Pages 1--32 from Untitled

Serving All of Maryland Washington DC Northeaster n West Virginia and Some of Southern Pennsylvania
Enrollment in the Plan is limited see page 5 for requirements
Enrollment Code LD1 Self Onl y
LD2 Self and Famil y

This Plan has full accreditation from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure and
our website at http www carefirst com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service

RI 73 146 1
1 Page 2 3
FreeState Health Plan 2000
Tab le of Contents

Page
Introduction 3

Plain Languag e 3
How To Use This Brochur e 3
Section 1 Health Maintenance Or ganizations 4
Section 2 How We Change For 2000 4 5
Section 3 How To Get Benefits 5 7
Section 4 What To Do If We Deny Your Claim Or Request For Service 8 9
Section 5 Benefits 9 23
Section 6 General Exclusions Things We Don't Co ver 23
Section 7 Limitations Rules That Affect Your Benefits 23 24
Section 8 FEHB FACTS 25 28
Department of Defense FEHB Demonstration Project 28 29
Inspector General Advisory Stop Healthcare F r aud 30
Summary Of Benefits Inside back co ver
Premiums Back cover

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FreeState Health Plan 2000
Introduction
FreeState Health Plan Inc 100 S Charles Street Baltimore MD 21201
This brochure describes the benefits you can receive from FreeState Health Plan under its contract CS 2010 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
pages 4 5 Premiums are listed at the end of this brochure

Plain Languag e
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 FreeState Health Plan as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable

We have not re written the Benefits section of this brochure You will find new benefits language next year
How To Use This Brochur e
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

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

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

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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FreeState Health Plan 2000
Section 1 Health Maintenance Or ganizations
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 immnuizations 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 or point of service benefits POS 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 or group of physicians 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
Pr ogram wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits

This year you have a right to more information about this Plan care management our networks
facilities and providers

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

You may review and obtain copies of your medical records on request If you want copies of
your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or 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 f ive years
This screening is for colorectal cancer

Changes to this Plan Your share of FreeState Health Plan's premium will increase by 93 for Self Only or 26.4 for Self and Family

The doctor's office copay is now 10 per visit Previously the copay was 5 per visit This
copay change also applies to visits for treatment for cleft lip and palate outpatient shortterm
rehabilitative therapy infertility treatment both the Partial Hospitalization and the
Medication Management provisions under Mental Conditions and Substance Abuse accidental
dental injury treatment and eye exams See page 9

The copay for prescription drugs is now 10 per prescription unit or refill for generic drugs
and 20 per prescription unit or refill for brand name drugs Previously a 5 copay applied
per prescription unit or refill for both generic and brand name drugs See page 16

Under Prescription Drug Benefits provision diet agents are now excluded Previously
diet agents were covered See page 16

Under Prescription Drug Benefits provision smoking cessation drugs and medications are
covered Previously smoking cessation drugs and medications were excluded See page 16

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FreeState Health Plan 2000
Section 2 How we change for 2000 continued
Under Prescription Drug Benefits Limited Benefits provision there are specific limitations
on drugs to treat sexual dysfunction Prev i o u s ly no limitations applied See pages 16 17

Under Prescription Drug Benefits Limited Benefits provision one copay will apply to
each month's supply of oral contraceptives Previously one copay applied to a 3 months
supply See pages 16 17

Under Medical and Surgical Benefits provision benefits include general anesthesia and
associated hospital or ambulatory facility charges in conjunction with dental care provided to
a plan member Previously no benefit was available See pages 11 12

Under Medical and Surgical Benefits provision coverage is available for patient cost related
to a Clinical Trial as a result of treatment provided for a life threatening condition or prevention
early detection and treatment studies of cancer Previously no coverage was available
See page 12

Under Other Benefits Vision Care provision there is no out of network benefit for routine
vision correction frames and lenses Prev i o u s ly an out of network benefit existed See page
1 9

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 service area Our service area is Maryland Washington DC Northeastern West Virginia and Some of
Southern Pennsylvania
The service area for this Plan includes the following areas
Baltimore City
Maryland Counties
Allegany Howard
Anne Arundel Kent
Baltimore Montgomery
Calvert Prince George's
Caroline Queen Anne's
Carroll St Mary's
Cecil Somerset
Charles Talbot
Dorchester Washington
Frederick Wicomico
Garrett Worcester
Harford

