Pages 1--24 from FEHB99.pm6.5

FALLON COMMUNITY HEALTH PLAN 2000
A Health Maintenance Organization

For changesin benefits 4
Serving Central and Eastern Massachusetts see page

Enrollment in this Plan is limited see page 21 for requirements

Enrollment Code
JV1 Self only
JV2 Self and family

This plan has been rated
excellent by the NCQA
See the 2000 Guide for more
information on NCQA

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

Authorized for distribution by the
United States Office of Personnel Management
Retir ement and Insurance Ser vice

RI 73 090 1
1 Page 2 3

Fallon Community Health Plan 2000
Table of Contents
Introduction 3

Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 18
Section 8 FEHB facts 19
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits Inside back cover
Premiums Back cover

2 2
2 Page 3 4
Fallon Community Health Plan 2000
Introduction
Fallon Community Health Plan 10 Chestnut Street Worcester MA 01608
This brochure describes the benefits you can receive from Fallon Community Health Plan under its contract CS 1917 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 4 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have

worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences

We refer to Fallon Community Health Plan as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons

easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

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

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

3 3
3 Page 4 5
Fallon Community Health Plan 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 To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care changes office visits

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

that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Your share of the premium will increase by 9.2 for Self Only or 9.1 for Self and Family Plan
The copayment for prescription drugs has changed from 5 per prescription unit or refill for generic and name brand drugs to 5 for generic and 10 for name brand for up to a 30 day supply For the Mail

Order Program the copay has changed from 3 for generic and name brand to 3 for generic and 8 for name brand for up to a 30 day supply

Scalp hair prosthesis wigs are covered for individuals who have suffered hair loss as the result of any treatment for cancer or leukemia Coverage is provided for up to 350 per member per calendar year
when determined to be medically necessary by a Plan doctor and the Plan
Hospice care is covered in full for the first five days in a hospice facility and you must pay all charges thereafter Hospice home visits are covered with a 5 copay per visit

The office visit copay has increased from 5 to 10 per visit

4 4
4 Page 5 6
Fallon Community Health Plan 2000
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 following Massachusetts counties all of Worcester Middlesex Norfolk and Suffolk

as well as parts of Bristol Essex Franklin Hampshire Hampden and Plymouth This includes the following towns in Massachusetts

Abington Dover Leicester Norwell Sudbury
Acton Dracut Leominster Norwood Sutton
Andover Dudley Lexington Oakham Swampscott
Arlington Dunstable Lincoln Oxford Swansea
Ashburnham Duxbury Littleton Palmer Taunton
Ashby East Bridgewater Lowell Paxton Templeton
Ashland East Brookfield Lunenburg Peabody Tewksbury
Athol East Walpole Lynn Pembroke Topsfield
Attleboro Easton Lynnfield Pepperell Townsend
Auburn Essex Malden Petersham Tyngsboro
Avon Everett Manchester Phillipston Upton
Ayer Fall River Mansfield Pinehurst Uxbridge
Barre Fitchburg Marblehead Plainville Village of Nagog
Bedford Foxborough Marlborough Plympton Woods
Bellingham Framingham Marshfield Princeton Wales
Belmont Franklin Maynard Quincy Wakefield
Berkley Freetown Medfield Randolph Walpole
Berlin Gardner Medford Raynham Waltham
Beverly Georgetown Medway Reading War e
Billerica Gloucester Melrose Rehoboth War r en
Blackstone Grafton Mendon Revere Watertown
Bolton Groton Methuen Rockland Waverly
Boston Halifax Middleboro Rockport Wayland
Boxboro Hamilton Middleton Rowley Webster
Boxford Hanover Milford Royalston Wellesley
Boylston Hanscom AFB Millbury Rutland Wenham
Braintree Hanson Millis Salem West Boylston
Bridgewater Hardwick Millville Saugus West Boxford
Brimfield Harvard Milton Scituate West Bridgewater
Brockton Hathorne Monson Seekonk West Brookfield
Brookfield Haverhill Nahant Sharon Westborough
Brookline Hingham Natick Sherborn Westford
Burlington Holbrook Needham Shirley Westminster
Cambridge Holden New Braintree Shrewsbury Weston
Canton Holland Newton Stoughton Westwood
Carlisle Holliston Norfolk Somerset Weymouth
Charlton Hopedale North Andover Somerville Whitman
Chelmsford Hopkinton North Attleboro South Hamilton Wilmington
Chelsea Hubbardston North Billerica South Walpole Winchendon
Clinton Hudson North Brookfield Southborough Winchester
Cohasset Hull North Southbridge Winthrop
Concord Ipswich Chelmsford Spencer Wobur n
Danvers Kingston North Reading Sterling Worcester
Dedham Lakeville Northborough Stoneham Wrentham
Dighton Lancaster Northbridge Stow
Douglas Lawrence Norton Sturbridge

