Pages 1--24 from FEHB2000

A Health Maintenance Organization
changes For
benefits 4 in
see page

Serving Washington DC Maryland Northern Virginia Roanoke Richmond and Tidewater area
Enrollment in this Plan is limited see page 4 for requirements
Enrollment Code
JP1 Self Only
JP2 Self and Family Commendable accreditation from

the National Committee for Quality
Assurance NCQA See the
2000 Guide for more information
on NCQA

Visit the OPM website at http www opm gov insure
ajd
this Plan's website at http www mamsi com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and insurance service RI 73 100 1
1 Page 2 3
MD Individual Practice Association Inc 2000
Table of Contents Page
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 4 6
Section 4 What to do if we deny your claim or request for service 6 8
Section 5 Benefits 8 15
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16 17
Section 8 FEHB facts 17 20
Department of Defense FEHB Demonstration 21
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits 23
Premiums Back Cover 2
2 Page 3 4
MD Indivudal Practice Association Inc 2000
Introduction
M D Individual Practice Association Inc 4 Taft Court Rockville Maryland 20850
This brochure describes the benefits you receive from M D IPAunder its contract CS1935 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 M D IPA 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
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MD Individual Practice Association Inc 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 wellbaby
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 chan ge
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 premiums 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 Plan Your share of the non postal premium will increase by 12.3 for Self Only or 18.9 for Self and Family

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 Washington D C all of Maryland the Virginia cities of Alexandria Charlottesville
Chesapeake Clifton Forge Colonial Heights Covington Emporia Fairfax Falls Church Franklin
Fredericksburg Hampton Hopewell Manassas Manassas Park Newport News Norfolk Petersburg
Poquoson Portsmouth Radford Richmond Roanoke Salem Suffolk Virginia Beach and Williamsburg
as well as the Virginia Counties of Accomack Albemarle Alleghany Amelia Arlington Augusta Bath
Bedford Bland Botetourt Buckingham Caroline Charles City Chesterfield Clarke Craig Dinwiddie
Fairfax Fauquier Floyd Franklin Giles Goochland Greensville Hanover Henrico Isle of Wight
James City King George King William King and Queen Loudoun Louisa Montgomery Nelson New
Kent Northampton Nottoway Orange Page Patrick Powhatan Prince William Rappahannock
Roanoke Southampton Spotsylvania Stafford Sussex Westmoreland and York

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 4
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MD Indivudal Practice Association Inc 2000
What is this Plan's If you or a covered family member move outside of our service area you can enroll in another plan If service area your dependents live out of the area for example if your child goes to college in another state you
continued should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open Season to change plans
Contact your employing or retirement office
How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount or for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive
services except for emergency care
After you pay 1,800 in copayments or coinsurance for one family member or 4,800 per family you
do not have to make any further payments for certain services provided or arranged by the Plan for the
rest of the year This is called a catastrophic limit However copayments or coinsurance for your
prescription drugs dental services eyeglasses or contact lenses do not count toward these limits and
you must continue to make these payments

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits

Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a provider claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as
soon as possible You must submit claims by December 31 of the year after the year you received the
service Either OPM or we can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time

Who provides my When you join M D IPA you receive care through a private doctor's office If your present doctor is an health care M D IPA participant you may continue with your current doctor patient relationship Otherwise you
must select a doctor from the Plan's list and establish a doctor patient relationship with the M D IPA
doctor of your choice Each member of the family can choose his or her own primary care doctor or
you can select one for everybody For example you might select an internist for an adult an
obstetrician gynecologist for a woman and a pediatrician for the children or a general family
practitioner for all members of the family

The first and most important decision you must make is the selection of a primary care doctor The
decision is important since it is through this doctor that you will obtain all other health services
particularly those of specialists

What do I do if my Call us We will help you select a new one
primary care
physician leaves the
Plan

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

What do I do if I'm First call our customer service department at 301 360 8080 or 1 800 251 0956 If you are new to the in the hospital when FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and
I join this 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 92 nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist Your primary care doctor is
specialty care responsible for obtaining any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization Services of other providers are covered only when you have 5
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MD Individual Practice Association Inc 2000
How do I get been referred by your primary care physician with the following exceptions female members may go specialty care directly to participating obstetricians or gynecologists or a participating Certified Nurse Midwife
continued without a referral from the primary care physician for obstetrical and gynecological care Obstetrical and gynecological services include routine care and follow up services as well as medically necessary
services and dental care and eye refractions are available from Plan providers without a referral
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan

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

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

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
my provider leaves provider unless the termination is for cause If you are in the second or third trimester of pregnancy the Plan or this Plan you may continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
condition or are in your second or third trimester Your new plan will pay for or provide your care for
up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in
your second or third trimester your new plan will pay for the OB GYN care you receive from your
current provider until the end of your postpartum care

How do you 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
services necessary and if it follows generally accepted medical practice

How do you decide We evaluate investigational experimental treatments on a case by case basis as well as on a continual if a service is basis as new and emerging treatments become available We use a variety of resources to assist the
experimental or Medical Director in deciding if a service is experimental or investigational including specific database investigational searches of the National Institutes of Health NIH and the Health Care Financing Administration
HCFA review by independent medical experts and an independent technology assessment firm

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 6
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MD Indivudal Practice Association Inc 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 will determine if we correctly applied the terms of our contract when we denied your claim or request
a denial for service

What if I have a Call us at 301 360 8080 or 1 800 251 0956 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 OPM
denied my request so that they can give your claim expedited treatment too Alternatively you can call OPM's health
for care and my benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious life threatening
condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as
or life threatening soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
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 to Your request must be complete or OPM will return it to you You must send the following information 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 letter 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 address Send your request for review to Office of Personnel Management Office of Insurance Programs
should I send my Contracts 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 7
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MD Individual Practice Association Inc 2000
What if OPM If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
upholds the Plan's year after the year in which you receive the disputed services or supplies
denial
continued

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

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

Your records and Chapter 90 of title 5 United States Code allows OPM to use the information it collects from you and us
the Privacy Act 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
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 copay per primary care
office visit a 15 copay per referral visit and nothing for obstetrical gynecological services performed
by a participating Certified Nurse Midwife Within the Service Area house calls will be provided if in
the judgment of the Plan doctor such care is necessary and appropriate you pay a 10 copay for a
primary care physician's house call a 15 copay for a referral doctor's house call nothing for home
visits by nurses health aides or therapists

The following services are included
Preventive care including well baby care and periodic check ups Diagnostic prostate examinations for men age 40 through age 75

Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years
for women age 50 through 64 one mammogram every year and for women age 65 and above
one mammogram every two years In addition to routine screening mammograms are covered
when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters Consultations by specialists

Diagnostic procedures such as laboratory tests and X rays Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor Office visit copays are waived for obstetrical care after the
first maternity care visit All office visit copayments are waived if services are performed by a
participating Certified Nurse Midwife The mother at her option may remain in the hospital up
to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will
be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of
the newborn child during the covered portion of the mother's hospital confinement for
maternity will be covered under either a Self Only and 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 or Family enrollment
Voluntary sterilization and family planning services including Norplant implantations injectable contraceptive drugs and IUD fittings

Chlamydia screening test if you are a a sexually active woman under the age of 20 years b a woman who is at least 20 years old and has multiple risk factors or c a man who has multiple
risk factors 8
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MD Indivudal Practice Association Inc 2000
What is covered Diagnosis and treatment of diseases of the eye
continued Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints Cornea heart heart lung single and double lung pancreas kidney and liver transplants

allogeneic donor bone marrow transplants autologous bone marrow transplants autologous
stem cell and peripheral stem cell support for the following conditions acute lymphocytic or
non lymphocytic leukemia advanced Hodgkin's lymphoma and 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
Blood products derivatives and components artificial blood products biological serum and the administration of the agent Blood products include any product created from a component of

blood such as but not limited to plasma packed red blood cells platelets albumin Factor VIII
immunoglobulin and prolastin
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and
excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding
the teeth are not covered including any dental care involved in treatment of temporomandibular joint
TMJ pain dysfunction syndrome The following treatments for cleft lip and cleft palate are covered
when referred by a primary care physician and approved by the Plan inpatient and outpatient
orthodontics oral surgery and otologic audiological speech language services

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending
physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech occupational chiropractic and acupuncture is
provided on an inpatient or outpatient basis for up to two months or up to 60 visits whichever is more
per condition if significant improvement can be expected within two months you pay a 15 copay per
outpatient visit for referral care a 25 copay per visit if treatment is provided in the outpatient
department of a hospital Speech therapy is limited to treatment of certain speech impairments of
organic origin Occupational therapy is limited to services that assist the member to achieve and
maintain self care and improved functioning in other activities of daily living