Pennsylvania Zip Codes Listed
15545 17250 17272 17321 17340 17361
17225 17256 17302 17325 17343 17363
17235 17268 17314 17329 17349
17236 17270 17320 17331 17352

West Virginia Zip Codes Listed
25401 25427
25419 25443

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 or point of service benefits We will not pay for any other health care services

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FreeState Health Plan 2000
Section 3 How To Get Benefits continued
If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in another
state you should consider enrolling in a fee for service plan or an HMO that has agreements
with affiliates in other areas For anyone away for at least 90 days the Plan offers Guest
Membership at an affiliated HMO near your travel destination Guest Membership allows you
and your family to enjoy the full range of benefits offered by the Host HMO 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 pa y You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percentage of charges Please remember you must pay this amount when
you receive services
Your out of pocket expenses for in network care are limited to the stated copayments which are
required for a few benefits However when using the New Choice self referral program after you
pay 2,000 in coinsurance for one family member or 4,000 for two or more family members
you do not have to make any further payments for certain services for the rest of the year This is
called a catastrophic limit However copayments or coinsurance for your prescription drugs
dental services and coinsurance amounts for failure to obtain pre authorization 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 ha ve to submit claims You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't contract with us or you use point of service benefits 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 pr ovides my FreeState Health Plan Inc is a Health Maintenance Organization HMO An affiliate health care corporation of CareFirst BlueCross BlueShield FreeState is a mixed mdoel HMO contracting
with medical centers and physicians to provide health care services to you
Medical care is available to you 24 hours a day seven days a week within the service area and on
an emergency basis if you are away

Upon joining FreeState Health Plan you select a participating medical center or physician to provide
health care to you and your family Each family member may select a different medical center
or physician to provide health services You then will choose a primary care doctor at the center
for yourself and each member of your family

What do I do if my primary Call us We will help you select a new one care physician lea ves
the Plan
What do I do if I need to Talk to your Plan physician If you need to be hospitalized your primary care physician or go into the hospital specialist will make the necessary hospital arrangements and supervise your care

What do I do if I'm in First call our customer service department at 410 654 8670 or 800 445 6036 If you are new to the hospital when the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
I join this Plan Program and are switching to us your former plan will pay for the hospital stay until

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FreeState Health Plan 2000
Section 3 How To Get Benefits continued
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 specialist except when you use the New Choice Point of Service benefits

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 The physician may have to get an authorization
or approval beforehand

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 part i c i p a t e
when I enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

What do I do if m y Call your primary care physician who will arrange for you to see another specialist You may specialist lea ves the Plan receive services from your current specialist until we can make arrangements for you to see
someone else
But what if I ha ve a serious Please contact us if you believe your condition is chronic or disabling You may be able to illness and my pr ovider continue seeing your provider for up to 90 days after we notify you that we are terminating our
leaves the Plan or this Plan contract with the provider unless the termination is for cause If you are in the second or third leaves the Pr ogram trimester of preg n a n cy you may continue to see your OB GYN until the end of your postpartum care

You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a
serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a medical services specialist or recommending follow up care Before giving approval we consider if the service is
medically necessary and if it follows generally accepted medical practice
How do you decide if a To decide whether a service is experimental or investigational the Plan considers the following service is experimental questions
or in vestigational 1 Can this service be legally used in testing or other studies on human patients

2 According to generally accepted medical standards is this service recognized as safe and
effective for the treatment of this condition

3 When this service was rendered was it approved by any governmental authority approval is
required

4 In the case of a drug therapeutic regimen or device has it been approved for human use by
the Federal Food and Drug Administration

Service also means any treatment procedure drug facility equipment device or supply or
the usage of any of these things 7 7
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FreeState Health Plan 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this
time limit if you show that you were unable to make a timely request due to reasons beyond
your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service
What if I ha ve a serious or Call us at 410 654 8670 800 445 6036 410 998 5768 TDD 800 828 3196 TDD and we will life threatening condition expedite our review
and you ha ven't responded to my request for service

What if you ha ve denied If we expedite your review due to a serious medical condition and deny your claim we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is serious OPM's health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m Eastern or life threatening Time 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 You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if

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

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

What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information

1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure

2 Copies of documents that support your claim such as physicians'letters operative reports
bills medical records and explanation of benefits EOB forms

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FreeState Health Plan 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service continued

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

Where should I mail m y Send your request for review to Office of Personnel Management Office of Insurance disputed claim to OPM 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 Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies

