Dallas Fort Worth and Austin Enrollment code
TW1 Self Only TW2 Self and Family
Enrollment in this Plan is limited see page 5 for requirements
Houston Beaumont area Enrollment code
UE1 Self Only UE2 Self and Family
Enrollment in this Plan is limited see page 5 for requirements
San Antonio area Enrollment code
UR1 Self Only UR2 Self and Family
Enrollment in this Plan is limited see page 5 for requirements
SPECIAL NOTICE The following counties have been eliminated from code TW's service area Archer Baylor Bell Brazos Clay Coryell
Falls McLennan Montague Wichita and Wilbarger Code TW enrollees in these areas must select another plan during Open Season If not you will have to travel to the plan's remaining service area to obtain full medical benefits
Humana Health Plan of Corpus Christi enrollment code TX has consolidated with this plan Current code TX enrollees will be covered under this plan unless you choose a different plan during Open Season
Visit the OPM website at www opm gov insure and
this Plan's website at www humana com
RI 73 070
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Humana Health Plan of Texas 2000
Table of Contents
Page
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 8 9
Section 5 Benefits 10 18
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19 20
Section 8 FEHB facts 21 24
Department of Defense FEHB Demonstration Project 25
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits 27
Premiums 28
Introduction Humana Health Plan of Texas Inc 8431 Fredericksburg Rd San Antonio Texas 78229
This brochure describes the benefits you can receive from Humana Health Plan of Texas Inc under its contract CS 1895 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 the 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 Humana Health Plan of Texas Inc as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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Humana Health Plan of Texas 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 HMOs 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
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate
your health care services The care you receive includes preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive
emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that
any one physician hospital or other provider will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment
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Humana Health Plan of Texas 2000
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes 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 n Enrollment code TW Your share of the non postal premium will increase by 24.6 for Self Only or 63.6 for Self and Family
n Enrollment code UE Your share of the non postal premium will increase by 8.4 for Self Only
or 8.4 for Self and Family
n Enrollment code UR Your share of the non postal premium will increase by 7.3 for Self Only
or 7.2 for Self and Family
n Enrollment code TX Your share of the non postal premium will increase by 7.1 for Self Only
or 0.8 for Self and Family
n We have reduced our service area
The following Texas counties have been eliminated from code TW's service area Archer Baylor Bell Brazos Clay Coryell Falls McLennan Montague Wichita and Wilbarger If you do not
change plans during Open Season you will have to travel to our remaining service area to obtain full benefits
n Humana Health Plan of Corpus Christi enrollment code TX has consolidated with Humana
Health Plan of Texas The Corpus Christi service area enrollment code TX is now part of this plan The Corpus Christi service area includes the Texas counties of Aransas Bee Jim Wells
Kleberg Nueces Refugio and San Patricio If you are enrolled in Humana Health Plan of Corpus Christi code TW you will automatically become effective in code TW under Humana
Health Plan of Texas
n Short term rehabilitative therapy will be provided with no visit limitation
n There is a 5 copay for generic formulary drugs a 10 copay for brand name formulary drugs
and a 25 copay for non formulary drugs
n You may obtain a 90 day supply of maintenance type drugs through our mail order drug program
for three times the applicable copay
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Humana Health Plan of Texas 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan's service Our service area is
area Austin Dallas and Ft Worth areas TW the Texas counties of Bastrop Bosque Burleson Burnet Caldwell Collin Cooke Dallas Denton Ellis Freestone Grayson Hamilton Hays Johnson Kaufman Lampasas Lee Limestone Milam Navarro Robertson Rockwall Tarrant
Travis Williamson and Wise
Corpus Christi area TX the Texas counties of Aransas Bee Jim Wells Kleberg Nueces Refugio and San Patricio
Houston and Beaumont areas UE the Texas counties of Austin Brazoria Chambers Colorado Fayette Fort Bend Galveston Grimes Hardin Harris Jefferson Liberty Madison Montgomery
Orange Waller Washington and Wharton
San Antonio area UR the entire Texas counties of Atascosa Bexar Blanco Comal Frio Guadalupe Karnes Kendall Medina and Wilson plus the following Texas zip codes 78003 and
78063
The Plan's service area is divided into five regions Austin Corpus Christi Dallas Ft Worth Houston Beaumont and San Antonio Participants in Austin Dallas Ft Worth Houston and San
Antonio may select primary care doctors from and listed in the Austin Dallas Houston or San Antonio provider directories Participants in the Corpus Christi area must select a primary care
doctor from the Corpus Christi provider directory To obtain a provider directory please call us at 1 888 393 6765
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other health care
services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another state
you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office
How much do I You must share the cost of some services This is called either a copayment a set dollar amount or pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services except for emergency care
