Pages 1--28 from junk

A Health Maintenance Organization

Serving Southeastern Michigan
Enrollment in this plan is limited For changesin page 7
see page 8 for requirements benefitssee

Enrollment code
K31 Self only
K32 Self and family

Visit the OPM website at http www opm gov insure

Authorized for distribution by the
Federal Employee
United States Health Benefits Program Office of

Personnel Management
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Table of Contents
Page
Introduction 5

Plain Language 5
How to Use This Brochure 5
Section 1 Health Maintenance Organizations 7
Section 2 How We Change for 2000 7
Section 3 How to Get Benefits 8
Section 4 What to do if we Deny Your Claim or Request for Service 10
Section 5 Benefits 12
Section 6 General Exclusions Things we Don't Cover 18
Section 7 Limitations Rules that Affect Your Benefits 21
Section 8 FEHB Facts 22
Inspector General Advisory Stop Healthcare Fraud 25
Summary of Benefits Inside Back
Cover
Premiums Back Cover

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Introduction
Comprehensive Health Services Inc d b a The Wellness Plan 2875 W Grand blvd Detroit MI 48202

This brochure describes the benefits you can receive from Comprehensive Health Services Inc dba The Wellness Plan under its contract CS1900 with the Office of Personnel Management OPM as
authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits
described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 7 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 The Wellness Plan as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier

How to use this brochure
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
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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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 do not have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any

one physician hospital or other provider will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits
This year you have a right to more information about this Plan care management our networks facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in
the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a

record that is not accurate not relevant or complete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will assist
you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Plan Your share of the non postal premium will increase by 5.3 for Self Only or 4.9 for Self and Family
Women age 40 and above are entitled to one mammogram every calendar year See page 12
We limit chiropractic services to eighteen 18 visits per member per year You must have a referral from your doctor See page 13

Our emergency room copay increased from 25.00 to 50.00 per visit See page 15

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Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our service area service area is the Michigan counties of Genesee Macomb Oakland and Wayne
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 other than reasonable charges that would have been covered if received from plan providers
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another state

you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open Season to change
plans Contact your employing or retirement office
How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount or for services coinsurance a set percentage of charges Please remember you must pay this amount where applicable
when you receive services
Your cost is limited to the stated copayments in this brochure

Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a provider 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 The Wellness Plan has been a staff model HMO since 1979 With the addition of individual IPA health care providers in Wayne Oakland Macomb and Genesee counties health services are provided currently
in a mixed staff and IPA model program Members must select one primary doctor who provides and arranges for the delivery of services to the members Primary care doctors will refer members to

specialists within his her provider group but will refer outside of the group if necessary
You will need to let us know which primary care physician you select for each member of the family If you need help in choosing a physician please call us at 1 800 875 WELL If you let us know by

the 10 th of the month your change will be effective the first of the following month

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

What do I do if I'm in First call our customer service department at 1 800 875 WELL If you are new to the FEHB Program the hospital when I we will arrange for you to receive care If you are currently in the FEHB Program and are
join this Plan switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or

The day your benefits from your former plan run out or
The 92nd day after you become a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

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Section 3 How to get benefits Continued
How do I get specialty Your primary care physician will arrange your referral to a specialist Your initial referral will indicate care the condition referred specialist and probable duration of the referral On a monthly basis the
specialist will call for eligibility and referral extension
You may see your participating gynecologist for your annual routine exam without a referral You must select a gynecologist in the same medical group as your primary care physician

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 when specialist ask if you can see your current specialist If your current specialist does not participate
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 Plan services from your current specialist until we can make arrangements for you to see someone else

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract 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 Our New Medical Technology Committee keeps pace with new medical technology and applications service is experimental of existing medical procedures device and pharmaceuticals to ensure that members have on going

or investigational and appropriate access to safe and effective care This process includes the review and evaluation of documents as follows published updated scientific medical literature and data official actions and
publications by appropriate governmental regulatory bodies and published opinions recommendations and reviews made by appropriate professionals and specialty organizations

