Pages 1--28 from 99broch.p65

A Health Maintenance Organization

For changes in benefitssee page
3
Serving Western New York and the Metro Hudson Area

Enrollment in this plan is limited see page 9 for requirements
Western New York Area
Enrollment code
QA1 Self Only
QA2 Self and Family

This plan has commendable Metro Hudson New York Area accreditation from NCQA See the

Enrollment code 2000 Guide for more information on NCQA
C11 Self Only
C12 Self and Family

Visit the OPM website at http www opm gov insure
and
Visit this Plan's website at http www independenthealth com

Authorized for distribution by the
RI 73 103 1
1 Page 2 3
Independent Health Association 2000
Table of Contents

Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4 6
Section 4 What to do if we deny your claim or request for service 6 7
Section 5 Benefits 8 16
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 17 18
Section 8 FEHB FACTS 18 19
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits 25
Premiums 26 2
2 Page 3 4
Independent Health Association 2000
Introduction
Independent Health 511 Farber Lakes Drive Buffalo NY 14221 This brochure describes the benefits you can receive from Independent
Health under its contract CS1933 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 3
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 Independent Health 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

1 3
3 Page 4 5
Independent Health Association 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons
easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

2 4
4 Page 5 6
Independent Health Association 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 the
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 changes 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 5.5 for Self Only or 5.8 for Self and Family under enrollment code C1

Your share of the non postal premium will increase by 21.6 for Self Only or 21.4 for
Self and Family under enrollment code QA

Prescription Drug copay has increased Three copay options are applicable 5 10 25
See page 13

The copay for insulin has increased from 5 to 8 See page 14
Durable Medical Equipment copay has increased See page 8
Coverage for contraceptive devices including contraceptive diaphragms is being added
See page 14

The copay for mammograms has been eliminated See page 8
The copayment for Pneumonia vaccinations and flu shots has been eliminated See page 8
Coverage for Second Opinion Regarding Cancer is explained See page 9
3 Coverage for prenatal sonograms has been clarified See page 8 5
5 Page 6 7
Independent Health Association 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 service area practice Our service area is Western New York enrollment code QA and Metro Hudson
New York enrollment code C1
You may also enroll with us if you live or work in the following places Western New York
area Allegany Cattaraugus Chautauqua Erie Genesee Niagara Orleans and Wyoming
counties Metro Hudson New York area Bronx Dutchess Kings Nassau New York
Orange Putnam Queens Richmond Rockland Suffolk Ulster and Westchester counties

Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care as described on pages 11 12
We will not pay for any other health care services

If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in
another state you should consider enrolling in a fee for service plan or an HMO that has
agreements with affiliates in other areas If you or a family member move you do not have to
wait until Open Season to change plans Contact your employing or retirement office

How much do I pay for You must share the cost of some services This is called either a copayment a set dollar services amount or coinsurance a set percentage of charges Please remember you must pay this

amount when you receive services except for
Inpatient hospitalization
Well childcare up to age 19
Immunizations up to age 19
Mammograms
Pap smears
Laboratory tests
Pneumonia vaccinations
Influenza vaccinations

Copayments are required for a few benefits Your out of pocket expenses for benefits covered
under this Plan limited to the stated copayments and coinsurance which are required for a few
benefits Copayments are due when a service is rendered except for emergency care There may
be a cost for the reproduction of your medical records and X rays The cost for the records is your
responsibility If they do not provide you your records call us and we will assist you

Do I have to submit claims You normally won't have to submit claims to us unless you receive emergency care or services from a 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 my health Services in Western New York are offered through more than 981 participating primary care care doctors and 1,676 specialists more than 18,000 participating pharmacies nationwide as well

as all of the area hospitals
Services in the Metro Hudson area are offered through more than 2,000 participating primary
care doctors and 4,300 specialists more than 53,000 participating pharmacies as well as all of
the area hospitals