After you pay 1,500 in copayments or coinsurance for one family member or 2,500 per family you do not have to make any further payments for certain services for the rest of the year This is
called a catastrophic limit However copayments or coinsurance for your prescription drugs or dental services do not count toward these limits and you must continue to make these payments
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 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 Humana Health Plan of Texas offers members an extensive choice of primary care physicians health care Humana contracts with both private office physicians and with physician networks When choosing
a physician from one of the physician networks for your primary care needs you should expect to receive all specialty care from providers affiliated with your primary care physician's network
Obstetricians gynecologists must be selected from providers affiliated with your primary care physician's network If your physician's network cannot provide the services you need your
primary care physician will make arrangements for you to receive the care from an appropriate provider To find out if your primary care physician is affiliated with a certain network check
5 the provider directory or call the Plan before you make your selection
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Humana Health Plan of Texas 2000
Section 3 How to get benefits continued
What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or to go into the hospital authorized specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm First call our customer service department at 1 800 4HUMANA If you are new to the FEHB in the hospital when 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
I join this Plan You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Except in a medical emergency for annual OB GYN services or when a primary care doctor has specialty care designated another doctor to see his or her patients you must receive a referral from your primary
care doctor before seeing any other doctor or obtaining special services Referral to a participating specialist is given at the primary care doctor's discretion if non Plan specialists or consultants are
required the primary care doctor will arrange appropriate referrals
When you receive a referral from your primary care doctor you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits All follow up care must
be provided or authorized by the primary care doctor Do not go to the specialist for a second visit unless your primary care doctor has arranged for and the Plan has issued an authorization for the
referral in advance
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
with us you must receive treatment from a specialist who does Generally we will not pay for you
when I enroll 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 the receive services from your current specialist until we can make arrangements for you to see
someone else
Plan
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
the provider unless the termination is for cause If you are in the second or third trimester of
provider leaves the pregnancy you may continue to see your OB GYN until the end of your postpartum care Plan or this Plan
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
leaves the Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
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Humana Health Plan of Texas 2000
Section 3 How to get benefits continued
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist medical services or recommending follow up care from a specialist Before giving approval we consider if the
service is medically necessary and if it follows generally accepted medical practice
How do you decide A drug biological product device medical treatment or procedure is determined to be if a service is experimental or investigational if reliable evidence shows it meets one of the following criteria
experimental or when applied to the circumstances of a particular patient is the subject of ongoing phase I II investigational or III clinical trials or
when applied to the circumstances of a particular patient is under study with written protocol to determine maximum tolerated dose toxicity safety efficacy or efficacy in comparison to
conventional alternatives or
is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board as required and defined by the USFDA or Department of Health and
Human Services
is not generally accepted by the medical community
Reliable evidence means but is not limited to published reports and articles in authoritative medical scientific literature or regulations and other official actions and publications issued by the USFDA
or the Department of Health and Human Services
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Humana Health Plan of Texas 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our decision
based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or
request for service
What if I have a Call us at 1 800 4HUMANA and we will expedite our review serious or life
threatening condition and you haven't
responded to my request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening
for care and my conditions are ones that may cause permanent loss of bodily functions or death if they condition is serious are not treated as soon as possible
or life threatening
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I Your request must be complete or OPM will return it to you You must send the following send 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
8 If you want OPM to review different claims you must clearly identify which documents apply to which claim
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Humana Health Plan of Texas 2000
Section 4 What to do if we deny your claim or request for service continued
Who can make Those who have a legal right to file a disputed claim with OPM are the request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and 3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the review request
