we're changing healthcare For Good SelectCare HMO 2000
A Health Maintenance Organization
Serving Greater Detroit Area
For changes 3
You must live or work in the service area to enroll in this plan See page 4 see page
Enrollment code
K61 Self only
K62 Self and family
This Plan has full accreditation
from the NCQA See the 2000 Guide
for more information on the NCQA
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www selectcare com
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service
RI 73 069
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SelectCare HMO 2000
Table of Contents
PAGE
Introduction
1
Plain Language
1
How to Use This Brochure
2
Section 1 Health Maintenance Organizations
3
Section 2 How We Change for 2000
3
Section 3 How to Get Benefits
4
Section 4 What to Do if We Deny Your Claim or Request for Service
6
Section 5 Benefits
8
Section 6 General Exclusions Things We Don't Cover
15
Section 7 Limitations Rules that Affect Your Benefits
15
Section 8 FEHB Facts
17
Inspector General Advisory Stop Health Care Fraud
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Summary of Benefits
21
Premiums
Back cover
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SelectCare HMO 2000
Introduction
SelectCare HMO
2401 West Big Beaver Road Suite 700
Troy MI 48084
This brochure describes the benefits you can receive from SelectCare HMO under its contract CS 1885 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 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 3 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 SelectCare HMO as this Plan throughout this brochure even though in other legal documents you will
see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it
more understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year
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SelectCare HMO 2000
How to Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO
Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do
if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
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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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 your 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 premium 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 Your share of the non postal premium will decrease by 1.1 for Self Only or 1.2 for Self and Family
Medical and Surgical Benefits now covers one mammogram each calendar year
for women 40 or older
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Section 3 How to Get Benefits
What is this Plan's To enroll with us you must live or work in the area described below This is where our providers
service area practice Our service area is Greater Detroit Area
You may also enroll with us if you live or work in the following places All of Macomb Oakland
and Wayne Counties and the following townships in Livingston St Clair and Washtenaw Counties
in the state of Michigan
Livingston County Port Huron Township Ypsilanti Brighton City Columbus Township Salem Township
Brighton Township St Clair Township Dexter Village
Hartland Township Casco Township Ann Arbor
Green Oak Township China Township Lima
Putnam Township East China Township Scio Township
Tyrone Township Ira Township Ann Arbor Township
St Clair County Cottrellville Township Superior Township Greenwood Township Clay Township Freedom Township
Grant Township Port Huron Saline City
Burtchville Township Marysville Lodi Township
Emmet Township St Clair Saline Township
Kenockee Township Marine City Pittsfield Township
Clyde Township New Baltimore Ypsilanti Township
Fort Gratiot Township Algonac York Township
Berlin Township Village of Emmett Milan Township
Wales Township Washtenaw County Manchester Township
Kimball Township Northfield Township Manchester Village
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 pay You must share the cost of some services This is called either a copayment a set dollar amount or
for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
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
Who provides my This Plan is a mixed model prepayment plan called a Health Maintenance Organization or HMO
health care Your care is provided by the primary care physician you select you may choose from over 1,440 physicians who practice in medical groups or in private offices throughout the service area In addition
approximately 3,800 specialists provide care on referral when necessary
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
to go into the hospital or specialist will make the necessary hospital arrangements and supervise your care
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What do I do if I'm First call our customer service department at 248 637 8080 If you are new to the FEHB Program
in the hospital when we will arrange for you to receive care If you are currently in the FEHB Program and are switching
I join this Plan 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
specialty care 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 A woman may see her gynecologist for
her annual routine examination without a referral
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 Call your primary care physician who will arrange for you to see another specialist You may
my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to
a serious illness and continue seeing your provider for up to 90 days after we notify you that we are terminating
my provider leaves our contract with your provider unless 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
leaves the Program your postpartum care
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
How do you decide if a The Plan evaluates the appropriate use of new medical technologies and new application of
service is experimental established technologies including medical procedures drugs and devices or procedures and
or investigational services used as alternatives to established technologies or services Evaluations are made based on specific Plan criteria and information obtained from various resources including the Plan's
Medical Director and committees such as the Technology Assessment Committee and the
Pharmacy and Therapeutics Committee
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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 must 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 your request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a Call us 1 888 302 3767 and we will expedite your review
serious or life threatening
condition 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 health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or life
or life threatening threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time limits initial denial or refusal 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
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What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on
specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative
reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify
which documents apply to which claim
Who can make a request Those who have a legal right to file a disputed claim with OPM are
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 Send your request for review to
I send my disputed Office of Personnel Management Office of Insurance Programs Contracts Division IV
claim to 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
I file a lawsuit review in 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 Privacy Act
Chapter 89 of Title 5 United States Code allows OPM to use the information it collects from 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
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Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors
and other Plan providers This includes all necessary office visits you pay 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 judgment of the Plan provider such care is necessary and appropriate you pay a
10 office visit copay for a doctor's house call or for home visits by nurses and health aides
Members with Part A and Part B pay nothing
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 and older one mammogram every calendar year
In addition to routine screening mammograms are covered when prescribed by the doctor as
medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery
and postnatal care by a Plan doctor Copays are waived for maternity care after a 10 copay for
the first prenatal visit The mother at her option may remain in the hospital up to 48 hours
after a regular delivery and 96 hours after a cesarean delivery Inpatient stays will be extended
if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will
not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn
child during the covered portion of the mother's hospital confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of an infant who
requires definitive treatment will be covered only if the infant is covered under a Self and
Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Routine hearing tests and vision screenings
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal devices such as pacemakers and artificial joints
Cornea heart kidney and liver transplants allogeneic donor bone marrow transplants autologous
bone marrow transplants autologous stem cell and peripheral stem cell support for the
following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple
myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian
germ cell tumors 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 inhalation therapy and antineoplastic therapy used to
treat neoplasia
Surgical treatment of morbid obesity except for the sole purpose of weight management
Orthopedic devices such as braces
Prosthetic devices are covered such as artificial limbs including repair or replacement once
a year external breasts prostheses and bras including their replacement and initial external
lenses following cataract removal
Durable medical equipment such as wheelchairs hospital beds oxygen equipment and
disposable needles and syringes needed to inject covered prescribed medication
excluding insulin see Prescription Drug Benefits
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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
Pain management is covered including the evaluation and treatment of intractable pain
Care must be coordinated through the primary care physician
All necessary medical or surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers
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 or surgical procedures occurring within or adjacent to the oral cavity or sinuses including
but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas
surrounding the teeth are not covered
Treatment of temporomandibular joint TMJ pain dysfunction syndrome is covered but not related appliances prosthetics
braces or orthotics You pay 50 of the charges
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that
has produced a major effect on the member's appearance and if the condition can reasonably be expected to be corrected by such
surgery For reconstructive surgery related to mastectomy coverage will be provided for 1 reconstruction of the breast on which the
mastectomy was performed 2 surgery and reconstruction of the other breast to produce a symmetrical appearance and 3 prostheses
and physical complications all stages of mastectomy including lymphedemas A patient and her attending physician may decide
whether to have breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to produce
a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to
sixty 60 consecutive days per condition per calendar year if significant improvement can be expected within sixty 60 days
you pay 10 per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist the member to achieve and maintain self care and improved functioning in
other activities of daily living
Diagnosis and treatment of infertility is covered you pay nothing up to the third attempt and 50 thereafter The following types
of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination
IUI The cost of donor sperm is not covered Fertility drugs are covered under the Prescription Drug Benefit when obtained at a
Plan pharmacy you pay 50 of the cost Other assisted reproductive technology ART procedures such as in vitro fertilization and
embryo transfer are not covered
Cardiac rehabilitation is provided for up to 18 visits per cardiac event following a heart transplant bypass surgery or a myocardial
infarction You pay nothing
Chiropractic services are covered when authorized by the primary care doctor and plan medical director
Penile prostheses are covered for impotency secondary to organic disease You pay 50 of the cost per insertion removal
repair or replacement
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids including fitting and related tests
Homemaker services
Foot orthotics
Support garments
Long term rehabilitative therapy
Surgery and related services solely to enhance athletic performance
Cognitive training
Radial keratotomy and
Transplants not listed as covered
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 doctor You pay nothing All necessary services are
covered including
Semi private room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 730 days each 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 These 730 days of extended
care will be reduced by two days for each day spent as an inpatient prior to transfer to an extended
care facility You pay nothing All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged
by the skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness
with a life expectancy of approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Limited Benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures 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
would be covered include hemophilia and heart disease the need for anesthesia by itself is
not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See