Diagnosis and treatment of infertility is covered you pay a 10 copay for primary care services
For services of other Plan providers you pay 50 of charges The following types of artificial
insemination are covered intravaginal insemination IVI intracervical insemination ICI and
intrauterine insemination IUI you pay 50 of charges for all related expenses cost of donor sperm is
not covered Except for Clomid fertility drugs are 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 on an inpatient or outpatient basis for up to two months or up to 60 visits whichever is more 9
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MD Individual Practice Association Inc 2000
Limited Benefits
continued per condition if significant improvement can be expected within two months you pay a 15 copay per outpatient visit for referral care a 25 copay per visit if treatment is provided in the outpatient

department of a hospital
Orthopedic devices such as braces prosthetic devices such as artificial limbs external lenses following cataract removal breast prostheses and surgical bras including their replacement and
durable medical equipment such as wheelchairs and hospital beds are covered You pay 50 of charges If any of these items will eliminate the need for a hospital admission then you pay nothing

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 Homemaker services
Foot orthotics Whole blood and concentrated red blood cells not replaced by the member
Routine circumcision Long term rehabilitative therapy
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 for inpatient care a 25 copay per visit
for services provided in the outpatient department of a hospital or outpatient surgery center All
necessary services are covered including

Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended Care The Plan provides a comprehensive range of benefits for up to 60 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are
covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled

nursing facility when prescribed by a Plan doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are provided under
the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life
expectancy of approximately six months or less

Ambulance Service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor

Limited Benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need
procedures for hospitalization for reasons totally unrelated to the dental procedures the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization

would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a
condition In addition general anesthesia and associated facility charges in conjunction with dental care
are covered for individuals who meet certain criteria as determined by a Plan doctor Services must be
preauthorized by the Plan 10
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MD Indivudal Practice Association Inc 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 12 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Whole blood and concentrated red blood cells not replaced by the member

Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Emergency Benefits

What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you as a emergency prudent layperson believe endangers your life or could result in serious injury or disability and
requires immediate medical or surgical care Some problems are emergencies because if not treated
promptly they might become more serious examples include deep cuts and broken bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes poisonings
gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies what they all have in common is the need for quick action

Emergencies within If you are in an emergency situation please call your primary care physician In extreme emergencies if the Service Area you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel
that you are a Plan member so they can notify the Plan You or a family member should notify the Plan
within 48 hours If is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If
you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan
hospital you will be transferred when medically feasible with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching
a Plan provider would result in death disability or significant jeopardy to your condition To be covered
by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or
provided by Plan providers

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers

You pay 40 per emergency room visit 20 per urgent care center visit for emergency care services that are covered benefits of the Plan If the emergency results in admission to a hospital the copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because of the Service Area 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 followup
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 40 per emergency room visit 20 per urgent care center visit for emergency care services that are covered benefits of the Plan If the emergency results in admission to a hospital the copay is waived 11
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MD Individual Practice Association Inc 2000
What is covered Emergency care at a doctor's office or urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service if 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 fore
seen 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 upon non Plan providers 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 reason for the denial and the provisions
of the contract on which denial was based If you disagree with the Plan's decision you may request
reconsideration in accordance with the disputed claims procedure described on pages 7 and 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 Unlimited outpatient visits You pay 20 of charges per visit for visits 1 through 5 35 of charges for visits 6 through 30 and 50 of charges for visit 31 and thereafter per calendar year
Inpatient care Diagnosis and treatment of acute psychiatric conditions without dollar or day limit
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a shortterm
psychiatric condition

Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any
other illness or condition Services for the psychiatric aspects are provided in conjunction with the
Mental conditions benefit shown above Outpatient visits to Plan providers for treatment are covered as
well as inpatient services necessary for diagnosis and treatment The Mental conditions benefit visit day
limitations and coinsurance copays apply to any covered substance abuse case

What is not covered Treatment that is not authorized by a Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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MD Indivudal Practice Association Inc 2000
Prescription Drugs

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 In lieu of name brand drugs generic drugs will be dispensed when
substitution is permissible You pay a 5 copay for generic drugs a 10 copay for name brand drugs in
the Plan's formulary or a 25 copay for name brand drugs not in the Plan's formulary You pay 20 up
to 50 for injectable drugs except for insulin