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contract Division IV P O Box 436 Washington DC 20044
OPM
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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the
review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record
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Humana Health Plan of Texas 2000
Section 5 Benefits Medical and Surgical
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 doctor such care is necessary and appropriate you pay a
10 copay for a doctor's house call and nothing for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years
for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms are covered
when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care The mother at her option may remain in
the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart single and double lung heart lung 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 Wiskott Aldrich syndrome severe combined immunodeficiency syndrome aplastic anemia Ewings sarcoma and testicular mediastinal retroperitoneal and
ovarian germ cell tumors Related medical and hospital expenses of the donor are covered
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics
Prosthetic devices such as artificial limbs breast prostheses and surgical bras including their replacements and lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds
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
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Blood and blood derivatives
Oxygen and other medical consumables for home use
Implantable drugs such as Norplant injectable drugs such as Depo Provera and contraceptive devices
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Humana Health Plan of Texas 2000
Section 5 Benefits Medical and Surgical continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts Additionally coverage is provided for diagnosis and
treatment specifically directed toward disorders of the temporomandibular joint TMJ Coverage for such services is subject to Plan guidelines All other procedures involving the teeth or intra oral
areas surrounding the teeth are not covered
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending physician 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 you pay a 5 copay per outpatient session and nothing per inpatient
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 50 of usual and customary charges The following types of artificial insemination are covered intravaginal insemination IVI
intracervical insemination ICI and intrauterine insemination IUI you pay 50 of usual and customary charges cost of donor sperm is not covered Other assisted reproductive technology
ART procedures such as in vitro fertilization and embryo transfer are not covered Fertility drugs are covered under the Prescription Drug benefit
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided for up to 30 sessions you pay nothing per inpatient session you pay a 5 copay per
outpatient session
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
Transplants not listed as covered Hearing aids
Long term rehabilitative therapy Chiropractic services
Homemaker services
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Humana Health Plan of Texas 2000
Section 5 Benefits Hospital Extended Care
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
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 60 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a 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 Inpatient hospice
care is limited to maximum coverage of 3,000 per member per calendar year Outpatient care is limited to maximum coverage of 2,000 per member per calendar year
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
procedures 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 nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care
12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Humana Health Plan of Texas 2000
Section 5 Benefits Emergency
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency believe endangers your life or could result in serious injury or disability and requires immediate
medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies the service area if you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member 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 in a non Plan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the
Plan within that time If you are hospitalized in non Plan facilities and 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 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 50 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required outside the because of injury or unforeseen illness
service area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time
If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medially 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 care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay
is waived
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Humana Health Plan of Texas 2000
Section 5 Benefits Emergency continued
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or 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 With your authorization the Plan will pay benefits directly to the providers of your emergency care for non Plan 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
providers with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on pages 8
and 9
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Humana Health Plan of Texas 2000
Section 5 Benefits Mental Conditions Substance Abuse
Mental conditions What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services
The medical management of mental conditions will be covered under this plan's Medical and Surgical Benefits provisions Related drug costs will be covered under this Plan's Prescription
