Family Health Plan Family Health Plan 2000
A Health Maintenance Organization
For changes
in benefits 4
Serving Southeastern Wisconsin see page
You must live in one of the following service areas to enroll in this Plan and must enroll in the the area where you live
Enrollment in the Plan is limited see page 5 for requirements
Enrollment code
WH1 Self Only
WH2 Self and Family
Service Area Services from Plan providers are available only in the following area
Milwaukee and Waukesha counties in Wisconsin
Visit the OPM website at http www opm gov insure
and
our website at http www familyhp org
Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service RI 73 081
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Family Health Plan Cooperative HMO 2000
Table of Contents
Page
Plain language
2
How to use this brochure
3
Section 1 Health Maintenance Organizations
4
Section 2 How we change for 2000
4
Section 3 How to get benefits
5 8
Section 4 What to do if we deny your claim or request for service
8 10
Section 5 Benefits
10 17
Section 6 General exclusions Things we don't cover
17
Section 7 Limitations Rules that affect your benefits
17 19
Section 8 FEHB facts
19 22
Inspector General Advisory Stop Healthcare Fraud
23
Summary of benefits
25
Premiums
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Family Health Plan Cooperative HMO 2000
Introduction
Family Health Plan Cooperative
11524 West Theodore Trecker Way
Milwaukee WI 53214
This brochure describes the benefits you can receive from Family Health Plan Cooperative HMO under its contract CS1906 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 10 17 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 Family Health Plan Cooperative HMO as this Plan throughout this brochure even though in other legal documents you
will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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Family Health Plan Cooperative HMO 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not
to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations 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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Family Health Plan Cooperative HMO 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 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 This year you have a right to more information about this Plan care management our networks
changes facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at your 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 our
medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your
record you may add a brief statement to it If they do not provide you your records call us and
we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer
Changes to this Our prescription drug plan changed from a 31 day supply to a 34 day supply
Plan The coverage has changed from 0 office copayment to a 10.00 copayment for all office visits
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Section 3 How to get benefits
What is this What is this Plan's service area To enroll with us you must live or work in our service area
Plan's service This is where our providers practice Our service area is Where Plan providers and facilities are
area located You may enroll in this Plan if you live or work inside the service area or live in the geographic area described below Benefits for care outside the service area are limited to
emergency services
You may also enroll with us if you live or work in the following places
Milwaukee and Waukesha counties as well as the following zip codes in Walworth Racine
Washington and Ozaukee counties
Walworth Racine Washington Ozaukee
53105 53105 53012 53112
53119 53108 53017 53024
53120 53120 53022 53092
53138 53126 53027 53217
53148 53130 53033
53149 53139 53037
53157 53149 53076
53176 53150 53077
53167 53086
53182
53185
53402
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 benefits Benefits are available for
any medically necessary health service that is immediately required because of injury or
unforeseen illness If you need to be hospitalized the Plan must be notified within 48 hours or
on the first working day following your admission unless it was not reasonably possible to
notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan
hospital you would 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 nothing for emergency services which are covered benefits of this Plan
Emergency care at a doctor's office or an urgent care center are covered Emergency care as an
outpatient or inpatient at a hospital including doctors services are covered Ambulance service
approved by the Plan is also covered We will not pay for any other health care services such as
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 cost
resulting from a normal full term delivery of a baby outside the Service Area
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 The Alliance of Community Health Plans ACHP
Reciprocity Program provides Family Health Plan members two levels of reciprocity expanded
care and travel care Members visiting an area covered by a HMOG home plan can obtain
routine and urgent care through the home plan for up to one year If members know they are
going to visit an ACHP plan area they can complete the necessary forms in advance Travel care
is available to members who are traveling out of the area for a short period of time and an urgent
situation arises If you would like more information about receiving care away from home
please call the Member Service Department at 414 256 5713 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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How much do I You must share the cost of some services This is called either a copayment a set dollar amount
pay for services or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services Your out of pocket expenses for benefits under the Plan are limited to the
copayments required for certain dental and prescription benefits as well as a 10.00 office visit
copay
You do not have an out of pocket maximum under this Plan
Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a
claims provider who doesn't contract with us When you are required to submit a claim to this Plan for covered expenses submit your claim promptly 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 Family Health Plan is a staff model health maintenance organization Family Health Plan hires
health care its own family doctors technicians nurses pharmacists counselors and many other professionals who serve Family Health Plan members As a member of Family Health Plan you
are eligible to take advantage of the many services this team can provide
When you join Family Health Plan you select one of our health centers and then
choose a primary care doctor on our staff at that health center to be your and your family's
personal doctor Family Health Plan's delivery system is based on the family
practice doctors so all family members are encouraged to select the same family practice doctor
The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this doctor that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care doctor
to obtain any necessary authorizations from the Plan before referring you to a specialist or
making arrangements for hospitalization Services of other Plan providers are covered only
when there has been a referral by the member's primary care doctor A woman at her request
may see a Plan OB GYN for her annual routine exam
Choosing your doctor
The Plan's provider directory lists primary care doctors generally family practitioners and