The first and most important decision each member must make is the selection of a primary
care doctor The decision is important since it is through this doctor that all other health
services particularly those of specialists are obtained It is the responsibility of your primary
care doctor to obtain any necessary authorizations from the Plan before referring you to a
specialist or making arrangements for hospitalization Services of other providers are covered
only when you have been referred by your primary care doctor The only exception is that a 4 6
6 Page 7 8
Independent Health Association 2000
Section 3 How to get benefits continued
Who provides my health woman may see her participating provider of obstetric and gynecological of record directly care continued with no need to be referred by her primary care doctor

The Plan's provider directory lists primary care doctors with their locations and phone numbers
Directories are updated on a regular basis and are available at the time of enrollment or upon request
by calling the Western New York Marketing Department at 716 631 5392 or 1 800 247 1466 or the
Metro Hudson Marketing Department at 1 914 631 0939 Or 1 800 654 5494 you can also find out
if your doctor participates with this Plan by calling this number

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

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

What do I do if I'm in the First call our customer service department at 716 631 5392 in the Western New York area or hospital when I join this Plan 914 631 0939 in the Metro Hudson region If you are new to the FEHB Program we will
arrange for you to receive care If you are currently in the FEHB Program and are switching to us
your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized
How do I get specialty care Your primary care physician will arrange your referral to a plan specialist

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

Second Opinion Regarding Cancer A Member who receives a positive or negative
diagnosis of cancer or a recurrence of cancer or a recommendation of a course of treatment for
cancer is entitled to a second medical opinion by an appropriate specialty physician including
but not limited to a specialty physician affiliated with a specialty care center for the treatment
of cancer This benefit requires a written referral from the Member's Attending or Primary
Care Physician If the Member obtains a referral to a Non Participating Physician IHA shall
reimburse that Non Participating Physician at billed charges up to 100 percent of the usual
customary and reasonable cost for the opinion provided IHA cannot be responsible however
for any charges made by a Non Participating Physician which exceed the usual customary and
reasonable rate unless IHA determines there is no Participating Physician with the appropriate
training and experience Diagnostic testing performed for the second opinion is covered only
when it is preauthorized by the Office of the Medical Director

What do I do if I am seeing a Your primary care physician will decide what treatment you need If they decide to refer you specialist when I enroll to a specialist ask if you can see your current specialist If your current specialist does not

participate with us you must receive treatment from a specialist who does Generally we will
not pay for you to see a specialist who does not participate with our Plan

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

5 7
7 Page 8 9
Independent Health Association 2000
Section 3 How to get benefits continued
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to continue illness and my provider leaves seeing your specialist for up to 90 days after we notify you that we are terminating our contract with
the Plan or this Plan leaves the provider unless the termination is for cause If you are in the second or third trimester of the Program
pregnancy you may continue to see your OB GYN until the end of your postpartum care You may
also be able to continue seeing your specialist if your plan drops out of the FEHB Program and you
enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
condition or are in your second or third trimester Your new plan will pay for or provide your care
for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you
are in your second or third trimester your new plan will pay for the OB GYN care you receive from
your current provider until the end of your postpartum care

How do you authorize medical Your physician must get our approval before sending you to a hospital referring you to a services specialist or recommending follow up care Before giving approval we consider if the

service is medically necessary and if it follows generally accepted medical practice
How do you decide if a service is Independent Health does not exclude procedures services and devices merely because they are experimental or investigational investigational or experimental rather our medical directors and other qualified physicians from the

community evaluate proposed treatments for efficacy Potential cases are reviewed and assigned a
case manager which in turn collects pertinant information from you the provider and through hospital
records The case manager then coordinates a conference with the medical director and primary
physician A decision is made within 30 days or within 48 hours if a life threatening situation exists

Any drug that is not approved by the FDA is considered to be experimental or investigational and
would therefore not be covered However upon an individual review such a drug may be covered if
it is determined that based on evidence and peer reviewed medical literature that such drugs could
positively affect the member's health status and where commonly accepted medical procedures have
either proven not to be successful or are known to be harmful or useless to the individual patient

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 in explaining why you believe our decision is wrong and
3 Be made within 30 days 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 30 days we will make our
decision based on the information we already have

