Pages 1--23 from Federal Brochure 2000.p65

HealthCarePlan 2000
A Health Maintenance Organization

For changes
in benefits page 4
See

Serving Western New York State

Enrollment in this Plan is limited see page 3 for requirements
Enrollment code
Q81 Self Only
Q82 Self and Family

This plan has full accreditation
from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www healthcareplan org

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

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HealthCarePlan 2000
Table of Contents

Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 4 7
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 9 14
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16 17
Section 8 FEHB Facts 17 20
Inspector General Advisory Stop Healthcare Fraud 21
Summary of benefits 22
Premiums Inside Back Cover

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HealthCarePlan 2000
Introduction

HealthCarePlan
Guaranty Building
28 Church Street Rm 100
Buffalo N Y 14202

This brochure describes the benefits you can receive from HealthCarePlan under its contract CS1891 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 a re 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 HealthCarePlan as this Plan throughout this brochure even though in other legal documents you will see a plan referred
to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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

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

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

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HealthCarePlan 2000
Section 1 Health Maintenance Organizations

Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services from non Plan providers 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 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 Your share of the non postal premium will increase by 14.9 for Self Only or 14.8 for Self and this Plan Family
HealthCarePlan will unite its two delivery systems the Medical Centers Delivery System and the
ChoiceCare Delivery System into one network of participating providers Members will continue to select a primary care physician from this network female Members should also select an OB GYN

See page 5

Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our service area service area is Western New York including Allegany Cattaraugus Chautauqua Erie Genesee
Niagara Orleans and Wyoming counties
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 unless pre approved in writing by a HealthCarePlan Medical Director
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
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HealthCarePlan 2000
Section 3 How to get benefits continued

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 except for laboratory services prenatal and postnatal maternity care well child care through
age 19 immunizations screening mammograms and routine health education social service and nutrition education and counseling

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

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit claims 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 HealthCarePlan provides its membership with comprehensive managed health care health care
The HealthCarePlan network of doctors and other medical providers throughout the community will
provide medical care diagnostic laboratory and x ray services pharmacy and optical services

Role of a Primary The first and most important decision each member must make is the selection of a doctor Each Care doctor member must select a doctor generally Family Practitioners Pediatricians and Internists who
participates with HealthCarePlan Women 16 years of age or older also must select an obstetrician
gynecologist Ob Gyn

All medical care and other health services including specialist visits and non emergency hospital
admissions must be authorized by your Plan doctor or for obstetric or gynecologic primary care by your Ob Gyn hereafter jointly called your Plan doctor Women have direct access to a participating

Ob Gyn provider of her choice for twice yearly primary and preventive obstetric and gynecological
services as well as follow up for Ob Gyn services Women who require Ob Gyn services may obtain that care from a participating Ob Gyn physician without a referral

HCP has agreements with various Independent Practice Associations IPAs and provider groups to
provide medical care and services to HCP Members Your primary care physician is an HCP Physician
who through employment or by contract is affiliated with one or more of these IPAs or groups For certain services you may be referred to participating providers selected by or affiliated with your

primary care physician HCP Physicians are reimbursed according to a number of methodologies
including i fee for service in accordance with an established fee schedule ii fee for service in accordance with an established fee schedule and with a percentage withhold and iii capitation

agreements
The Plan's Participating Provider Directories list participating doctors with their locations and phone
numbers Directories are provided to all interested enrollees at the time of enrollment or you may
request a directory by calling the Plan's Marketing Department at 847 0881 Directories are subject to change without notice and are updated on a regular basis You may change doctors after one month

of membership by notifying the Plan 30 days in advance Check the participation status of any provider
by telephoning the provider directly or by calling 847 0881 If you are interested in receiving care from a specific provider who is listed in the directory call the provider to verify that he or she still

participates with the Plan and is accepting new patients Important note When you enroll in this
Plan services except for emergency benefits are provided through the Plan's network of providers the continued availability and or participation of any one doctor hospital or other provider cannot

be guaranteed

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HealthCarePlan 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
If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered services leaves the Plan
until the Plan can arrange with you for you to be seen by another participating doctor