internists with their locations and phone numbers and notes whether or not the doctor is
accepting new patients Directories are updated on a regular basis and are available at the time of
enrollment or upon request by calling the Marketing Department at 414 256 0040 you can also
find out if your doctor participates with this Plan by calling this number
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 delivery system the continued availability and or participation of
any one doctor hospital or other provider cannot be guaranteed
Should you decide to enroll you will be asked to complete a primary care doctor selection form
and send it directly to the Plan indicating the name of the primary care doctor you select for you
and each member of your family Members may change their doctor selection by notifying the
Plan 30 days in advance
What do I do if my Call us We will help you select a new one In the event a member is receiving services from a
primary care physician doctor who terminates a participation agreement the Plan will provide payment for covered
leaves the Plan services until the Plan can make reasonable and medically appropriate provisions for the assumption of such services by a participating doctor
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What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or
to go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm in the First call our customer service department at 414 302 2300 If you are new to the FEHB
hospital when I join this Program we will arrange for you to receive care If you are currently in the FEHB Program and
Plan are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Your primary care physician will arrange your referral to a specialist Except in a medical
care emergency or when a primary care doctor has designated another doctor to see patients when he or she is unavailable you must contact your primary care doctor for a referral before seeing any
other doctor or obtaining special services Referral to a participating specialist is given at the
primary care doctor's discretion if specialists or consultants are required beyond those
participating in the Plan the primary care doctor will make arrangements for appropriate
referrals
When you receive a referral from your primary care doctor you must return to the primary care
doctor after the consultation All follow up care must be provided or authorized by the primary
care doctor On referrals the primary care doctor will give specific instructions to the consultant
as to what services are authorized If additional services or visits are suggested by the consultant
you must first check with your primary care doctor Do not go to the specialist 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
seeing a specialist when a specialist ask if you can see your current specialist If your current specialist does not
I enroll participate with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves receive services from your current specialist until we can make arrangements for you to see
the Plan someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to
serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the contract with the provider unless the termination is for cause If you are in the second or third
Plan or this Plan leaves trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Program care
You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
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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
medical services specialist or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
How do you decide if a The following describes this Plan's criteria for determining when a medical treatment or
service is experimental procedure or a drug device or biological product is experimental or investigational
or investigational A medical surgical or pharmacological regime or facility is considered to be experimental or investigational if for example it is being performed under a formal investigational protocol is
primarily used in a laboratory research setting or has progressed to only limited human use
Family Health Plan determines it is or if generally not accepted by the local medical community
A medical surgical or pharmacological regime or facility is considered to be not proven effective
if for example it is not covered under Medicare
Other considerations
Plan providers will follow generally accepted medical practice in prescribing any course of
treatment Before you enroll in this Plan you should determine whether you will be able to
accept treatment or procedures that may be recommended by Plan providers
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
to review a denial refusal OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
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What if I have a Call us at 414 256 0040 and we will expedite our review If we expedite your review due to a
serious or life threatening serious medical condition and deny your claim we will inform OPM so that they can give your
condition and you claim expedited treatment too Alternatively you can call OPM's health benefits Contract
haven't responded to my Division 4 at 202 606 0191 between 8 a m and 5 p m Serious or life threatening conditions
request for service 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 limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We did 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 do 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 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
What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our
Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
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Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record
Section 5 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 10.00 copay 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
Plan doctors also provide all necessary medical or surgical care in a hospital or extended care facility at no additional cost to you
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through 39 one mammogram during these five years for women 40
through 49 one mammogram every one or two years for women age 50 through 64 one mammogram every year and for women
age 65 and above one mammogram every two years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists you pay a 10.00 copay
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 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
Cornea heart kidney and liver transplants allegoric donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple
myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical
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
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hospital up to 48 hours after the procedure
Dialysis
Chiropractic services you pay a 10 copay
Chemotherapy radiation therapy and inhalation therapy
Inhospital administration of blood products including blood processing
Surgical treatment of morbid obesity when medically necessary Implants The procedure will be covered although the cost of the
device may be excluded
Orthopedic devices such as braces except for orthotic fittings and devices for the feet
Prosthetic devices such as artificial limbs and lenses following cataract removal
External breast prosthesis and surgical bras
Durable medical equipment such as wheelchairs and hospital beds
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan
doctor who will periodically review the program for continuing appropriateness and need