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

or request for service

6 8
8 Page 9 10
Independent Health Association 2000
Section 4 What to do if we deny your claim or request for service continued
What if I have a serious or life Call our Advocacy Department at 716 635 3950 our Member Services Department at threatening condition and you 1 800 501 3934 or send a fax to 716 635 3504 attention Member Advocate and we will
haven't responded to my expedite our review request for service

What if you have denied my If we expedite your review due to serious medical condition and deny your claim we will request for care and my inform OPM so that they can give your claim expedited treatment too Alternatively you may
condition is serious or life call OPM's health benefit Contracts Division III at 202 606 0755 between 8 a m and 5 p m threatening
Serious or life threatening conditions are ones that may cause permanent loss of bodily
functions or death if they are not treated as soon as possible

Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if

1 We 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 OPM Your request must be complete or OPM will return it to you You must send the following information

1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters opera
tive reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call If you want OPM to
review different claims you must clearly identify which documents apply to
which claim

Who can make the request Those who have a legal right to file a disputed claim with OPM are

1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as
the enrolled person's representative They must send a copy of the person's
specific written consent with the review request

Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance disputed claim Programs Contract Division III P O Box 436 Washington D C 20044

What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our decision Plan's denial your only recourse is to sue If you decide to sue you must file the suit against OPM in Federal court by
December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if I file a Federal law governs your lawsuit benefits and payment of benefits The Federal court will base lawsuit its review on the record that was before OPM when OPM made its decision on your claim You

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

Your records and the Your records and the Privacy Act Chapter 89 of title 5 United States Code allows OPM to use Privacy Act the information it collects from you and us to determine if our denial of your claim is correct
The information OPM collects during the review process becomes a permanent part of your
disputed claims file and is subject to the provisions of the Freedom of Information Act and
the Privacy Act OPM may disclose this information to support the disputed claim decision
If you file a lawsuit this information will become part of the court record 7 9
9 Page 10 11
Independent Health Association 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10
office visit copay and a 10 copay for X rays but no additional copay for laboratory tests No
copay is charged for prenatal and postnatal office visits after the initial visit However
sonograms are subject to the 10 copay for X rays even as part of a prenatal visit Within the
service area house calls will be provided if in the judgement of the Plan doctor such care is
necessary and appropriate you pay a 10 copay for a doctor's house call and a 10 copay for
home visits by nurses and health aides

The following services are included Preventive care including well child care up to age 19 with no copayment and periodic check ups
Mammograms are covered in full with no copayment as follows for women age 35 through
age 39 one mammogram every one or two 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
Pneumonia vaccinations and flu shots are covered in full with no copayment
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 The mother at her option may remain in the hospital up
to 48 hours after a regular delivery and 96 hours after a caesarian delivery Inpatient stays
will be extended if medically necessary If enrollment in the Plan is terminated during
pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary
nursery care of the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self and Family
enrollment other care of an infant who requires definitive treatment will be covered only if
the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Injectable Depro Provera contraceptive you pay a 10 office visit copay
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy
serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Prosthetics which are devices that replace all or part of a body organ such as artificial eyes
artificial limbs ostomy supplies and breast prostheses or surgical bras and their replacements
In addition appliances which are devices used to support weak or a deformed part of
the body such as trusses or rigid devices which support the orthopedic system
Nonexperimental transplants including kidney heart corneal liver heart lung lung single or
double and pancreas transplants allogeneic donor bone marrow transplants autologous bone
marrow transplants autologous stem cell and peripheral stem cell support and high dose chemotherapy
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 multiple myeloma breast cancer and
epithelial ovarian cancer Related medical and hospital expenses of the donor are covered when the
recipient is covered by this Plan Benefits are subject to approval of the Medical Director
Durable medical equipment such as wheelchairs and hospital beds You pay a 50 copay
per device
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

8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
10 Page 11 12
Independent Health Association 2000
Section 5 BENEFITS continued
Medical and Surgical Benefits continued
What is covered continued Chemotherapy radiation therapy and inhalation therapy Autologous blood when medically necessary you pay a 20 member copayment

Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications
when confinement in a hospital or skilled nursing facility would otherwise be required
in the absence of home health care and 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 except for a 10 copay for outpatient surgery visits
Chiropractic Care Coverage will be provided for care by a Plan licensed chiropractor for
symptoms or conditions determined to be medically necessary by the Medical Director This
care must be provided in connection with the detection and correction by manual or mechanical
means of any structural imbalance distortion or subluxation in the human body Chiropractic
care is provided only when your plan Primary Care Physician issues a referral for
such services Each covered chiropractic visit is subject to a 10 copay
Second Opinion regarding cancer is covered only when it is preauthorized by the Office of
the Medical Director

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 Second opinions for
these procedures are required All other procedures involving the teeth or areas surrounding
the teeth are not covered including shortening of the mandible or maxillae for cosmetic
purposes correction of malocclusion and any dental care involved in treatment of temporomandibular
joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional
defect or from an injury or surgery that has produced a major effect on the member's
appearance and if the condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician will decide whether or not to have breast reconstruction
surgery following a mastectomy including whether or not to have surgery on the other breast
in order to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an
inpatient or outpatient basis for up to two consecutive months per condition if significant
improvement can be expected within two months you pay a 15 copay per outpatient
session Speech therapy is limited to treatment of certain speech impairments of organic
origin Occupational therapy is limited to services that assist the member to achieve and
maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered including drug treatment when pre approved by
the Medical Director you pay 20 Intracervical insemination ICI and intrauterine insemination
IUI is covered you pay 20 Cost of donor sperm is not covered Fertility drugs are
covered under the Prescription Drug Benefit you pay 20 Other assisted reproductive technology
ART procedures such as in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction
is provided at a Plan facility for up to 36 visits you pay 10 copay per visit

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

Costs related to travel food and lodging for transplant recipient or donor
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Orthopedic devices such as braces and foot orthotics

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9 11
11 Page 12 13
Independent Health Association 2000
Section 5 BENEFITS continued
Hospital Extended Care Benefits

What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including

Semi private room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations
Specialized care units such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits up to 45 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 The
member certified shall be eligible for up to 210 days of Hospice Services on an inpatient and
outpatient basis including medically necessary supplies and drugs In addition family
members covered by this contract are entitled to five 5 visits of bereavement counseling

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
you pay a 25 copay

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there
procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will
cover the hospitalization but not the cost of the professional dental services Conditions for
which hospitalization would be covered include hemophilia and heart disease the need for
anesthesia by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification diagnosis treatment of medical conditions and medical management of withdrawal symptoms
acute detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 13 for non medical substance abuse benefits

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

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
12 Page 13 14
Independent Health Association 2000
Section 5 BENEFITS continued
Emergency Benefits
What is a medical emergency A medical emergency means the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires

immediate medical or surgical care Some problems are emergencies because if not treated
promptly they might become more serious examples include deep cuts and broken bones
Others are emergencies because they are potentially life threatening such as heart attacks
strokes poisonings gunshot wounds or sudden inability to breathe There are many other
acute conditions that the Plan may determine are medical emergencies what they all have in
common is the need for quick action

Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies if service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone

system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel
that you are a Plan member so they can notify the Plan You or a family member should notify the
Plan within 48 hours It is your responsibility to ensure that the Plan has been timely notified

If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours
or on the first working day following your admission unless it was not reasonably possible to
notify the Plan within that time If you are hospitalized in non Plan facilities and Plan doctors
believe care can be better provided in a Plan hospital you will be transferred when medically
feasible with any ambulance charges covered in full

Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the plan or provided by Plan providers

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

You pay 35 per hospital emergency room visit or 35 per urgent care center visit for emergency
services that are covered benefits of this Plan If the emergency results in admission to a
hospital the copay is waived

Emergencies outside the Benefits are available for any medically necessary health service that is immediately required service area because of injury or unforeseen illness

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

To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the plan or provided by Plan providers

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

You pay 35 per hospital emergency room visit or 35 per urgent care center visit for emergency
services that are covered benefits of this Plan If the emergency results in admission to a
hospital the copay is waived

What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services

Ambulance service approved by the Plan

11 13
13 Page 14 15
Independent Health Association 2000
Section 5 BENEFITS continued
What is not covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the
service area