What laws apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will base a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from the Pri vacy Act 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

Section 5 Benefits
Medical and Surgical Benefits
What is co vered 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 pa y a 10 office visit
copay but no additional copay for laboratory tests x rays and prenatal office visits You pa y
nothing for well child care for children under 5 years of age Within the service area house calls
will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you
pay nothing for a doctor's house call or home visits by nurses and health aides

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS 9 9
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FreeState Health Plan 2000
Section 5 Benefits continued
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups copay waived for wellchild
care for children up to age 5

Vision and hearing screening when performed by a Plan primary care doctor complete
hearing exam only when referred by a Plan primary care doctor

M a m m ograms are covered as follows for women age 35 through age 39 one mammogr a m
during these five years for women age 40 through 49 one mammogram eve ry one or two
years for women age 50 through 64 one mammogram eve ry year and for women age 6 and
a b ove one mammogram eve ry two years In addition to routine screening mammograms are
c overed 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 Copays are waived for maternity care 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 when provided by a Plan
doctor during the covered portion of the mother's hospital confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of an infant who
requires definitive treatment will be covered only if the infant is covered under a Self and
Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy
serum You pay nothing

The insertion of internal prosthetic devices such as pacemakers and artificial joints breast
prosthesis and surgical bras as well as their replacement

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

Women who undergo mastectomies may at their option have this procedure performed on
an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis you pay nothing
Chemotherapy and radiation therapy you pay nothing
Inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics including replacement or adjustmen
limited to that necessitated by the member's physical changes or growth

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
10 STANDARD HMO BENEFITS 10
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FreeState Health Plan 2000
Section 5 Benefits continued
Prosthetic devices such as art i f icial limbs and lenses following cataract removal including
replacement or adjustment limited to that necessitated by the member's physical changes or
growth

Standard durable medical equipment such as wheelchairs hospital beds glucometers and
oxygen for home use including equipment you pay nothing

Home health services by nurses and home health aides including intravenous fluids and
medications when prescribed by your Plan doctor who will periodically review the program
for continuing appropriateness and need you pay nothing

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors
and other Plan providers

Limited benefits Oral and maxillofacial sur gery 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 cove r e d including shortening of the mandible or maxillae
for cosmetic purposes correction of malocclusion and any dental care invo l ved in treatment
of temporomandibular joint TMJ pain dysfunction syndrome except as defined on pages 17 19

Reconstructi ve sur gery 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 surger y
following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance

Short term rehabilitati ve therap y physical speech and occupational is provided on an inpatient
basis for up to two months per condition if significant improvement can be expected within
two months you pa y nothing per session Short term rehabilitative therapy is provided on an outpatient
basis a combined benefit maximum for physical and occupational therapy is 90 visits
per condition per contract year you pa y 10 per visit Speech therapy is covered for 90 visits
per condition per contract year you pa y 10 per visit 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 Plan benefits are only available to the extent that the plan provider determines
they can be expected to result in the improvement of a member's condition

Diagnosis and treatment of infertility is covered You pa y 10 per office visit The following
type of artificial insemination is covered Intracervical insemination ICI you pa y a 10 copay
per visit Cost of donor sperm is not covered Fertility drugs are not covered Other assisted
reproductive technology ART procedures such as in vitro fertilization embryo transfer and
intrauterine insemination IUI are not covered

General anesthesia and associated hospital ambulatory facility char ges in conjunction with
dental car e provided to a member if the member is

1 seven years of age or younger or is developmentally disabled
2 an individual for whom a successful result cannot be expected from dental care provided
under local anesthesia because of a physical intellectual or other medically compromising
condition of the member and

3 an individual for whom a superior result can be expected from dental care provided under
general anesthesia

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE 11 11
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FreeState Health Plan 2000
Section 5 Benefits continued
Or if the member is
1 an extremely uncooperative fearful or uncommunicative child who is 17 years of age or
younger with dental needs of such magnitude that treatment should not be delayed or
deferred and

2 an individual for whom lack of treatment can be expected to result in oral pain infection
loss of teeth or other increased oral or dental morbidity

Plan benefits provided by these services are subject to applicable copayments Please contact the
Plan for additional information regarding these copayments

Clinical Trials Plan benefits include coverage for patient costs related to a Clinical Trial as a
result of treatment provided for a life threatening condition or prevention early detection and
treatment studies on cancer These Plans benefits are provided only if

