infertility services are not available when either member of the family has been voluntarily surgically sterilized Drugs used for covered infertility treatments are provided under the
Prescription Drug Benefit at 50 of the over the counter charge to members who do not have a prescription drug benefit Drugs related to non covered infertility treatments are not covered

Orthopedic devices prosthetic devices and durable medical equipment are covered when the plan determines that the equipment is medically necessary for your condition This Plan
will provide benefits only for basic models of the equipment and only for equipment that can withstand repeated use This Plan will determine whether it will rent or purchase the item This
Plan will select the provider or vendor that will furnish covered devices and durable medical equipment This Plan will cover repairs to the orthopedic devices or durable medical equipment
but not routine maintenance expenses You pay 20 of the charges for the purchase or rental of the equipment or devices The maximum lifetime benefit that will be paid for any member is
250,000 This limit will not apply to breast protheses and surgical bras and their replacements The following items are not covered foot orthotics comfort and convenience equipment
sports exercise and hygiene equipment disposable supplies devices to perform medical tests eye glasses dentures and dental appliances devices not medical in nature such as sauna baths
and elevators climate and environmental control devices modifications to home or auto
Chiropractic services defined as manual manipulation of the spine to correct nerve interference caused by distortion misalignment or subluxation of the vertebral column are covered All
other forms of chiropractic services are excluded

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance licensing governmental attending school
or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
External and internally implanted hearing aids
Homemaker services
Blood and blood derivatives not replaced by the member
Long term rehabilitative therapy
Transplants not listed as covered
Any eye surgery solely for the purpose of connecting refractive defects of the eye such as nearsightedness myopia farsightedness hypezopia and astigmatism

Special programs or clinics such as those for pain sports diet weight reduction acupuncture biofeedback hypnosis or massage

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued

Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan physician You pay nothing All necessary services are

covered including

Semiprivate room accommodations when a Plan physician determines it is medically necessary the physician may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan physician and approved by the Plan You pay nothing All necessary services are covered including

Bed board and general nursing care
Prescribed drugs and their administration biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan physician

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or Plan approved hospice facility You pay nothing Services include inpatient and outpatient care
and family counseling these services are provided under the direction of a Plan physician who certifies that the patient is in the terminal stages of illness with a life expectancy of
approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan physician You pay nothing

Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines
procedures there is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions
for which hospitalization may be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan physician determines that outpatient management is not medically appropriate See page 15 for non medical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member
Custodial care and care in an intermediate care facility

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Section 5 Benefits continued

Emergency Benefits
What is a medical A medical emergency is an injury or the sudden and unexpected onset of a condition or injury emergency that you 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 primary care physician the service area
If you are in an emergency situation and are unable to contact your primary care physician 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 must notify the Plan within 48 hours
unless it was not reasonably possible to do so 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 unless it was not reasonably possible to notify the Plan within that time If you are hospitalized in non Plan
facilities and Plan physicians believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your
condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per visit to a hospital or urgent care center for emergency care that are covered benefits of
this Plan If the emergency results in admission to a hospital you pay nothing

Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within
that time If a Plan physician believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or 10 per hospital office visit or urgent care center visit for emergency services that are covered by this Plan If the emergency results in admission to a
hospital you pay nothing
What is covered Emergency care at a physician's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including physicians services
Ambulance service approved by the Plan

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Kaiser Permanente 2000
Section 5 Benefits continued

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 leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500
claim form Submit claims to Kaiser Permanente Claims Department PO Box 15109 Albany New York 12212 5109 If you are required to pay for the services submit itemized bills and
your receipts to the Plan along with an explanation of the services and the identification information from your ID card Payment will be sent to you or the provider if you did not pay the
bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based If
you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on page 7

Mental Conditions Substance Abuse Benefits
Mental Conditions What is covered To the extent shown below this Plan provides the following services necessary for the

diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance You pay 10 per visit These visits are not charged as mental health outpatient visits

Hospitalization including inpatient professional services
Outpatient care Up to 25 outpatient visits to Plan physicians consultants or other psychiatric personnel each calendar year you pay 10 per visit

Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for 30 days all charges thereafter
If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent
What is not covered Care for psychiatric conditions which in the professional judgment of Plan physicians are not subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan physician to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Section 5 Benefits continued

Substance abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the
medical nonpsychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any other illness In addition the Plan provides

Outpatient care All necessary outpatient visits to Plan providers for treatment each calendar year you pay 10 for each covered visit
Inpatient care Services for the psychiatric aspects are provided in conjunction with the inpatient mental conditions benefit shown above The mental conditions day limit applies
If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent
What is not covered Treatment that is not authorized by a Plan physician
Substance abuse treatment on court order or as a condition of parole or probation unless determined by a Plan physician to be necessary and appropriate