Drug Benefits and any costs for psychological testing or psychotherapy will be covered under this Plan's Mental Conditions Benefit Office visits for the medical aspects of treatment do not count
toward the 20 outpatient Mental Conditions visit limits
Outpatient Up to 20 outpatient visits to Plan doctors or other psychiatric personnel each calendar year care you pay a 5 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject
covered to significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition
Serious mental illness What is covered Serious mental illness benefits are provided for the following diagnoses a schizophrenia b
paranoid and other psychotic disorders c bipolar disorders hypomanic manic depressive and mixed d major depressive disorders e schizo affective disorders f pervasive developmental
disorders g obsessive compulsive disorders and h depression in childhood and adolescence
Outpatient Up to 60 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you care pay a 10 copayment for each covered visit all charges thereafter
Inpatient care Up to 45 days of hospitalization each calendar year you pay nothing for the first 45 days all charges thereafter
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 subject to applicable copayments In addition the
Plan provides all necessary inpatient and outpatient rehabilitation and counseling services for the treatment of substance abuse including treatment in an approved chemical dependency treatment
center You pay 10 per outpatient visit and nothing for inpatient care
What is not
covered Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Humana Health Plan of Texas 2000
Section 5 Benefits Prescription drug
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 30 day supply You pay one of the following copays per prescription unit or
refill
5 for generic drugs listed on our formulary 10 for brand name drugs with no generic equivalent listed on our formulary
25 for generic or brand name drugs not listed on our formulary
If there is no generic equivalent you pay the 10 brand name formulary copay If generic is available and you or the doctor requests the brand name you pay the applicable generic formulary
or non formulary copay plus the difference in cost between the brand and generic drugs
What is a Our formulary is a continually updated list of drug products including strengths dispensing limits
formulary and and any prior authorization requirements that represent the current clinical judgment of the members
how are drugs of our Pharmacy and Therapeutics Committee This committee is comprised of both physicians and pharmacists The formulary contains both brand name and generic drugs all of which have FDA
added to it approval
A generic drug is a drug that is manufactured distributed and available from several pharmaceutical manufacturers and identified by the chemical name or as defined by the national
pricing standard
A brand name drug is a drug that is manufactured and distributed by only one pharmaceutical manufacturer or as defined by the national pricing standard
Proposed additions or deletions to the Formulary are welcomed at any time and will be reviewed by the Committee
Our mail order For your convenience you may receive up to a 90 day supply of a prescribed maintenance
program medication for the cost of three applicable copays per 90 day supply
Maintenance medications are drugs that are generally prescribed for the treatment of long term chronic sicknesses or injuries
Covered Drugs for which a prescription is required by law
medications Oral contraceptive drugs
and accessories Fertility drugs Insulin
Diabetic supplies including testing agents lancet devices alcohol swabs glucose elevating agents and insulin delivery devices
Self administered injectable drugs Disposable needles and syringes to inject covered prescribed medication
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Humana Health Plan of Texas 2000
Section 5 Benefits Prescription drug continued
Limited benefits Drugs to treat sexual dysfunction are limited Contact the plan for dosage limits You pay the applicable drug copayment up to the dosage limits and all charges after that
What is not covered Drugs available without a prescription or for which there is a non prescription available Vitamins fluoride dietary and nutritional substances
Drugs obtained at a non Plan pharmacy except for out of area emergencies Drugs used for cosmetic purposes
Drugs to enhance athletic performance Smoking cessation drugs and medications including nicotine patches
Any drug used for the purpose of weight control Prescriptions that are to be taken by or administered to the member in whole or part while a
patient in a hospital skilled nursing facility convalescent hospital inpatient facility or other facility where drugs are ordinarily provided by the facility on an inpatient basis
Medical supplies such as dressings and antiseptics
Section 5 Benefits Other
Dental care Restorative services and supplies necessary to promptly repair but not replace sound natural Accidental injury teeth The need for these services must result from an accidental injury You pay nothing
benefit
Vision care What is covered In addition to the medical and surgical benefits provided for the 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 per visit
What is not Eyeglasses contact lenses or the exam for fitting
covered Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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Humana Health Plan of Texas 2000
Section 5 Benefits Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is
not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out ofpocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedures
Expanded dental benefits
DEN 983 Comprehensive preventive and restorative dental services are available from Participating Dentists at discounted rates
No additional premium required
DEN 984 Comprehensive preventive and restorative dental services are available from Corpus Christi area Participating Dentists at discounted rates