page 15 for non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television and Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action
What is a medical Emergencies within the service area
emergency If you are in an emergency situation please call your primary care doctor In extreme emergencies
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 primary care doctor
You or a family member should notify the primary care doctor within 48 hours It is your responsibility
to ensure that the primary care doctor has been notified in a timely manner
If you need to be hospitalized the primary care doctor must be notified within 48 hours or on
the first working day following your admission unless it was not reasonably possible to notify the
primary care doctor within that time If you are hospitalized in non Plan facilities and Plan doctors
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 if delay in reaching
a Plan provider would result in death disability or significant jeopardy to your condition
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay Nothing for each emergency room visit for emergency care services that are covered benefits of this Plan Members with Medicare Part A and Part B pay nothing You pay 10 for emergency
care at a doctor's office or an urgent care center
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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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 doctor believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay Nothing for each emergency room visit or a 10 copay for an urgent care center visit for emergency care services that are covered benefits of this Plan Members with Medicare Part A
and Part B pay nothing
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services and
Ambulance service approved by the Plan
What is not covered Elective care or non emergency care Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area and
Medical and hospital costs resulting from a normal full term delivery of a baby
outside the Service Area
Filing Claims for non Plan Providers
With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims
Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized
bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will
receive notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based
If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure
described on page 6
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy and
Hospitalization including inpatient professional services
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
year you pay nothing for each covered visit all charges thereafter
Inpatient care Up to 45 days of hospitalization per hospital confinement you pay nothing for the first 45 days
per hospital confinement all charges thereafter Hospital confinement means successive hospital
admissions separated by less than 60 days
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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What is not covered Inpatient care for psychiatric conditions that in the professional judgment of Plan doctors
are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation
unless determined by a Plan doctor to be necessary and appropriate and
Psychological testing when 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 and to the extent shown below services necessary for
diagnosis and treatment
Outpatient care Visits to Plan providers for treatment are covered for up to the greater of thirty five 35 visits per calendar year or the calendar dollar minimum per member as determined by the Michigan
Insurance Bureau
Inpatient care Inpatient services necessary for diagnosis and treatment are provided in conjunction with the inpatient mental conditions benefit The mental conditions day limitations apply to any covered
substance abuse care
Emergency detoxification Emergency room visit for emergency detoxification care services You pay nothing
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply or in greater quantities if defined by the Plan Formulary you
pay 2 or fifty percent 50 of charges whichever is less per prescription order or refill except as
noted If a member requests a brand name drug in the absence of a physician indicated DAW the
member will be required to pay the difference in price between the brand name drug and the generic
drug plus the applicable co payment
The Plan formulary is considered an open modified list which consists of approximately 1000
drugs All newly FDA approved medications are considered non formulary until reviewed at the
quarterly SelectCare Pharmacy Therapeutics Committee Drugs excluded from the formulary
require a physician request to override non coverage of the medication Requests are handled in a
timely manner
If the FDA approved prescription drug ordered by a Plan doctor is not stocked or is out of stock at
a Plan pharmacy members will be reimbursed 100 less co payment for prescriptions filled at a
non affiliated pharmacy Submit the prescription drug receipt along with a note stating that the prescription
was not stocked or was out of stock to the Plan within 90 days of the date of purchase
Covered medications and accessories include
Drugs that by law require a prescription
Disposable needles and syringes used with insulin administration see Medical
and Surgical Benefits for other covered disposable needles and syringes
Oral and injectable contraceptive drugs and contraceptive devices
Implanted time release medications such as Norplant and
Intravenous fluids and medication for home use implantable drugs see Medical
and Surgical Benefits for other covered injectable drugs
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Limited benefits Fertility drugs are covered if obtained at a Plan pharmacy you pay 50 of the cost
Drugs to treat sexual dysfunction are covered if obtained at a Plan pharmacy you pay
50 of the cost and
Insulin is limited to three 3 bottles per prescription or refill
Insulin syringes and needles are limited to a maximum of 120 per month
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
Refill prescriptions due to loss or theft
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Anorexic medications
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs for weight loss
Diabetic supplies except for needles and syringes
Drugs obtained while confined in an unskilled nursing home
Any charge for the administration or injection of any drug biological or immunization agent
except as provided for under the Plan
Drugs reimbursable under other programs
Medication for which the cost is recoverable under any Worker's Compensation state
or government agencies or which is provided free of charge or would be provided free of
charge under these programs
Any experimental or investigational drug as defined by the Plan or any drug that has not been
finally approved by the Food and Drug Administration FDA or is being used in dose route or
for an indication which is not approved by the FDA