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Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you 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 to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or
request for service

What if I have a serious or Call us 1 800 875 WELL and we will expedite our review life threatening condition

and you haven't responded to my request
for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's

my condition is serious or health benefits Division III at 202 606 0755 between 8 a m and 5 p m Serious or life threatening 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 time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for additional
information

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Section 4 What to do if we deny your claim or request for service Continued
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make the Those who have a legal right to file a disputed claim with OPM are 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 my Send your request for review to disputed claim to OPM
Office of Personnel Management Office of Insurance Programs 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 I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its 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 the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and 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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Section 5 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 of 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

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
Sigmoidoscopy screening for colorectal cancer every five years
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 and above one mammogram every year In addition to

routine screening mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness

Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays additional copay does not apply
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care received from a Plan

Obstetrician Gynecologist 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 testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints The cost of the devices is covered except for penile implants

Cornea heart heart lung kidney liver lung single or double pancreas and skin transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous
stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma and testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer Transplants are covered
when medically necessary and approved by the Plan medical director Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan

Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics

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Section 5 Medical and Surgical Benefits Continued
Prosthetic devices such as artificial limbs and lenses following cataract removal breast prostheses and surgical bras as well as replacements
Durable medical equipment such as wheelchairs and hospital beds Repair replacement and maintenance of durable medical equipment not provided for under a manufacturer's warranty or
purchase agreement will be covered
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your 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 at no additional cost to you

Limited benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas

surrounding the teeth are not covered 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 nothing Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member to
achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay nothing The following types of Artificial insemination are covered and limited to three attempts intravaginal insemination IVI

intracervical insemination ICI and intrauterine insemination IUI you pay nothing cost of donor sperm is not covered Fertility drugs are covered under the Prescription Drug Benefit Other
assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for up to two months you pay nothing
Hearing aids are limited to one per ear in any 36 consecutive months
Chiropractic services are limited up to 18 visits per year You must have a referral from your doctor
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
Blood and blood derivatives not replaced by the member
Long term rehabilitation therapy
Homemaker services

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Section 5 Hospital Extended Care Benefits
What is covered 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
Hospital Care 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 730 days per confinement when fulltime 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 hospice facility Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less

Ambulance Service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient Dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
Procedure need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization

would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition

Acute Inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
Detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See

page 16 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

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Section 5 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 please call your primary care doctor In extreme emergencies if the service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member should notify the

Plan within 48 hours It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time 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 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 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 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

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

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

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Section 5 Emergency Benefits Continued
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 10

Section 5 Mental Conditions Substance Abuse Benefits
Mental conditions For services you must call the Wellness Plan Liaison of the Managed Care Group at 1 800 570 3990 The Managed Care Group is available twenty four hours daily The Plan will determine and authorize
the appropriate number of visits A referral form from your primary care doctor is not required

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
Outpatient Care Up to 35 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar you pay nothing for each covered visit all charges thereafter

Inpatient Care Up to 45 days of hospitalization renewable after 60 consecutive days of non confinement per calendar year you pay nothing for first 45 days in each confinement all charges thereafter
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 that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance Abuse
What is Covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same
as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment

Outpatient Care Up to 60 outpatient visits to Plan providers for treatment each calendar year you pay nothing for each covered visit all charges thereafter
Inpatient Care Up to 60 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the
benefit period all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor
All charges if the member does not complete the treatment program

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Section 5 Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 35 day supply or 100 unit doses whichever is greater or one commercially
prepared unit i e one inhaler one vial ophthalmic medication or insulin You pay a 5 copay per prescription unit or refill Drugs are prescribed by Plan doctors and dispensed in accordance with the

Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor
Covered medications Drugs for which a prescription is required by law and accessories include Oral contraceptive drugs contraceptive diaphragms