Filing claims for non Plan With your authorization the Plan will pay benefits directly to the providers of your emergency providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500

claim form If you are required to pay for the services submit itemized bills and your receipts
to the Plan along with an explanation of the services and the identification information from
your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the
denial and the provisions of the contract on which denial was based If you disagree with the
Plan's decision you may request reconsideration in accordance with the disputed claims
procedure described on pages 6 8

12 14
14 Page 15 16
Independent Health Association 2000
Section 5 BENEFITS continued
Mental Conditions Substance Abuse Benefits

Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis
and treatment of acute psychiatric conditions including the treatment of mental illness or
disorders

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Any office service performed by a participating psychiatrist specifically for pharmacotherapy
pharmaceutical management as treatment for a mental health condition will be covered as a
medical office visit subject to a 10 copayment Any tests or visits to monitor the pharmaceutical
will be covered as a medical benefit not a mental health benefit

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
year you pay 15 copay per visit for each visit up to 20 visits and all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for first 30 days you
pay all charges thereafter 20 visits by your Plan doctor are covered while hospitalized

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation
unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment
of a short term psychiatric condition

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

Outpatient care The Plan provides up to 60 outpatient visits per calendar year for the diagnosis and treatment
of alcoholism and drug addiction of which up to twenty 20 visits may be for family therapy
you pay a 10 copay for each covered visit and all charges thereafter

Inpatient care One 30 day substance abuse rehabilitation program per calendar year in an Alcohol Detoxification
Center or Rehabilitation Center approved by the Plan you pay nothing during the
benefit period You pay all charges thereafter

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

Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or designated doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply Drugs are prescribed by Plan doctors and dispensed in

accordance with the Plan's formulary You pay a 5 copay per prescription unit or refill for generic
formulary drugs You pay a 10 copay per prescription unit or refill for brand name formulary drugs
You pay a 25 copay per prescription unit or refill for non formulary generic and brand name drugs

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
15 Page 16 17
Independent Health Association 2000
Section 5 BENEFITS continued
Prescription Drug Benefits continued

What is covered continued Formulary drug inclusion All formulary decisions are based on recommendations from Independent Health's Pharmacy Therapeutics Committee which are forwarded to the
Independent Health Board after each quarterly meeting The Independent Health board
reviews the recommendation and makes a decision regarding the pharmaceutical

Independent Health's formulary is currently available to members upon request
Covered medications and accessories include
Drugs for which a prescription is required by law
Growth hormones you pay a 10 copay per formulary or 25 copay for non formulary
prescription unit or refill
Insulin with an 8 copay charge applied to each vial
Smoking cessation drugs and medication including nicotine patches nicotine replacement
therapy covered only in conjunction with the Plan's stop smoking program
Disposable needles and syringes needed to inject covered prescribed medication you pay a
20 copayment
Oral contraceptives and contraceptive devices including contraceptive diaphragms
Implanted time release medications such as Norplant you pay a 20 copayment
Nutritional supplements medically necessary for the treatment of phenylketonuria PKU and
other related disorders
Self administered injectable drugs which must have written pre approval by the Medical
Director you pay a 5 copay per prescription until or refill copay
Infertility drugs you pay 20 of the cost of the drug
Diabetic supplies and equipment Pre authorization by IHA's Medical Director is required
for medically necessary diabetic durable medical equipment This equipment includes items
such as injection aids insulin pumps and appurtenances thereto insulin infusion devices
data management systems blood glucose monitors and blood glucose monitors for the legally
blind you pay an 8 member copay for each item
Up to a thirty 30 day supply of test strips for glucose monitors and visual reading and urine
testing strips syringes lancets and cartridges for the legally blind you pay the lesser of a
20 member copay of the total cost of the item or an 8 member copay for each item
Intravenous fluids and medication for home use implantable drugs and some injectable
drugs such as Depro Provera are covered under Medical and Surgical Benefits

Limited Benefits Sexual dysfunction drugs have dispensing limitations Contact the plan for details
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription except as
shown above
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance

DRUGS MUST BE PRESCRIPTION BY A PLAN DOCTOR OR DESIGNATED DOCTOR

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
16 Page 17 18
Independent Health Association 2000
Section 5 BENEFITS continued
Other Benefits
Dental care

What is covered
Accidental Restorative services and supplies necessary to promptly repair but not replace sound natural
injury benefit teeth are covered The need for these services must result from an accidental injury occurring
while the member is covered under the FEHB Program you pay a 10 copay per 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 eye refractions are covered once every two calendar years you pay a 10
copayment

What is not covered Eye glass corrective lenses or frames contact lenses services and procedures to correct
vision
Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 17
17 Page 18 19
Independent Health Association 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 procedure

Fitness Programs Independent Health covers a number of wellness programs through our Feeling Fit program These include Stop Smoking classes Nutritional Consulting Parenting
Classes and Stress Management workshops to name just a few Please contact Independent
Health's Feeling Fit Department Line at 1 800 834 9565 in Western New York or
Membership Services in the Metro Hudson area at 1 800 654 5494 for more information
on these expanded benefits as well as our new Member Discount program The
Discount program includes savings on vision dental services entertainment sporting
goods and more

Medicare prepaid enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 19 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 re enroll 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
the 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 will have to pay Contact
your retirement system for information on dropping your FEHB enrollment and changing
to the Medicare prepaid plan Contact us at 716 631 9452 or 1 800 453 1910 for
information on the Medicare plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare Choice HMO
Encompass 65 sponsored by this Plan without dropping your enrollment in this Plan's
FEHB plan call 1 800 453 1910 for information on the benefits available under the
Medicare HMO

Independent Health's Medicare Choice Plan Encompass 65
Independent Health's Encompass 65 is a comprehensive flexible health plan for Medicare
beneficiaries in Western New York To be eligible for Independent Health's Encompass
65 coverage you must be enrolled in Medicare's Medical Insurance Part A and Part
B or Part B only If you have Part B only you will need to pay a higher premium or
purchase Part A from the Social Security Administration office You must live in
Allegany Cattaraugus Chautauqua Erie Genesee Niagara Orleans or Wyoming county
in New York State and not be out of the service area for more than 90 consecutive days

If you are interested in enrolling contact your retirement system for information on
canceling your FEHB enrollment and joining Independent Health's Encompass 65
You may also choose to enroll in Independent Health's Encompass 65 and retain your
enrollment in Independent Health's FEHB plan For more information on plan benefits
copayments and premiums contact Independent Health's marketing department at
716 631 9452 or 1 800 453 1910 Monday through Friday 8 a m until 8 p m

For more information be sure to visit our website at www independenthealth com

Benefits on this page are not part of the FEHB contract
16 18
18 Page 19 20
Independent Health Association 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefit
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 For information on the
Medicare Choice plan offered by this Plan see page 16

Other group insurance coverage When anyone has coverage with us and with another group health plan it is called double coverage You must tell us if you or a family member has double coverage You must also

send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The
other plan is secondary it pays benefits next We decide which insurance is primary according
to the National Association of Insurance Commissioners Guidelines

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

We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double coverage
17 19
19 Page 20 21
Independent Health Association 2000
Section 7 Limitations Rules that affect your benefit continued
Circumstances beyond our Under certain extraordinary circumstances we may have to delay your services or be unable to control provide them In that case we will make all reasonable efforts to provide you with necessary care

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

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover

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

Workers compensation We do not cover services that You need because of a workplace related disease or injury that the Office of Workers Compensation

Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government Agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for

Section 8 FEHB FACTS
You have a right to information OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the about your HMO 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 in Western New York call 716 631 5392 or write to
511 Farber Lakes Drive Buffalo NY 14221 You may also contact us by fax at 716 631 8554
or visit our website at www independenthealth com

If you want specific information about us in the Metro Hudson region call 914 631 0939 or
write to 200 White Plains Road Tarrytown NY 10591 You may also contact us by fax at
914 631 2103 or visit our website at www independenthealth com

Where do I get information Your employing or retirement office can answer your questions and give you a Guide to about enrolling in the FEHB Federal Employees Health Benefits Plans brochures for other plans and other materials you