If a you are undergoing a course of treatment with a Plan provider when the provider leaves the HCP
network you may be able to continue to receive care from the provider for up to ninety 90 days
after being notified that the provider is leaving If you are pregnant and in at least the second trimester you may be able to continue care with the provider through the delivery and post partum care directly

related to the delivery

What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist to go into the hospital will make the necessary hospital arrangements and supervise your care

What do I do if I'm First call our customer service department at 800 337 3338 If you are new to the FEHB Program we in the hospital when will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
I join this Plan 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 Except in an emergency and specialty care other limited circumstances you must receive a referral from your primary care doctor before seeing
any other doctor or obtaining special services
You do not need a referral from your primary care physician to obtain behavioral health services or
routine eye care from Plan providers Female members do not need a referral from the primary care physician to obtain primary and preventive obstetric and gynecologic services from a Plan Ob Gyn

provider
When you receive a referral from your primary care doctor you must return to the primary care doctor
after the consultation before obtaining additional specialty services 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
when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive specialist leaves the services from your current specialist until we can make arrangements for you to see someone else
Plan

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HealthCarePlan 2000
Section 3 How to get benefits continued

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
provider leaves the Plan the provider unless the termination is for cause If you are in the second or third trimester of pregnancy or this Plan leaves the you may continue to see your Ob Gyn until the end of your postpartum care
Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide your
care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If
you are in your second or third trimester your new plan will pay for the Ob Gyn care you receive from your current provider until the end of your postpartum care

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 A device drug or biological product must have Food and Drug Administration FDA or comparable service is experimental approval to market for those specific indications and methods of use that the Technology Assessment
or investigational Committee is reviewing Approval to market refers to permission for commercial distribution
Plan providers will follow generally accepted medical practice in prescribing any course of treatment

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or
request for service

What if I have a serious Call us at 800 337 3338 and we will expedite our review or life threatening
condition and you haven't responded to my
request for service

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

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 Alternately you can call OPM's health
my condition is serious benefits Contract Division III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening or life 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

What do I send Your request must be complete or OPM will return it to you You must send the following information to OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure

2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to
which claim

Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with the review

request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim Contract Division III 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 decision the Plan's denial 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 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 and the Privacy Act 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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HealthCarePlan 2000
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 and routine X rays which do not require the attendance of a doctor to plan perform or assist a radiologic study Within the service area house calls will be provided

if in the judgment of your Plan doctor such care is necessary and appropriate you pay nothing for a
doctor's house call or 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 Office visit copay is waived
for well child care through the attainment of 19 years of age

Routine immunizations and boosters
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 Office visit copay is waived

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 or participating certified nurse midwife Copayments 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 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
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
Nonexperimental transplants including cornea heart kidney heart lung lung single or double
liver and pancreas 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 Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be provided in a

non randomized clinical trial Related medical and hospital expenses of the donor are covered
when the recipient is covered by this Plan

Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces
Prosthetic devices such as artificial limbs and lenses following cataract removal and breast
prostheses and surgical bras following mastectomies as well as their replacement

Hearing aids replacement of lost or broken hearing aids is not covered
Durable medical equipment such as wheelchairs and hospital beds

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HealthCarePlan 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need You pay nothing for visits 1 20 you pay 10 for each additional visit thereafter in a calendar year

Diabetes supplies such as test strips for glucose monitors and visual reading and urine testing strips syringes cartridges for the legally blind and additional diabetes supplies specified by the
Commissioner of Health
Diabetes equipment such as blood glucose monitor blood glucose monitor for the legally blind
injection aids insulin pumps and appurtenances insulin infusion devices data management systems and additional diabetes equipment specified by the Commissioner of Health

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Chiropractic services when authorized by your Plan doctor Such services shall be limited to the
detection and correction by manual or mechanical means of structural imbalance distortion or
subluxation in the human body for the purpose of removing nerve interference and the effects thereof where such interference is the result of or related to distortion or misalignment or

subluxation of the vertebral column You pay a 10 copay per visit

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 All other procedures involving the teeth or intraoral areas
surrounding the teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

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 for up to two months per condition if significant improvement can be expected
within two months you pay a 10 copay per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist
the member to achieve and maintain self care and improved functioning in other activities of daily
living