Prescription Drug Benefits
What is covered Prescription drugs prescribed by Plan physicians or dentists and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply You pay 20 of the cost per prescription or refill
It may be possible for you to receive refills by mail at no extra charge Delivery may be made available at an additional charge Ask for details at a Plan pharmacy

This Plan uses a formulary to determine which prescribed drugs will be provided to members If the physician specifically prescribes a nonformulary drug because it is medically necessary
the nonformulary drug will be covered If you request the nonformulary drug when your physician has prescribed a substitution the nonformulary drug is not covered However you may
purchase the nonformulary drug from a Plan pharmacy at prices charged to members for noncovered drugs

The following drugs are provided you pay 20 of the cost
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs
Insulin
Glucose test strips
Disposable needles and syringes needed for injecting covered prescribed medication you pay nothing

Medically necessary enteral formulas proven to be effective as a disease specific treatment for individuals who are or will become malnourished or suffer from disorders which if untreated
will cause disability retardation or death
Modified solid food products for the treatment of certain inherited diseases of amino acid or organic acid metabolism to a maximum of 2500 per person per calendar year

Intravenous fluids and medication for home use are covered under Medical and Surgical Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Section 5 Benefits continued

Limited Benefits Drugs to treat sexual dysfunction have dispensing limitations You pay 50 of charges Contact the Plan for details

If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent
What is not covered Drugs available without a prescription or for which there is a non prescription 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 except as specifically noted

Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Fertility drugs
Drugs for non covered services

Other Benefits
Dental care Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth are covered The need for these services must result from an accidental injury You pay 10 per visit

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 What is covered diseases of the eye annual eye refractions which include the written lens prescription for
eyeglasses may be obtained from Plan providers You pay 10 per visit
What is not covered Corrective eye glasses and frames or contact lenses including the fitting of the lenses
Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 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 physician 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 doctors or hospitals 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
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 800 638 6833

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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 insurance 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
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 responsible for that another person caused you must reimburse us for whatever services we paid for We will
injuries 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 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 determine they must

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

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency Agencies directly or indirectly pays for

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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 information about the right to information about your health plan its networks providers and facilities You can
your HMO also find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website http www opm gov insure lists the specific types of information that we must make available to you

If you want specific information about us call 800 638 0668 or write to Kaiser Permanente 1 CHP Plaza Latham NY 12210 You may also contact us by fax at 518 785 2741 or visit our
website at http www kaiserpermanente org
Where do I get Your employing or retirement office can answer your questions and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the need to make an informed decision about FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been 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 coverage are your unmarried dependent children under age 22 including any foster or stepchildren your
available for my employing or retirement office authorizes coverage for Under certain circumstances you may family and me also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

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Section 8 FEHB FACTS continued

Are my medical We will keep your medical and claims information confidential Only the following will have and claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract

This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

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

OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification 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 conditions before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this

Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your 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

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Section 8 FEHB FACTS continued

What is TCC 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 If you are leave Federal service your employing office will notify you of your right to enroll TCC under TCC You must enroll within 60 days of leaving or receiving this notice whichever
is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling
in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

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

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

If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
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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Kaiser Permanente 2000
Section 8 FEHB FACTS 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 that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health Plan health insurance or other health care coverage You must arrange for the other coverage 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 518 783 1864 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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Kaiser Permanente 2000
Notes

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Kaiser Permanente 2000
Notes

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Kaiser Permanente 2000
Summary of Benefits for Kaiser Permanente 2000

Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE FOLLOW UPAND CONTINUING CARE AND CARE RECEIVED ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services with no dollar or day maximum Includes in hospital physician care room and board general nursing

care private room and private nursing care if medically necessary diagnostic
tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing 12

Extended care All necessary services no dollar or day limit You pay nothing 12

Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 14
Substance abuse Covered under Mental conditions 15
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 a 10 copay
per house call by a physician 9

Home health care All necessary visits by nurses and health aides You pay 10 copay per visit 10

Mental conditions Up to 25 outpatient visits per year You pay a 10 copay per visit 14
Substance abuse All necessary outpatient visits per year You pay a 10 copay per visit 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each emergency room visit
You pay in full any charges for services that are not covered by this Plan 13
Prescription drugs Drugs prescribed by a Plan physician and obtained at a participating pharmacy You pay 20 of the cost per prescription unit or refill 15

Dental care Accidental injury benefit You pay a 10 copay 16
Vision care Annually one refraction and treatment for illness or injury You pay a 10 copay 16

Out of pocket maximum Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for a few benefits 5

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2000 Rate Information for Kaiser Permanente

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

Hudson Valley area
Self Only QB1 78.83 29.66 170.80 64.26 93.06 15.43 93.26 15.23

Self and Family QB2 175.97 97.95 381.27 212.22 207.74 66.18 201.02 72.90

Albany Cooperstown areas
Self Only PW1 75.80 25.27 164.24 54.75 89.70 11.37 89.70 11.37

Self and Family PW2 175.97 75.72 381.27 164.06 207.74 43.95 201.02 50.67

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