Members may obtain up to a consecutive 90 day supply of maintenance prescription medications with
one copay for each month's supply through the Plan's HomeCall HomeRx program or at a retail
pharmacy You pay a 5 copay for generic drugs a 10 copay for name brand drugs in the Plan's
formulary or a 25 copay for name brand drugs not in the Plan's formulary per one month supply You
pay 20 up to 50 for injectable drugs except for insulin Maintenance medications are those drugs
used on a continual basis for the treatment of chronic health conditions such as high blood pressure
ulcers or diabetes To participate in the HomeRx program call the Plan at 301 360 8080 or
1 800 251 0956

When obtaining prescription drugs from a retail pharmacy or by mail order if generic substitution is
permissible i e a generic drug is available and the prescribing doctor does not require the use of a
name brand drug but you request the name brand drug you pay the name brand copay 10 for name
brand drugs in the Plan's formulary or 25 for name brand drugs not in the Plan's formulary plus the
cost difference between the generic and the name brand drug

The Plan covers the cost of drugs and devices used while participating in clinical trials approved by the
National Institutes of Health NIH an NIH cooperative group or center the Food and Drug
Administration FDA or the Department of Veterans Affairs for treatment of a life threatening
condition and early detection and treatment of cancer Experimental and investigational drugs and
devices not approved for any use by the FDA are not covered Experimental and investigational drugs
and devices that have FDA approval are covered

Covered medications and accessories include
Drugs for which a prescription is required by Federal law Oral contraceptive drugs up to three cycles of oral contraceptive drugs may be obtained at one

time with a copay charge applied to each cycle contraceptive devices
Insulin with a copay charge applied to each vial Diabetic supplies including insulin syringes needles glucose test tablets and test tape

Benedict's solution or equivalent and acetone test tablets
Disposable needles and syringes needed to inject covered prescribed medication

Intravenous fluids and medications for home use implantable drugs such as Norplant some injectable
drugs and diabetic self management training and education services are covered under Medical and
Surgical Benefits

Limited Benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dosage limits You pay a 5 copay for generic drugs a 10 copay for name brand drugs in the Plan's formulary or a 25 copay for name
brand drugs not in the Plan's formulary up to the dosage limits and all charges above that

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 prescription
Medical supplies such as dressings and antiseptics Fertility drugs except for Clomiphene citrate Clomid
Smoking cessation drugs and medication including nicotine patches Drugs for cosmetic purposes

Drugs to enhance athletic performance 13
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MD Individual Practice Association Inc 2000
Other Benefits
Dental care This Plan provides the following comprehensive program of dental coverage through participating dentists

What is covered The following list summarizes the fees for dental services provided by a participating PLAN GENERAL DENTIST ONLY All services rendered by a Plan dental specialist are provided at a 25 reduction of
costs the copays listed below do not reflect the payment to a Plan dental specialist There is no need to
obtain a referral from your primary care physician to obtain the following dental care services For a
complete fee schedule and list of participating dentists please contact M D IPA at 301 360 8080 or 1
800 251 0956

The Plan provides benefits based on a discount fee from the usual customary and reasonable UCR
fees charged by Plan general dentists Fees for care from dental specialists are usually higher

What you pay for the following is approximately 50 below UCR fees
Plan provides You Pay Plan provides You Pay
Preventive Services Restorative Services
Office visit 14 18 Silver fillings amalgam 32 75
Diagnostic and Prophylaxis cleaning
limited to 2 per member per year Diagnostic Services 10
includes oral cancer exam oral hygiene Radiologic Services single X rays
instruction topical fluoride treatment 20 24 Full mouth X rays 40

What you pay for the following is 25 below UCR fees
Plan provides You pay Plan provides You Pay
Restorative Services Oral Surgery Services
Composite or plastic fillings 77 Simple removal of a single tooth 40 60
Inlay onlay noble metal 192 240 Surgical extraction 76 210
Crowns full cast or porcelain metal or
stainless steel 60 430 Prosthetic Services
Recement crown or inlay 40 Dentures complete upper or lower 450
Partial dentures 475 480
Denture relines partial or complete 84 144
Periodontal Services denture
Periodontal Maintenance Procedure 34 Plus lab costs
Gingivectomy or gingivoplasty Some denture repairs 17 22
per quadrant 186 Plus lab costs
Root scaling planing per quadrant 70
Orthodontic and
Other Specialty Services
Endodontic Services
Root canals excluding final restoration 295 441 Any treatment received from Plan 25 below usual
Pulpotomy excluding restoration 32 Participating dental specialists and customary fees