Diagnosis and treatment of infertility is covered you pay 50 of covered charges The following types of artificial insemination are covered intracervical insemination ICI and intrauterine

insemination IUI you pay 50 cost of donor sperm is not covered Fertility drugs are covered you
pay 50 of covered charges Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation stages I and II is covered when recommended by your Plan doctor You pay 50 of the charges Stage III which generally includes support group activities is not covered

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
Blood and blood derivatives not replaced by the member
Long term rehabilitative therapy
Homemaker services
Foot orthotics

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HealthCarePlan 2000
Section 5 Benefits continued
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under authorization of your Plan doctor You pay nothing All necessary services are

covered including
Semiprivate room accommodations when your attending 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 45 days when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined
by your 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 your 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 your 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 your Plan doctor

Limited benefits
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 your Plan doctor determines that outpatient management is not medically

appropriate See page 13 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
Hospitalization for dental services except for covered accidental dental injury benefit

Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency 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 you are encouraged to call your Plan doctor In extreme
the service area emergencies 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

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HealthCarePlan 2000
Section 5 Benefits continued
Emergency Benefits continued 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
you are hospitalized in non Plan facilities and your 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
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 and 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 35 per hospital emergency room visit or 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 outside Benefits are available for any medically necessary health service that is immediately required because the service area 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

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan and 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 35 per hospital emergency room visit or 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

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 you pay a 35 copay

What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area

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

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers 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 7

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HealthCarePlan 2000
Section 5 Benefits continued
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 to determine the appropriate treatment for a short term psychiatric condition
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay per visit for each covered visit all charges thereafter

Inpatient care All services for up to 30 days per confinement with a maximum of 180 days during any calendar year You pay nothing
What is not covered 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

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 the services necessary for diagnosis
and treatment

Outpatient care Up to 60 outpatient visits for alcoholism and drug abuse at a Plan medical center or provider's office designated by the Plan each calendar year If the member has family coverage then 20 of the 60 visits
may be used for family therapy related to the member's abuse of or addiction to alcohol and or substance abuse Visits for family therapy may be used by members of the subscriber's family who are
covered under this Plan You pay a 10 copay for each covered visit all charges thereafter

Inpatient care Same as Mental conditions benefit shown above
What is not covered Treatment that is not authorized by your Plan doctor

Prescription Drug Benefits
What is covered
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy the
registered pharmacy at an HCP Medical Center and such other locations the Plan may designate will be dispensed for up to a 31 day supply except that for treatment of a chronic condition the supply

may be for 100 unit doses or one commercially prepared unit for example one inhaler one vial
ophthalmic medication or insulin You pay a 5 copay per prescription unit or refill

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HealthCarePlan 2000
Section 5 Benefits continued
Prescription Drug Benefits continued Covered medications and accessories include
Drugs for which a prescription is required by law
All FDA approved oral and injectable contraceptive drugs contraceptive devices such as Norplant and IUDs are covered under medical benefits

Insulin for the treatment of diabetes including oral agents for controlling blood sugar
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are
covered under Medical and Surgical Benefits

Allergy treatment materials
Drugs for the treatment of infertility you pay 50 of charges
Self administered injectable drugs other than insulin you pay a 5 copay

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

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance

Other Benefits
Dental care
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result from an accidental injury 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 which include the written lens prescription may be obtained from

Plan providers You pay a 10 copay for each covered visit all charges thereafter

What is not covered Corrective lenses and frames
Eye exercises

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HealthCarePlan 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program
but are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB premium any charges for these services do not count toward any FEHB

deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure
Please call 1 800 427 8490 for more information on the following programs

Health Education Prepared Childbirth Classes are designed to help both parents prepare for birth Programs through exercise relaxation and communication
Adult Weight Control is a program to help modify habits improve exercise
practices and develop other life skills which can help manage weight

Smoking Cessation assistance options offered include coverage of American
Lung Association and Roswell Park classes American Cancer Society classes HCP's nicotine dependency clinics and Freedom From Smoking Workbooks

Arthritis Education is designed to help increase participants flexibility strength and balance
Diabetes Education teaches nutrition self care and monitoring skills necessary
to cope with diabetes