No additional premium required
Expanded vision care VIS 200 No charge for contact lenses exams and discounts for specified frames and lenses
including certain contact lenses at participating optical providers Discounts for other services are listed in the separate Plan description
An additional premium of 15 per year for Self only or 40 per year for Self and family is required
VIS 903 Discounts listed in the separate Plan description for frames and lenses including contacts at participating vision care providers
No additional premium required
VIS 920 Annual eye examination for a 5 copayment limit 1 per year Corpus Christi area Discounts listed in the separate Plan description for frames and lenses including
contacts at participating vision care providers No additional premium required
Expanded hearing care
HER 903 Free hearing aid evaluations at participating hearing aid providers Free follow up visits and adjustments for hearing aid within 60 days at participating
hearing aid providers Discounts listed in the separate Plan description for hearing aids
No additional premium required
Contact us for additional information concerning specific benefits exclusions limitations eligible providers and other provisions for each of the above coverages
Medicare prepaid plan enrollment This plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 19 annuitants and former spouses with FEHB coverage and Medicare Part B may
elect to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later reenroll in the FEHB program Most Federal annuitants have Medicare Part A Those without Medicare Part A may
join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your
retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan Contact us at 800 238 7157 for information on the Medicare prepaid plan and the cost of that enrollment
Benefits on this page are not part of the FEHB contract
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Humana Health Plan of Texas 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to
prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric
practice Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice
plan offered by this Plan see page 18
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Humana Health Plan of Texas 2000
Section 7 Limitations Rules that affect your benefits continued
Other group When anyone has coverage with us and with another group health plan it is called double 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 beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary
care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness responsible for injuries that 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 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 directly agencies or indirectly pays for
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Humana Health Plan of Texas 2000
Section 8 FEHB facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about 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
your HMO management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 1 800 4HUMANA or write to Humana Health Plan of Texas Inc P O Box 400040 San Antonio Texas 78229 You may also contact us by
fax at 210 615 3320 or visit our website at www humana com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
an informed decision about
enrolling in the When you may change your enrollment FEHB Program 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 and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1
effective
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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are available unmarried dependent children under age 22 including any foster or step children your employing
or retirement office authorizes coverage for Under certain circumstances you may also get
for my family and me 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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Humana Health Plan of Texas 2000
Section 8 FEHB facts continued
Are my medical and We will keep your medical and claims information confidential Only the following will have 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 before
conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in Your enrollment ends unless you cancel your enrollment or
this 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
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Humana Health Plan of Texas 2000
Section 8 FEHB facts continued
What is TCC Temporary Continuation of Coverage TCC If you leave federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I If you leave Federal service your employing office will notify you of your right to enroll under
enroll in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
How can I convert to You may convert to an individual policy if individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
not pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice However
if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
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Humana Health Plan of Texas 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
health insurance or other health care coverage You must arrange for the other coverage within
Group Health 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations Plan Coverage 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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Humana Health Plan of Texas 2000
Department of Defense FEHB Demonstration Project
What is the The National Defense Authorization Act for 1999 Public Law 105 261 established the Department of Defense DoD FEHBP Demonstration Project It allows some active and retired uniformed service members
and their dependents to enroll in the FEHB Program The demonstration will last for three years
DoD and beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be effective FEHB Program January 1 2000 DoD and OPM have set up some special procedures to successfully implement