Immunization agents biological serum blood or blood plasma except as provided for
under the Plan and
Drugs for preventive dental therapy
Other Benefits
Dental care
Accidental injury benefit Initial restorative services and supplies necessary to promptly within 48 hours repair but not
replace sound natural teeth are covered The need for these services must result from an accidental
injury occurring while the member is covered under the FEHB Program you pay nothing
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription for eyeglasses may be
obtained from Plan providers You pay a 10 copay for each office visit Members with Medicare
Part A and Part B pay nothing
What is not covered Eye exercises Corrective glasses and frames or contact lenses including fitting of contact lens and
Exams related to contact lenses
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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
or eligible self referred services
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the
fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that Affect Your Benefits
Medicare
Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for
medical services and we will coordinate the payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare 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 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 call 248 637 5388 to receive
information on SelectCare Medicare Gold
Other Group Insurance Coverage
When anyone has coverage with us and with another group health plan it is called double 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Circumstances beyond our control
Under certain extraordinary circumstances we may have to delay your services or be unable to provide them
In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for 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 Agencies
We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
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Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your
health plan its networks providers and facilities You can also find out about care management which includes medical practice
guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
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 248 637 8080 or 888 302 3767 or write to the Plan at 2401 West Big Beaver Road
Suite 700 Troy MI 48084 You may also contact us by fax at 248 637 6713 or visit our website at http www selectcare com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
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 The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
and 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
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of
Coverage which is described later in this section
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for my unmarried dependent children under age 22 including any foster or step children your employing or
family and me 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
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Are my medical We will keep your medical and claims information confidential
and claims records Only the following will have 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 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
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
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What is TCC You pay the total premium and generally a 2 percent administrative charge
continued 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 and
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
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 that
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage 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
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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 248 637 6777 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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Summary of Benefits for SelectCare HMO 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Outpatient care Physician office visits consultations including physical exams OB GYN exams pediatric exams allergy testing eye exams
and hearing tests You pay 10 office visit copay 8
Durable medical equipment and prosthetic devices all outpatient
diagnostic X ray services and laboratory tests You pay nothing 8
Allergy and other injections and immunizations outpatient surgery
voluntary sterilization health education You pay nothing 8
Physical occupational and speech therapy You pay nothing
for 60 consecutive days per condition 9
Infertility You pay nothing for first three procedures thereafter
you pay 50 percent 9
Treatment of TMJ You pay 50 percent 9
Inpatient care Semi private room or private room when medically necessary physician services consultations surgery and related services
anesthesia diagnostic and therapeutic X ray services laboratory
tests EKGs EEGs etc physical therapy You pay nothing 10
Emergencies Emergency care emergency ambulance You pay nothing 11
Urgent care covered for any condition requiring medical attention
You pay 10 copay 11
Maternity services Delivery in hospital newborn care in hospital newborn check up You pay nothing 8
Prenatal and postnatal You pay initial 10 office visit copay 8
Mental health Inpatient mental health services You pay nothing for 45 days Substance abuse service renewable after 60 days 12
Outpatient mental health services You pay nothing for first
20 visits per member per year 12
Inpatient substance abuse treatment You pay nothing for 45 days
service renewable after 60 days 13
Outpatient substance abuse treatment You pay nothing up to state
mandated amount or 35 vists per member per year 13
Skilled nursing care Home health care You pay nothing 9
Nursing care facility You pay nothing up to 730 days per episode of illness 9
Prescription drugs Prescription drugs including oral contraceptives You pay nothing after 2 copay 13
Dental care Accidental injury benefit You pay nothing 14
Vision care One refraction annually You pay a 10 office visit copay per visit 14
Out of pocket maximum Your out of pocket expenses for benefits under this Plan are limited to the stated co payments required for a few benefits 8 14
Please note The office visit copay may apply to any covered services provided to a member who receives care in an outpatient provider setting
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2000 Rate Information for
SelectCare HMO
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member
of a special postal employment class refer to the category definitions in the Guide to Federal Employees Health Benefits Plans
for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members
of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
Southeast Michigan
Self Only K61 54.60 18.20 118.30 39.43 64.61 8.19 64.61 8.19
Self and Family K62 152.90 50.97 331.29 110.43 180.93 22.94 180.93 22.94
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