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

5 5
5 Page 6 7
Fallon Community Health Plan 2000
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 For information on this Plan's coverage for students who are outside the Fallon service
area please see page 16 Due to reciprocal arrangements many health maintenance organizations HMOs provide arrangements for emergency and urgent care to Fallon members who are outside the
Fallon service area You may call 1 800 223 0654 for the name and location of the closest HMO in the area 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 You must share the cost of some services This is called either a copayment a set dollar amount or I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you

services receive services except for laboratory and X ray services
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents for your

claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides The Fallon Community Health Plan is a mixed model prepayment plan that offers three provider my health options from which to choose The Fallon Plus option offers a choice of over 252 physicians practicing

care in multi specialty medical centers throughout Central Massachusetts The UMass Group Practice option offers a choice of nearly 350 physicians based primarily at the UMass Medical Center a stateof
the art teaching hospital The Fallon Affiliates option offers a network of over 2,502 independent practitioners practicing in offices throughout Central and Eastern Massachusetts

You are asked to select a provider option for each member of your family at the time of enrollment However you may switch from the Fallon Plus to Fallon Affiliates option and vice versa at any time of
the year the change will become effective on the first of the month following the Plan's receipt of notification Changes in or out of the UMass Group Practice option can only be made on your anniversary
date
Each member of a family may choose a different doctor from separate provider options A member's personal doctor provides routine and emergency care and arranges for specialty care as needed

The Plan provides coverage for urgent and emergency care around the world Within the Plan's service area you must call your doctor for directions before seeking care Of course if the emergency is life
threatening go to the nearest emergency room Outside of the service area you are covered for emergency services obtained at any medical facility but should call for authorization before seeking
follow up care
What do I do if Call us We will help you select a new one my primary care

physician leaves the Plan

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

What do I do if First call our customer service department at 800 868 5200 If you are new to the FEHB Program we I'm in the will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
hospital when your former plan will pay for the hospital stay until I join this
You are discharged not merely moved to an alternative care center or Plan

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

6 6
6 Page 7 8
Fallon Community Health Plan 2000
How do I get Your primary care physician will arrange your referral to a specialist with the following exceptions specialty care annual eye examinations mental health and substance abuse services or a woman may see her Plan

gynecologist for her annual routine examination without a referral from her primary care doctor
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 and will obtain Plan authorization for the additional referrals

What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a if I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with
specialist when us you must receive treatment from a specialist who does Generally we will not pay for you to see a I enroll 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 services from your current specialist until we can make arrangements for you to see someone else
the Plan

But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue a serious illness seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
and my provider provider unless the termination is for cause If you are in the second or third trimester of pregnancy leaves the Plan or you may continue to see your OB GYN until the end of your postpartum care
this Plan leaves the You may also be able to continue seeing your provider if your plan drops out of the FEHB Program 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 Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize medical recommending follow up care Before giving approval we consider if the service is medically necessary
services and if it follows generally accepted medical practice