There is a surcharge for any restoration made with gold precious noble metal based on the market value
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The benefit need for these services must result from an accidental injury occurring while the member is covered
under the Plan Services must be received within 72 hours of the injury You pay a 10 copay per
primary care visit a 15 copay per referral visit a 40 copay per emergency room visit

What is not covered Other dental services not shown as covered
Vision Care What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the
eye annual eye refractions to provide a written lens prescription may be obtained from Plan providers
You pay a 25 copay per visit

What is not covered Corrective lenses or frames
Eye exercises 14
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MD Indivudal Practice Association Inc 2000
Non FEHB benefits available to Plan members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These

benefits are not subject to the FEHB disputed claims procedure

OPTICAL SERVICES Discounts are available on eyewear and related services at participating optical centers listed in the Plan's Provider Directory
Members need only show their member identification card at a participating center to receive the following savings
Eyeglasses including single multifocal or designer other optical services Member pays 80 85 of the usual and customary fees

Contact lenses may also be available at a discount Please contact Member Services for the names of participating providers

MLH INDEMNITY DENTAL PLAN
Type I Procedures Preventive Coverage
Initial and Periodic Oral Exams Cleanings Prophylaxis

Space Maintainers 100 of Usual and Customary X Rays no deductible
Fluoride Application under age 16 Sealants under age 16

Type II Procedures Basic Simple Extractions
Recementation of Crowns Fillings Amalgam and Synthetic Restorations 80 of Usual and Customary
Full and Partial Denture Repair after deductible Repair of Crowns and Bridges

Type III Procedures Major
Surgical Extractions Root Canals Endodontics
Gum Disease Periodontics Alveolar or Gingival reconstructions
Crowns 50 of Usual and Customary Dentures after deductible
Pontics Bridges
Inlays
Type IV Orthodontia No Coverage
Contract Year Deductible 50 per person 150 per family Contract Year Maximum Benefit

For Type I II and III Procedures 1,000 per person

The MLH Indemnity Dental Plan is provided through administered and billed by MAMSI Life and Health Insurance Company This
is a summary of benefits only please refer to the indemnity policy for complete details Services can be provided by any licensed
dentist Usual and customary amounts are determined by the Plan Send Claims to MAMSI Life and Health Insurance Company
Claims Division P O Box 940 Frederick MD 21705 For more information call MLH Member Services at 1 800 224 8535 or
1 301 360 8035

Benefits on this page are not part of the FEHB Contract 15
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MD Individual Practice Association Inc 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 obstetrical and gynecological care for female members including routine and follow up services as well as
medically necessary services and dental care and eye refractions
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 endanged if the fetus

were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and

Expenses you incurred while you were not enrolled in this Plan

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

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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833

Other group When anyone has coverage with us and with another group health plan it is called double coverage You
insurance coverage 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 16
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MD Indivudal Practice Association Inc 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 cost
injuries 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 any 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

If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it malpractice claim 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 required that all FEHB plans comply with the Patient's Bill of Rights which gives you the right to information about information about your health plan its networks providers and facilities You can also find out about
your HMO 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 the Plan's Member Services Office at 301 360 8080 or at
1 800 251 0956 TTY 301 360 8111 or 1 800 553 7109 or write to P O Box 933 Frederick
Maryland 21705 You may also contact us by fax at 301 360 8907 or visit our website at
www mamsi com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about
FEHB Program When you may change your enrollment
How you can cover your family members What happens when you transfer to another Federal agency go on leave without pay enter

military service or retire
When your enrollment ends and The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office 17
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MD Individual Practice Association Inc 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 When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in
I retire 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 a
and my family 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
enrollent begin on the first day of the pay period in which the child is born or becomes an eligible family
member

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

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

Are my medical and We will keep your medical and claims information confidential Only the following will have access to
claims records it
confidential
OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of Worker's

Compensation Programs OWCP when coordinating benefit payment 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 deductible under my old plan
Your old plan's deductible continues until our coverage begins

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled 18
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MD Indivudal Practice Association Inc 2000
When you lose benefits What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in
this Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's

employing or retirement office to get more information about your coverage choices

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

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I 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 19
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MD Individual Practice Association Inc 2000
How can I You may convert to an individual policy if
convert to
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or You are not eligible for coverage under TCC or the spouse equity law

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

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

How can I If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
get a Certificate indicates how long you have been enrolled with us You can use this certificate when getting health
of Group insurance or other health care coverage You must arrange for the other coverage within 63 days of
Health Plan leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for
Coverage 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 20
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MD Indivudal Practice Association Inc 2000
Department of Defense FEHB Demonstration Project