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 Medically necessary diagnostic procedures and medically necessary surgical or nonsurgical treatment including
but not limited to intraoral splint therapy devices for the correction of temporomandibular disorders TMJ caused by
congenital developmental or acquired deformity disease or injury Coverage is limited to procedures or devices used to
control or eliminate infection pain disease or dysfunction All other procedures involving the teeth or areas surrounding the
teeth are not covered including shortening of the mandible or maxillae for cosmetic purposes
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
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two
consecutive 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 including hyper ovulatory drugs example Clomid up to six months of treatment
or Pergonal up to two 2 menstrual cycle attempts per lifetime The following types of artificial insemination are covered
intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay a 10 copay cost of
donor sperm is not covered 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
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
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Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Long term rehabilitative therapy
Homemaker services
Transplants not listed as covered
Hospital Extended Care Benefits
What is covered
Hospital care
The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan
doctor You pay nothing All necessary services are covered including
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 30 days per confinement when full time skilled nursing care is
necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor 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 procedures
Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for reasons
totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services
unless such services are covered under the Plan's dental benefits 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 detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of medical conditions
and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is
not medically appropriate
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What is not covered
Custodial care rest cures domiciliary or convalescent care
Personal comfort items such as telephone and television
What is a medical emergency
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies
because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have
in common is the need for quick action
Emergencies within the service area
If you are in an emergency situation please call your primary care doctor In extreme emergencies if you are unable to contact your
doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to
tell the emergency room personnel that you are a Plan member so they can notify the 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 in a non Plan facility the Plan must be notified within 48 hours or on the first working day following
your admission unless it was not reasonably possible to notify the Plan within that time If you are hospitalized in non Plan facilities
and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any
ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would
result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by
Plan providers
Plan pays
Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay
Nothing for emergency services which are covered benefits of the Plan
Emergencies outside the service area
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission
unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a
Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
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
Nothing for emergency services which are covered benefits of this Plan
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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
Filing claims for non Plan providers
With your authorization the Plan will pay benefits directly to the providers of your emergency care upon receipt of their claims
Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized
bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based If you
disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on
page 8
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered
To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric
conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care
All medically necessary outpatient mental health care subject to plan approval you pay a 10.00 copay for each covered visit
Inpatient care
All medically necessary inpatient mental health care subject to plan approval
you pay nothing for each covered visit
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
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Family Health Plan Cooperative HMO 2000
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 20 outpatient visits to Plan providers for treatment each calendar year you pay a 10.00 copay for each covered visit all
charges thereafter An additional up to five outpatient visits are provided for college students who live out of the service area but in
Wisconsin upon approval by the Plan
Inpatient care
Up to 30 days per calendar year for substance abuse rehabilitation intermediate care program in an alcohol detoxification or
rehabilitation center approved by the Plan you pay nothing during the benefit period all charges thereafter
Transitional treatment up to a maximum of 24 visits or substance abuse services worth 2,700 per contract year approved by the
medical director and subject to the contract year maximum limit for substance abuse services can be substituted
What is not covered
Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day
supply or 100 unit supply whichever is less 240 milliliters of liquid 8 oz 60 grams of ointment creams or topical preparation or
one commercially prepared unit i e one inhaler one vial ophthalmic medication or insulin You pay nothing for formulary drugs
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Family's Pharmacy and
Therapeutics committee meets on a regularly scheduled basis and reviews drugs for inclusion in its formulary based on effectiveness
and cost of the drug for treatment of the disease or condition for which it was intended
All non formulary prescription drugs require a 10 copayment per 34 day supply or dispensing unit
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs
Insulin
Diabetic supplies including insulin syringes needles chem strips and test tape
Implanted time release medications such as Norplant
Disposable needles and syringes needed to inject covered prescribed medication
Hyper ovulatory drugs are covered under the infertility treatment benefit on page 11
Intravenous fluids and medication for home use implantable drugs and some injectable drugs
are covered under Medical and Surgical Benefits
Limited benefits
Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay a 10 copay for up to the dosage limit and
all charges above that
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription for eyeglasses
obtained from Plan providers You pay nothing
What is not covered Corrective lenses or frames or contact lenses including the fitting of lenses Eye exercises
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Family Health Plan Cooperative HMO 2000
Dental Benefits
Dental care
What is covered
This Plan provides the following comprehensive program of dental coverage through participating Plan dentists The emphasis is on