How do you decide The Plan's Benefits Technology Assessment Committee determines what procedures devices and if a service is services are experimental investigational using FDA guidelines and long term clinical studies Clinical
experimental or studies are used to ensure that the procedure device or service has proven to be more effective over investigational currently accepted procedures devices or services

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
7 7
7 Page 8 9
Fallon Community Health Plan 2000
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request

denial for service

What if I have a Call us at 800 868 5200 and we will expedite our review serious or life
threatening condition and you
haven't responded to my request for
service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefit Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they are
or life threatening not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial time limits denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send Your request must be complete or OPM will return it to you You must send the following information to OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

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

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

review request
What address Send your request for review to Office of Personnel Management Office of Insurance Programs should I send my Contract Division IV P O Box 436 Washington D C 20044

disputed claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision upholds the Plan's your only recourse is to sue
denial 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

8 8
8 Page 9 10
Fallon Community Health Plan 2000
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may

recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure

described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and the Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the review

process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record

Section 5 Benefits
A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but

no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate You pay nothing
for a doctor's house call and for home visits by nurses and health aides
The following services are included
Preventive care including well baby care and periodic checkups
Baseline mammogram for women age 35 40 annual mammogram for women age 40 and older
Routine immunizations and boosters no copay required
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor or certified nurse midwife You pay a 10 office visit copayment for

the first office visit all remaining prenatal office visits are covered in full
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 allergy injections do not require a copay

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney and liver transplants heart lung transplants for patients under age 60 with end stage primary or secondary pulmonary hypertension lung single or double transplants for

patients under age 60 with end stage obstructive or restrictive pulmonary disease 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
testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer Related medical and hospital expenses of the
donor are covered when the recipient is covered by this Plan Services must be provided at a Planaffiliated transplant facility subject to the member's acceptance into the facility's program The
transplant facility makes the final determination on eligibility for transplant coverage
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

Chemotherapy
Radiation therapy and inhalation therapy no copay required
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications

9 9
9 Page 10 11
Fallon Community Health Plan 2000
when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Outpatient dialysis at a Plan designated center or Continuous Ambulatory Peritoneal Dialysis CAPD no copay required
Cardiac rehabilitation
Diagnosis and treatment of infertility is covered Artificial insemination is covered including intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination

IUI Other assisted reproductive technologies ART including gamete intrafallopian transfer intracytoplasmic sperm injection zygote intrafallopian transfer and in vitro fertilization are
covered Donor sperm for male factor infertility is covered Fertility drugs are covered under Prescription Drug Benefits To qualify for coverage the member must be diagnosed as being
infertile by a Plan Fertility Specialist and coverage will be provided as defined under Massachusetts law

Food products which have been modified to be low in protein for individuals diagnosed with phenylketonuria Coverage provided up to 2,500 in each calendar year
Medication visits to monitor evaluate or adjust the prescription medication dosage that is being prescribed for a medical or psychological condition
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 removal of impacted teeth biopsy of oral lesions treatment of fractures and excision of tumors and cysts All other procedures

involving the teeth or 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 and for removal of breast implants due to complications of non cosmetic surgery or autoimmune disease 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 basis for up to two months per condition if significant improvement can be expected within two months
Outpatient short term rehabilitative therapy physical speech and occupational is provided for up to 20 nonconsecutive visits or 60 consecutive days whichever is greater per condition in a calendar
year You pay a 10 copay per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the
member to achieve and maintain self care and improved functioning in other activities of daily living
Orthopedic and prosthetic devices and durable medical equipment such as braces artificial limbs breast prostheses and surgical bras implanted lenses following cataract removal wheelchairs and

hospital beds are provided up to a maximum benefit of 1,500 per member per calendar year
Scalp hair prosthesis wigs are covered for members who have suffered hair loss as a result of any treatment for cancer or leukemia for up to a maximum Plan payment of 350 per member per calendar

year
Chiropractic services are provided for the treatment of acute musculoskeletal conditions The condition treated must be new or an exacerbation of a previous condition Treatment must be provided by a

participating chiropractor and requires a referral by a primary care doctor Coverage is provided for up to 20 office visits You pay a 10 copay for visits 1 10 and a 25 copay for visits 11 20