Nutritional Counseling relates to the management of disease or medical
condition

Cardiopulmonary Resuscitation CPR Adult and Pediatric combined or
pediatric alone programs follow the guidelines of the American Heart Association

There is a registration fee for some of the programs however special arrangements are available for financial hardship Some programs require a referral from your
Plan doctor

Dental Services Preventive dental services are available from a select list of Western New York dentists A set of services includes an examination bite wing x rays and a
prophylaxis Limited to one set of services every six months and subject to a
35 copayment for each set of services received

Vision Services As part of your vision coverage you can take advantage of discounts through Vision Service Plan VSP a nationally recognized vision services provider You
can receive a 20 discount on lenses and frames and a 15 discount on fitting fees for contact lenses from participating providers

Acupuncture and Professional acupuncture and massage therapy services that are not medically Massage Therapy necessary are available at a 20 discount from participating providers Members
must present their identification cards to the participating providers Fees for
services will be posted at participating locations

Benefits on this page are not part of the FEHB Contract

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HealthCarePlan 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 reenroll 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

Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan
is secondary it pays benefits next We decide which insurance is primary according to the National Association of Insurance Commissioners Guidelines

If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever
is less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage

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HealthCarePlan 2000
Section 7 Limitations Rules that affect your benefits continued

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our control 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 We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for

Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right information about to information about your health plan its networks providers and facilities You can also find out
your HMO about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov
lists the specific types of information that we must make available to you
If you want specific information about us call 800 427 8490 or write to HealthCarePlan Marketing Department 28 Church Street Rm 100 Buffalo New York 14202 You may also contact us by fax at

716 847 1257 or visit our website at www healthcareplan org

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
enrolling in the 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

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HealthCarePlan 2000
Section 8 FEHB FACTS continued
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 When you retire you can usually stay in the FEHB Program Generally you must have been enrolled I retire in the FEHB Program for the last five years of your Federal service If you do not meet this requirement
you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which
is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for me unmarried dependent children under age 22 including any foster or step children your employing or
and my family retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled
in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access claims records 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 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

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HealthCarePlan 2000
Section 8 FEHB Facts continued
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Your enrollment ends unless you cancel your enrollment or Plan ends
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage 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 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does
not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

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

Former spouses You or your former spouse must notify your employing or retirement office within 60
days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for coverage

or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline

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HealthCarePlan 2000
Section 8 FEHB Facts continued
When you lose benefits continued
How can I convert to You may convert to an individual policy if individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage
due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage 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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HealthCarePlan 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 877 800 0910 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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HealthCarePlan 2000
Summary of Benefits for HealthCarePlan 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 11
Extended care All necessary services for up to 45 days You pay nothing 11

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days per confinement of conditions inpatient care with a maximum of 180 days during any calendar year You pay nothing 13

Substance Covered under Mental conditions 13 abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
care including specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay

a 10 copay per office visit copays are waived for maternity care and nothing per house call
by a doctor You pay nothing for well baby care immunizations and mammogram screenings 9 10

Home health All necessary visits by nurses and health aides You pay nothing for visits 1 20 you pay care 10 for each additional visit thereafter in a calendar year 10
Mental Up to 30 outpatient visits per year You pay a 10 copay per visit 13 conditions
Substance Up to 60 outpatient visits per year for alcoholism and substance abuse You pay a 10 copay abuse per outpatient visit 13

Emergency care Reasonable charges for services and supplies required because of a medical emergency Yo u pay a 35 copay to the hospital for each emergency room visit and any charges for services
that are not covered benefits of this Plan 11 12

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill 13 14

Dental care Accidental injury benefit You pay nothing 14
Vision care One refraction annually You pay a 10 copay per visit 14
Out of pocket maximum Your out of pocket expenses for benefits under this Plan are limited to the stated copayments required for a few benefits 5

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HealthCarePlan 2000
2000 Rate Information for HealthCarePlan

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

Western New York
Self Only Q81 56.12 18.70 121.58 40.53 66.40 8.42 66.40 8.42
Self and Family Q82 158.97 52.99 344.44 114.81 188.11 23.85 188.11 23.85

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