Program 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 we cannot change your 18
enrollment status without information from your employing or retirement office 20
20 Page 21 22
Independent Health Association 2000
Section 8 FEHB FACTS continued
When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1
What happens when I retire When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB Program for the last five years of your Federal service If you do not

meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section

What types of coverage are Self Only coverage is for you alone Self and Family coverage is for you your spouse and available for my family and your unmarried dependent children under age 22 including any foster or step children Under

me certain circumstances you may also get coverage for a disabled child 22 years of age or older
who is incapable of self support

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

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

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

Are my medical and claims We will keep your medical and claims information confidential Only the following will have records confidential access to it without your permission

OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose
your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You

can also use an Employee Express confirmation letter
What if I paid a deductible Your old plan's deductible continues until our coverage begins under my old plan

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

19 21
21 Page 22 23
Independent Health Association 2000
When you lose benefits
What happens if my enrollment You will receive an additional 31 days of coverage for no additional premium when 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 spouse If you are divorced from a Federal employee or annuitant you may not continue to get coverage benefits under your former spouse's enrollment But you may be eligible for your own FEHB

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

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC

For example you can receive TCC if you are not able to continue your FEHB enrollment after
you retire You may not elect TCC if you are fired from your Federal job due to gross
misconduct

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

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

How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

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

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

Divorce
Loss of spouse equity coverage within 36 months after the divorce

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

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

20 22
22 Page 23 24
Independent Health Association 2000
When you lose benefits continued
How can I convert to individual You may convert to an individual policy if coverage

Your coverage under TCC or the spouse equity law ends If you canceled your coverage
or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

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

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

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

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

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

21 23
23 Page 24 25
Independent Health Association 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 716 631 5392 in Western New York or 914 631 2103
in the Metro Hudson Region 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 24
24 Page 25 26
Independent Health Association 2000
Notes

23 25
25 Page 26 27
Independent Health Association 2000
Notes

24 26
26 Page 27 28
Independent Health Association 2000
Summary of Benefits for Independent Health Association 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 care
Hospital Comprehensive range of medical and surgical services without 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 10

Extended care All necessary services for up to 45 days You pay nothing 10
Mental conditions Diagnosis and treatment of acute psychiatric conditions for 30 days
of inpatient care per year You pay nothing 13

Substance abuse All necessary services for up to 30 days per year in a substance
abuse treatment program 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 check ups and routine immunizations laboratory
tests and X rays complete maternity care You pay 10 per office
visit and for a doctor's house call and 10 copay for X rays 8

Home health care All necessary visits by nurses and health aides You pay 10 copay 9
Mental conditions Up to 20 outpatient visits per year You pay a 15 copay per visit 13
Substance abuse Up to 60 outpatient visits per year You pay a 10 copay per visit 13

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 35 copay to the hospital for each
emergency room visit and 35 per urgent care visit and any charges
for services that are not covered by this Plan 11

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for generic drugs
a 10 copay per prescription unit or refill for formulary brand name
drugs you pay a 25 copay per prescription unit or refill for nonformulary
generic and non formulary brand 13 14

Dental care Accidental injury benefit you pay a 10 copay per visit 15
Vision care Routine eye exam covered once every two calendar years You pay a 10 copay per visit 15

Out of pocket maximum Your out of pocket expenses for benefits under this Plan are limited
to the stated co payments that are required for a few benefits 4

25 27
27 Page 28
Independent Health Association 2000
2000 Rate Information for Independent Health Association
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 Enrollment Code Gov't Share Your Share Gov't Share Your Share USPS Share Your Share USPS Share Your Share

Western New York
Self Only QA1 QA1 51.92 17.31 112.50 37.50 61.44 7.79 61.44 7.79
Self and Family QA2 QA2 145.81 48.60 315.92 105.30 172.54 21.87 172.54 21.87

Metro Hudson
Self Only C11 C11 78.83 29.16 170.80 63.18 93.06 14.93 93.26 14.73
Self and Family C12 C12 175.97 110.85 381.27 240.17 207.74 79.08 201.02 85.80

26 28

Page Navigation Panel