Early intervention services for children up to age 3 years and 3 months for medically necessary physical speech and occupational therapy nursing care and psychological counseling is covered in
full for up to a 3,200 maximum Plan payment per calendar year and a 9,600 maximum Plan payment per lifetime

10 10
10 Page 11 12
Fallon Community Health Plan 2000
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Orthopedic shoes or other support devices for the feet including foot orthotics
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered

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 Hospital care 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

Maternity and newborn care services Covered services include but are not limited to childbirth nursery charges routine examination hearing screening and medically necessary treatments of
congenital defects birth abnormalities or premature birth 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 However we may pay for a shorter stay if your attending provider after consulting with you discharges you or your newborn earlier 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
Specialized care units such as intensive care or cardiac care units
Blood and blood derivatives
Extended The Plan provides a comprehensive range of benefits for 100 days per calendar year when full time care 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 certified that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less Short term inpatient care is provided for up
to 5 days of continuous inpatient care
You pay nothing for the first 5 days in a hospice facility all charges thereafter
You pay a 10 copay per home visit
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor service

Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need Inpatient dental
for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization
procedures 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
11 11
11 Page 12 13
Fallon Community Health Plan 2000
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 13 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care

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 If you are in an emergency situation please call your personal doctor In extreme emergencies if you within the are unable to contact your doctor contact the local emergency system e g the police department or

service area fire department or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member must notify
the Plan within 24 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been notified in a timely manner

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 a non Plan facility 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

Any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays All charges for emergency services rendered in an emergency room or in a doctor's office to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit waived if admitted or 5 per Fallon urgent care visit
Emergencies Benefits are available for any medically necessary health service that is immediately required because outside the of injury or unforeseen illness

service area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when

medically feasible with any ambulance charges covered in full
Any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

Plan pays All charges for emergency care services rendered in an emergency room or in a doctor's office to the extent the services would have been covered if received from Plan providers
You pay 25 copayment per hospital emergency room visit waived if admitted
What is covered Emergency care at a doctor's office

Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan

12 12
12 Page 13 14
Fallon Community Health Plan 2000
What is not Elective care or non emergency care covered
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If
providers you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions
of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on page 7

Mental Conditions Substance Abuse Benefits
Mental conditions To the extent shown below this Plan provides the following services necessary for the diagnosis and What is covered 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 25 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 per visit copay for each covered visit all charges thereafter

Inpatient care This Plan provides an unlimited number of days in a general hospital and up to 60 days in a psychiatric hospital in each calendar year you pay nothing for first 60 days in a psychiatric hospital all charges
thereafter Services in a day treatment setting may be provided in place of one inpatient day when you agree to the substitution Day treatment is defined as intensive structured treatment for a minimum of

3 hours a day three times a week with no overnight stay
What is not Care for psychiatric conditions which in the professional judgment of Plan doctors are not subject covered to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the medical What is covered non psychiatric aspects of substance abuse including alcoholism and drug addition the same as for
any other illness or condition
Outpatient care All necessary outpatient visits to Plan providers for treatment provided you pay a 10 copay for each visit

Inpatient care All necessary inpatient substance abuse rehabilitation programs in an alcohol detoxification or rehabilitation center approved by the Plan are covered you pay nothing Rehabilitation services in a daytreatment
setting may be provided in place of one inpatient day when you agree to the substitution Day treatment is defined as intensive structured treatment for a minimum of 3 hours a day three times
a week
What is not Treatment not authorized by a Plan doctor covered

13 13
13 Page 14 15
Fallon Community Health Plan 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor on an authorized visit and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply you pay a 5 copay for generic or a 10 copay

for name brand per prescription unit or refill If the price of the prescription is less than 5 the normal copay amount your copay is the lower amount You are entitled to a discount of 2 for each 30 day
supply of covered prescription medication refill s obtained through the Fallon Clinic Pharmacy or affiliated pharmacy mail order program Services are provided through the pharmacy network designated
by your health care option For additional information about this program you may call our Member Services Department at 1 800 868 5200