the Demonstration Project noted below Otherwise the provisions described in this brochure apply
Demonstration Project
Who is eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for Medicare You are a qualified former spouse of an active or retired uniformed service member and you have
not remarried or You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you are not eligible to enroll under the DoD FEHBP Demonstration Project
Where are the Dover AFB DE demonstration areas Commonwealth of Puerto Rico
Fort Knox KY Greensboro Winston Salem High Point NC
Dallas TX Humboldt County CA area
Naval Hospital Camp Pendleton CA New Orleans LA
When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information
Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff will verify your eligibility and provide you with FEHB Program information plan brochures enrollment
instructions and forms The toll free phone number for the IPC is 1 877 DOD FEHB 1 877 363 3342
You may select coverage for yourself self only or for you and your family self and family during the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following
the Open Season that you enrolled
If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact the IPC to find out how to enroll and when your coverage will begin
DoD has a web site devoted to the Demonstration Project You can view information such as their Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area locations
and zip code lists at www tricare osd mil fehbp You can also view information about the demonstration project including The 2000 Guide to Federal Employees Health Benefits Plans
Participating in the DoD FEHBP Demonstration Project on the OPM web site at www opm gov
Am I eligible for See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the Temporary only individual eligible for TCC is one who ceases to be eligible as a member of family under
your self and family enrollment This occurs when a child turns 22 for example or if you divorce
Continuation of and your spouse does not qualify to enroll as an unremarried former spouse under title 10 United Coverage TCC States Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP
Demonstration Project ends TCC enrollment terminates after 36 months or the end of the Demonstration Project whichever occurs first You your child or another person must notify the IPC
when a family member loses eligibility for coverage under the DoD FEHBP Demonstration Project
TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your coverage or your coverage is terminated for any reason TCC is not available when the
demonstration project ends
Do I have the 31 day These provisions do not apply to the DoD FEHBP Demonstration Project extension and right to
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Humana Health Plan of Texas 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or
misrepresented any information do the following
Call the provider and ask for an explanation There may be an error If the provider does not resolve the matter call us at 1 800 4HUMANA 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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Humana Health Plan of Texas 2000
Summary of Benefits for Humana Health Plan of Texas 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes care in hospital doctor care room and board general nursing care private room and private
nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care You pay nothing 12
Extended Care All necessary services up to 60 days per calendar year 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 for the first 30 days 15
Substance Abuse Treatment for substance abuse in a chemical dependency treatment center Treatment
for medical aspects and detoxification provided under hospital benefits No dollar or day limit You pay nothing 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including care 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 copays are waived for maternity care 10 per house call by a doctor 10 11
Home Health Care All necessary visits by nurses and health aides You pay nothing 10
Mental Conditions Up to 20 outpatient visits per year You pay a 5 copay per visit 15
Substance Abuse All necessary outpatient visits for treatment of substance abuse including treatment in
a chemical dependency treatment center 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 50 copay to the hospital for each emergency room visit and any charges
for services that are not covered by this Plan 13 14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay for generic formulary drugs a 10 copay for brand name formulary drugs or a 25 copay for
generic or brand name non formulary drugs 16 17
Dental care Accidental injury benefit you pay nothing 17
Vision care One refraction annually You pay a 10 copay per visit 17
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,500 per Self Only or 2,500 per Self and Family enrollment per
calendar year covered benefits will be provided at 100 This copay maximum does not include charges for prescription drugs or dental services 5
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Authorized for Distribution by the
United States Office of Personnel Management
2000 Rate Information for
Humana Health Plan of Texas Inc
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
Corpus Christi area
Self Only TX1 75.40 25.13 163.37 54.45 89.22 11.31 89.22 11.31
Self and Family TX2 175.97 65.32 381.27 141.53 207.74 33.55 201.02 40.27
Dallas Ft Worth and Austin areas
Self Only TW1 76.44 25.48 165.62 55.21 90.45 11.47 90.45 11.47
Self and Family TW2 175.97 85.97 381.27 186.27 207.74 54.20 201.02 60.92
Houston and Beaumont areas
Self Only UE1 57.44 19.14 124.44 41.48 67.96 8.62 67.96 8.62
Self and Family UE2 161.03 53.67 348.89 116.29 190.55 24.15 190.55 24.15
San Antonio area
Self Only UR1 61.49 20.50 133.24 44.41 72.77 9.22 72.77 9.22
Self and Family UR2 158.06 52.68 342.45 114.15 187.03 23.71 187.03 23.71
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