What is the 1 The National Defense Authorization Act for 1999 Public Law 105 261 established the DoD FEHBP
Department of Demonstration Project It allows some active and retired uniformed service members and their
Defense DoD and dependents to enroll in the FEHB Program The demonstration will last for three years beginning with
FEHB Program the 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000
Demonstration DoD and OPM have set up some special procedures to successfully implement the Demonstration
Project Project noted below Otherwise the provisions described in this brochure apply

Who is Eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare You are a dependent of an active or retired uniformed service member and are eligible for
Medicare
You are a qualified former spouse of an active or retired uniformed service member and you have not remarried or

You are a survivor dependent of a deceased active or retired uniformed service member and You live in one of the eight geographic demonstration areas

2 If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program
you are not eligible to enroll under the DoD FEHBP Demonstration Project

Where are the Dover AFB DE
demonstration Commonwealth of Puerto Rico
areas Fort Knox KY
Greensboro Winston Salem High Point NC Dallas TX

Humboldt County CA area Naval Hospital Camp Pendleton CA
New Orleans LA
When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information
Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff will
verify your eligibility and provide you with FEHB Program information 21
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MD Individual Practice Association Inc 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 301 360 8080 or 1 800 251 0956 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
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MD Indivudal Practice Association Inc 2000
Summary of Benefits for M D IPA 2000

Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and
exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to
enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes
appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Care Includes in hospital doctor care room and board general nursing care private

room and private nursing care if medically necessary diagnostic tests drugs and
medical supplies use of operating room intensive care and complete maternity
care You pay nothing for inpatient care a 25 copay for services in an outpatient
department of a hospital or outpatient surgery center 10

Extended All necessary services for up to 60 days per year You pay nothing 10 care

Mental Diagnosis and treatment of acute psychiatric conditions without dollar or 12 conditions day limit
Substance Covered under Mental Conditions 12
Abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or Care injury including specialist's care preventive care including well baby care
periodice check ups and routine immunizations laboratory tests and X rays
complete maternity care You pay a 10 copay per primary care office visit of
house call a 15 copay per referral care office visit or house call 8 9

Home health All necessary visits by nurses and home health aides You pay nothing 8 care

Mental Unlimited outpatient visits You pay 20 of charges per visit for visits 1 through conditions 5 35 of charges for visits 6 through 30 and 50 of charges for visit 31 and
thereafter per calendar year 12
Substance Covered under Mental conditions 12 13 abuse

Emergency Reasonable charges for services and supplies required because of a medical Care emergency You pay a 40 copay to the hospital for each emergency room visit and any charges
for services that are not covered by this Plan 11 12
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 drugs copay for generic drugs 10 copay for name brand drugs in the Plan's formulary or a

25 copay for name brand drugs not in the Plan's formulary per prescription or refill
Up to a 90 day supply of maintenance drugs is available from a retail pharmacy or by
mail order you pay a 5 copay for generic drugs in the Plan's formulary or a 25

Dental Care Accidental injury benefit preventive dental care comprehensive range of services You pay variable copays 14
Vision care One refraction annually You pay a 25 copay per visit 14 Out of pocket maximum Copayments are required for a few benefits however after your out of pocket
expenses reach a maximum of 1,800 per Self Only or 4,800 per Self and Family
enrollment per calendar year covered benefits will be provided at 100 This
copay maximum does not include prescription drugs dental care eyeglasses or
contact lenses 5 23
23 Page 24
MD Individual Practice Association Inc 2000
2000 Rate Information for

MD Individual Practice Association Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide
for that category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to
as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but
not a member of a special postal employment class refer to the category definitions in The Guide to Federal Employees
Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or
associate members of any postal employee organization Such persons not subject to postal rates must refer to the applicable
Guide to Federal Employees Health Benefits Plans

NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Govt Your Govt Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share

Washington DC area
Self Only JP1 78.46 26.15 170.00 56.66 92.84 11.77 92.84 11.77
Self and Family JP2 175.97 75.15 381.27 162.82 207.74 43.38 201.02 50.10

N VA Cntrl VA Richmond Tidewater Roanoke
Self Only JP1 7846 2615 17000 5666 9284 1177 9284 1177
Self and Family JP2 17597 7515 38127 16282 20774 4338 201025010

All of Maryland
Self Only JP1 7846 2615 17000 5666 9284 1177 9284 1177
Self and Family JP2 17597 7515 38127 16282 20774 4338 20102 5010 24

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