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary The drug formulary is developed and maintained by the Fallon Drug Evaluation Committee under the
direction of the Pharmacy and Therapeutics Committee Non formulary drugs will be covered when prescribed by a Plan doctor and approved by the Plan It is the prescribing doctor's responsibility to
obtain authorization for non formulary drugs before they are dispensed
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin
Disposable needles and syringes needed for injecting covered prescribed medication including insulin

Allergy serum
Oral contraceptive drugs
Injectable contraceptive drugs Depo Provera you pay a 30 copay per 3 month supply when dispensed by a pharmacy No copay applies if supplied by your physician

Devices used for contraception intra uterine device or diaphragm This includes the fitting and provision of the device by a Plan physician You pay nothing for the device and a 10 copay for the
office visit
Blood glucose test strips for insulin dependent diabetics
Fertility drugs
Emergency prescription medication up to a 14 day supply provided out of the service area as part of an approved emergency medical treatment

Limited benefit Implanted time release medication such as Norplant For Norplant you pay a one time copay of 400 per implantation procedure For other internally implanted time release medication you pay
200 for implantation There will be no refund of any portion of these copays if the implanted timerelease medication is removed before the end of its expected life

Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available covered

Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased with or without a prescription
Medical supplies such as dressings and antiseptics
Diabetic supplies except for needles and syringes and blood glucose test strips for non insulin dependent diabetics

Drugs for cosmetic purposes
Drugs to enhance athletic performance
Nicotine patches gum or other smoking cessation products

14 14
14 Page 15 16
Fallon Community Health Plan 2000
Other Benefits
Dental Care Preventive dental care services are covered services are available twice per calendar year you pay a What is covered
10 copay for the office visit and additional copayments for minor restorative care services as follows

ADA Code Description Copayment

110 Initial oral examination 10
120 Periodic oral examination 10
130 Emergency oral examination 10
140 Ltd oral evaluation problem focused 10
150 Comprehensive oral evaluation 10
220 Intraoral periapical first film 10
230 Intraoral periapical each additional film 10
240 Intraoral occlusal film 10
270 Bitewing single film 10
272 Bitewings two films 10
273 Bitewings three films 10
274 Bitewings four films 10
460 Pulp vitality tests 10
470 Diagnostic casts 10
Preventive Cleanings
1110 Prophylaxis adult every 6 months 10
1120 Prophylaxis child every 6 months 10
1201 Top application fluoride includes prophylaxis child age 16 10
1203 Top application fluoride excludes prophylaxis child age 16 10
1205 Top application fluoride includes prophylaxis adult age 16 and over 10
1998 Bundled diagnostic preventive services Dependent child 10
1999 Bundled diagnostic preventive services Adult 10
Minor Restorative Fillings
2110 Amalgam one surface primary 12
2120 Amalgam two surfaces primary 16
2130 Amalgam three surfaces primary 20
2131 Amalgam four or more surfaces primary 25
2140 Amalgam one surface permanent 14
2150 Amalgam two surfaces permanent 18
2160 Amalgam three surfaces permanent 20
2161 Amalgam four or more surfaces permanent 25
2330 Resin one surface anterior 17
2331 Resin two surfaces anterior 20
2332 Resin three surfaces anterior 25
2335 Resin three surfaces or involving incisal angle anterior 30

15 15
15 Page 16 17
Fallon Community Health Plan 2000
What is not Dental services not shown as covered covered

Vision care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the What is covered eye this Plan provides annual eye refractions including written lens prescriptions for eyeglasses from
Plan providers You pay a 10 copay per visit
What is not Eye exercises covered

Corrective glasses and frames or contact lenses
Eye examinations for contact lenses including the fitting of the lenses