Implanted time release medications such as Norplant For Norplant you pay a one time copay of 5 per prescription For other internally time release medications you pay 5 There is no
charge when the device is implanted during a covered hospitalization There will be no refund of any portion of these copays if the implanted time release medication is removed before the end
of its expected life
Insulin with a 5 copay charge applied to each vial
Diabetic supplies including insulin syringes and needles glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets

Disposable needles and syringes needed to inject covered prescribed medication
Fertility drugs
Intravenous fluids and medication for home use provided under home health services at no charge contraceptive devices other than diaphragms and some covered injectable drugs such as

Depo Provera are covered under Medical and Surgical Benefits
Limited benefits Sexual dysfunction drugs have dosage limitations Contact the Plan for details

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
Smoking cessation drugs and medication including nicotine patches

Section 5 Other Benefits
Accidental Injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth Benefit The need for these services must result from an accidental injury You pay nothing

Vision Care 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 may be obtained from Plan
providers You pay nothing per visit
What is covered Contact lenses following cataract surgery when medically necessary and authorized by your doctor you pay nothing per visit

Eye exercises
What is not covered Corrective lenses or frames
Eyeglasses

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Section 6 General Exclusions Things We Don't Cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent
diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits

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

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NON FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered not 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 and 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

The Wellness Plan offers a discount dental program for all enrollees The program is
offered through Dental Preferred Provider Organization DPPO and extends discounts
ranging from 20 50 depending on the reason for the visit The Wellness Plan will
provide members with a discount fee schedule and a list of participating dental providers
Call 313 875 WELL press 1 1 Members Services

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT

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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

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 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 as long as you use our providers

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Section 7 Limitations Rules that Affect Your Benefits Continued
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 Patient's 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 1 800 875 WELL or write to 2875 W Grand Blvd Detroit MI 48202 Attn Member Services You may also contact us by fax at 313 202 8657

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 FEHB informed decision about Program When you may change your enrollment

How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

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

When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums begin January 1

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 my unmarried dependent children under age 22 including any foster or step children your employing or
family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member

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Section 8 FEHB FACTS Continued
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 party such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating Benefit Payments to subrogating claims

Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members

Identification Cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use
an Employee Express confirmation letter
What if I paid a deductible Your old plan's deductible continues until our coverage begins
under my old plan

Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you
enrolled in this Plan solely because you had the condition before you enrolled

When You Lose Benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Your enrollment ends unless you cancel your enrollment or plan ends

You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits under 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 member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
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When You Lose Benefits Continued
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

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

Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for

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

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 Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that of Group Health Plan indicates how long you have been enrolled with us You can use this certificate when getting health

Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or
hospital has charged you for services you did not receive billed you twice for the same service
or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 875 WELL
and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud
Also the Inspector General may investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you

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Summary of Benefits for The Wellness Plan 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 Care Includes in hospital doctor care room and board general nursing care private room and
private nursing care if medically necessary diagnostic test drugs and medical supplies use of operating room intensive care and complete maternity care You pay nothing 14

Extended care All necessary services up to 730 days You pay nothing 14
Mental condition Diagnosis and treatment of acute psychiatric conditions for up to 45 days of inpatient care renewable after 60 consecutive days of non confinement You pay nothing 16

Substance abuse Up to 60 days per year in an approved rehabilitation center You pay nothing 16
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 services received

from a Plan Obstetrician Gynecologist and nothing for house call by a doctor
Home health care All necessary visits by nurses and health aides You pay nothing 12
Mental conditions Up to 35 outpatient visits per year You pay nothing 16
Substance abuse Up to 60 outpatient visits per year You pay nothing 16

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 15

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill 17

Dental care Accidental injury benefit you pay nothing 17
Vision Care One refraction annually You pay nothing 17 27
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2000 Rate Information for The Wellness Plan
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

Self Only K31 58.84 19.61 127.49 42.49 69.62 8.83 69.62 8.83
Self and Family K32 160.05 53.35 346.78 115.59 189.39 24.01 189.39 24.01 28

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