prevention with preventive and diagnostic dental services provided with no copayment For all other dental services you pay 50
of charges
The following list summarizes the dental services provided by participating Plan dentists
DIAGNOSTIC
X rays including bite wings and
panoramic once a year oral
examination and treatment
plan vitality test and oral
cancer exam
Study model
PREVENTIVE
Prophylaxis annual topical
application of fluoride preventive
dental instruction
RESTORATIVE fillings
Amalgam on surface
Amalgam two surface
Amalgam three surface
Amalgam four or more surfaces
Plastic or composite single surface
Plastic or composite two surfaces
Plastic or composite three surfaces
ORAL SURGERY
Post operative treatment extraction
simple
Alveoplasty per quadrant
Impaction soft tissue
Impaction partial bony
Impaction complete bony
PROSTHODONTICS
Complete upper or lower
Cast chrome partial upper or lower
Acrylic partial upper or lower
Repair broken denture
Reline upper or lower complete denture or partial
CROWN caps
Crown Metal full or 3 4 cast
Crown Porcelain metal
PERIODONTICS gum treatment
Treatment of diseases of gums
and bones supporting teeth
per quadrant
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Family Health Plan Cooperative HMO 2000
ENDODONTICS
Root canal anterior
Root canal bicuspid
Root canal molar
Apicoectomy per root
ORTHODONTICS braces
Limited to age 19
You pay 50 of charges up to a lifetime maximum of 1,150.00 per person
The Plan pays in full thereafter
Dental medical emergencies within the service area are covered you pay 50 of charges Out of area service received outside of
50 mile radius of the dental clinic is covered at 50 of charges up to 50 per person per year maximum
Accidental injury benefit
Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered You pay nothing
What is not covered
Other dental services not shown as covered
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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
Custodial care rest cures domiciliary or convalescent care
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
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Family Health Plan Cooperative HMO 2000
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833
Plan does not offer a Medicare Choice plan at this time
Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not
seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage
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Family Health Plan Cooperative HMO 2000
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
Agencies or indirectly pays for
If you have a malpractice If you have a malpractice claim because of services you did or did not receive from a plan
claim provider it must go to binding arbitration Contact us about how to begin our binding arbitration process
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about your right to information about your health plan its networks providers and facilities You can also
HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 414 256 0040 or write to 11524 West Theodore
Trecker Way Milwaukee WI 53214 7260 You may also contact us by fax at 414 256 0069 or
visit our website at www familyhp org
Where do I get information Where do I get information about enrolling in the FEHB Program
about enrolling in the FEHB Your employing or retirement office can answer your questions and give you a Guide to Federal
Program Employees Health Benefits Plans brochures for other plans and other materials you need to make an informed decision about
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your
enrollment status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
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Family Health Plan Cooperative HMO 2000
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been
I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What happens when Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
I retire unmarried dependent children under age 22 including any foster or step children your employing or retirement office authorizes coverage for Under certain circumstances you may also get
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
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
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
Plan ends Your enrollment ends unless you cancel your enrollment or
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Family Health Plan Cooperative HMO 2000
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
coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed
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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Family Health Plan Cooperative HMO 2000
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
What is TCC If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us You can use this certificate when getting
health insurance or other health care coverage You must arrange for the other coverage within 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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Family Health Plan Cooperative HMO 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 414 256 0040 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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Family Health Plan Cooperative HMO 2000
NOTES
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Summary of Benefits for Family Health 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 Includes in
care hospital doctor care room and board general nursing care 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 12
Extended care All necessary services for up to 30 days per confinement You pay nothing 12
Mental Conditions All medical necessary inpatient mental health care subject to plan approval
You pay nothing 14
Substance abuse Up to 30 days per year in a substance abuse program You pay nothing 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including
care specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay for
office visits see specific benefit coverage for applicable 10 copay fee for the above Outpatient
services 10
Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions All medically necessary outpatient mental health care subject to plan approval You pay a 10 copayment 14
Substance abuse Up to 20 outpatient visits per year You pay a 10 copayment 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay nothing to the hospital for each emergency room visit and any charges for services that are not
covered by this plan 13 14
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay nothing for formulary drugs All non formulary drugs require a 10 copayment 15
Dental care Accidental injury benefit you pay nothing emergency dental care preventive dental care comprehensive range of restorative orthodontic and other services
You pay nothing for preventive and diagnostic services 50 of charges for all other covered
services 16 17
Vision care One refraction annually You pay a 10 copayment 15
Out of pocket maximum Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for certain dental and prescription benefits only 6
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2000 Rate Information for
Postmasters Benefit 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 Gov't
Enrollment Share Share Share Share Share Share Share Share
Milwaukee area
Self Only WH1 78.73 34.57 170.80 74.90 93.06 20.34 93.26 20.14
Self and Family WH2 175.97 117.89 381.27 255.43 207.74 86.12 201.02 92.84
26 27