Out of Area Student Students attending school outside the Plan service area are covered for additional benefits for services Coverage received out of area if authorized in advance by the Plan up to age 22 or marriage whichever occurs
first
What is covered Outpatient services to treat the abuse of or addiction to alcohol or drugs are covered up to 20 office visits in each calendar year You pay a 10 copay per visit

Non elective inpatient services if the Plan is notified within 48 hours of admission You pay nothing

Non routine office visits You pay a 10 copay per visit
Diagnostic lab and X ray services connected with non routine office visits You pay nothing
Outpatient services to diagnose and or treat mental conditions covered up to 25 office visits in each calendar year combined with any in area visits You pay 10 per visit

Short term rehabilitation services including physical occupational and speech therapy covered up to 20 outpatient office visits in each calendar year combined with any in area visits You pay a
10 copay per visit
What is not Routine physicals gynecological exams vision screening and hearing screening covered
Maternity care or delivery
Outpatient surgical procedures that could have been delayed until return to the Plan service area
Durable medical equipment e g wheelchairs including maintenance or replacement
Preventive dental care
Second opinion
Home health care
Non emergency prescription drugs
Routine preventive care
Weight Watchers Program

What is covered One twelve consecutive week membership in each calendar year You pay nothing

What is not More than one membership per member in each calendar year covered
Food products

Weight Watchers is a registered trademark of Weight Watchers International Inc

16 16
16 Page 17 18
Fallon Community Health Plan 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members who are members of this Plan The cost of the benefits described

on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedures

Dental services discounts The Plan has arranged for discounts for non covered dental services If you would like a list of the services and the fee schedule contact the Plan at 1 800 868 5200
Peace Of Mind Program If you are a Fallon Plus or Fallon Affiliates member and you want to receive care from a Boston based physician rather than a Plan physician you may do so under the Peace of Mind Program The physician
that you choose must be on staff at either Massachusetts General Hospital Brigham and Women's Hospital Children's Hospital Boston or Dana Farber Cancer Institute

Whenever you need specialty care you must first obtain a referral from your personal physician to see a Plan specialist If after seeing the Plan specialist you decide you want to see a physician at one of the above hospitals you may elect to
use the Peace of Mind Program The referral must be arranged by either your Plan specialist or personal physician You may see the Boston physician for a consultation and may continue on for treatment with that specialist or you may
return to your Fallon specialist for care
You may elect to use Peace of Mind for all specialty care except psychiatry substance abuse optometry or chiropractic services You may not use the Peace of Mind Program for any primary care including internal medicine family practice

dental pediatrics or routine obstetrics
All care authorized under the Peace of Mind Program must be for covered services as described in this brochure
Eyewear discounts Fallon has arranged for a 25 discount on the first pair of eyeglass frames and prescription lenses purchased from participating Fallon optical providers When you purchase multiple pairs of prescription eyeglasses at the

same time you receive a 35 discount on the additional pairs In addition you receive a 10 discount on all complete contact lens packages purchased at participating Fallon optical providers This discount does not apply to individual
lenses the evaluation fitting of contact lenses or others items services which are not specifically listed above
Hearing aid discounts The Plan has arranged for discounts of 20 to 30 off the regular price of hearing aids and assistive listening devices Contact the Plan at 1 800 868 5200 for a complete list of providers

Fitness center discounts Members of the Plan are entitled to discounted memberships at several area health clubs Discounts vary from club to club For information on participating health clubs and the associated discounts call the
Fallon Customer Service Department at 1 800 868 5200
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 18 annuitants and former spouses with FEHB coverage and Medicare Part B may elect

to drop their FEHB coverage and enroll in a Medicare prepaid plan when one is available in their area They may then later reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may
join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you have to pay Contact your
retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan Contact us at 1 800 868 5200 for information on the Medicare prepaid plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan call 1 800 868 5200 for information on the benefits available under the
Medicare HMO

Benefits on this page are not part of the FEHB contract

17 17
17 Page 18 19
Fallon Community Health Plan 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose

or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self referred services

Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act

of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may 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 For information on the Medicare Choice plan offered
by this Plan see page 17
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance You must tell us if you or a family member has double coverage You must also send us documents

coverage 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

18 18
18 Page 19 20
Fallon Community Health Plan 2000
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our control them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the

primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must provide

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for

Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find out

about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 868 5200 or write to Fallon Community Health Plan 10 Chestnut Street Worcester MA 01608 You may also contact us by fax at 508 831 0912 or

visit our website at www fchp org
Where do I get information about enrolling in the FEHB Program
Your employing or retirement office can answer your questions and give you a Guide to Federal 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

19 19
19 Page 20 21
Fallon Community Health Plan 2000
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants

premiums effective premiums begin January 1

What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled when 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for me retirement office authorizes coverage for Under certain circumstances you may also get coverage for and my family 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 We will keep your medical and claims information confidential Only the following will have access to it and claims records
OPM this Plan and subcontractors when they administer this contract confidential

This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and subrogating claims

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

OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an

Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible

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

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

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

20 20
20 Page 21 22
Fallon Community Health Plan 2000
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the

spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
Key points employing or retirement office about TCC
You can pick a new plan

If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I If you leave Federal service your employing office will notify you of your right to enroll under TCC enroll in 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 You may convert to an individual policy if to individual
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not coverage 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

21 21
21 Page 22 23
Fallon Community Health Plan 2000
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your coverage

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

Health Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for
health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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 800 868 5200 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

22 22
22 Page 23 24
Fallon Community Health Plan 2000
Summary of Benefits for Fallon Community 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 OR OTHER AUTHORIZED PROVIDERS E G DENTISTS PHYSICIAN ASSISTANTS OR NURSE PRACTITIONERS

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services with no dollar or day
limit Includes in hospital doctor care room and board general nursing care private
room and private nursing care if medically necessary diagnostic tests drugs and
medical supplies use of operating room intensive care and complete maternity
care You pay nothing 11

Extended care All necessary services for up to 100 days in a calendar year
You pay nothing 11

Mental Diagnosis and treatment of acute psychiatric conditions for an unlimited number
conditions of days in a general hospital and up to 60 days of inpatient care in a psychiatric
hospital per calendar year You pay nothing 13

Substance abuse All necessary Plan approved substance abuse rehabilitation programs
You pay nothing 13

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic

checkups and routine immunizations limited chiropractic services laboratory tests
and X rays complete maternity care first prenatal visit only You pay a 10 copay
per office visit nothing per home visit 9

Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions Up to 25 outpatient visits per year You pay a 10 copay per visit 13
Substance abuse All necessary outpatient visits per year You pay a 10 copay per visit 13
Emergency care Actual charges for services and supplies required because of a medical emergency You pay 25 copayment when services are received in a hospital emergency

room 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay generic 10 copay name brand per prescription unit or refill

or the cost of the prescription whichever is less Emergency prescription medication
provided out of area as part of an emergency medical treatment You pay a 5 copay
generic 10 copay brand name per 14 day supply Prescription medication
obtained through the mail order program of your health care option You receive a
2 discount off your regular copay per 30 day supply 14

Dental care Preventive dental care services twice per calendar year you pay a 10 copay per
visit Fillings you pay a 12 30 copay per filling Out of area emergency dental care
services loose filling tooth ache limited to 50 per incident you pay 10 copay
per visit 15

Vision care One visit for eye refractions annually You pay a 10 copay per visit 16
Out of pocket maximum Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments that are required for a few benefits

23 23
23 Page 24
Fallon Community Health Plan 2000
2000 Rate Information for Fallon Community Health 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 Share Share Share

Central Eastern Massachusetts
Self Only JV1 65.55 21.85 142.03 47.34 77.57 9.83 77.57 9.83
Self and Family JV2 168.92 56.31 366.00 122.00 199.89 25.34 199.89 25.34

24 24

Page Navigation Panel