1 The treatment is being provided or the studies are being conducted in a Phase I Phase II
Phase III or Phase IV Clinical Trial for cancer or

2 the treatment is being provided in a Phase II Phase III or Phase IV Clinical Trial for any
other life threatening condition and

3 the treatment is being provided in a Clinical Trial approved by one of the National Institutes
of Health an NIH Cooperative Group or NIH Center the FDA in the form of an investigational
new drug application the federal Department of Veterans Affairs or an institutional
review board of an institution in the State of Maryland that has a multiple project assurance
contract approved by the Office of Protection From Research Risks of the NIH and

4 There is no clearly superior nonivestigational treatment alternative

What is not co vered 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
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Cardiac rehabilitation
Chiropractic services
Organ donor related transportation expenses
Acupuncture services

Hospital Extended Care Benefits
What is co vered
Hospital car e 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 pa y nothing All necessary services are covered
including

Semiprivate room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS

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FreeState Health Plan 2000
Section 5 Benefits continued
Specialized care units such as intensive care or cardiac care units
Blood and blood derivatives

Extended car e The Plan provides a comprehensive range of benefits for up to 100 days each 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 You pa y 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 car e 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
procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
the hospitalization but not the cost of the professional dental services Conditions for which hospitalization
would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate
See page 15 for nonmedical substance abuse benefits

What is not co vered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS

Emer gency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emer gency 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 the sudden inability to breathe There are many other acute conditions
that the Plan may determine are medical emerg e n c i e s what they all have in common is the need for
quick action

13 13
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FreeState Health Plan 2000
Section 5 Benefits continued
Emer gencies within If you are in an emerg e n cy situation please call your primary care doctor In extreme emergencies the service area if you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room Be sure to tell the emergency room
personnel that you are a Plan member so they can notify the Plan You or a family member
should notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been
timely notified

If you need to be hospitalized 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 except as covered under POS benefits

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

You pay 25 per hospital emergency room or urgent care center visit for emergency services which are
covered benefits of this Plan If the emergency results in admission to a hospital the copay is
waived

Emer gencies outside Benefits are available for any medically necessary health service that is immediately required the 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 except as covered under POS benefits

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

You pay 25 per hospital emergency room or urgent care center visit for emergency services which are
covered benefits of this Plan If the emergency results in admission to a hospital the copay is
waived

What is co vered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors'services
Ambulance service approved by the Plan

What is not co vered Elective care or nonemergency care except as covered under POS benefits
Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area except as covered under POS benefits

Medical and hospital costs resulting from a normal full term delivery of a baby outside the
service area except as covered under POS benefits
14 14
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FreeState Health Plan 2000
Section 5 Benefits continued
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
non Plan pr ovider s care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim
form If you are required to pay for the services submit itemized bills and your receipts to the
Plan along with an explanation of the services and the identification information from your ID
card Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the denial
and the provisions of the contract on which denial was based If you disagree with the Plan's
decision you may request reconsideration in accordance with the disputed claims procedure
described on page 8

Mental Conditions Treatment for mental health conditions and substance abuse may be obtained by calling Magellan Substance Abuse Benefits Behavioral Health formerly known as Green Spring Health Management Services or other vendor
determined by the Plan call 800 245 7013
What is co vered To the extent shown below this Plan provides the following medically necessary services for the
diagnosis and treatment of mental illness or emotional disorder drug abuse and alcohol abuse
This Plan provides medical and hospital services such as acute detoxification for the medical
non psychiatric aspects of drug abuse and alcohol abuse under the same terms and conditions as
for any other illness or condition Outpatient visits to Plan mental health providers for follow up
care are covered as well as inpatient services necessary for diagnosis and treatment

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

Outpatient Car e Unlimited outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
year you pay 15 per visit for visits 1 through 5 25 per visit for visits 6 through 30 35
per visit thereafter for the remainder of the calendar year

Inpatient Car e Up to 365 days of hospitalization each calendar year you pa y nothing
Partial Up to 60 days of partial hospitalization each calendar year you pa y a 10 copay per day all
Hospitalization charges thereafter

Medication Unlimited visits to a Plan doctor each calendar year you pa y a 10 copay per visit
Management

What is not co vered Care for psychiatric drug abuse and alcohol abuse conditions which in the professional
judgment of Plan doctors are not treatable

Psychiatric drug abuse and alcohol abuse evaluations 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 condition

Treatment which is not authorized by a Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS

15 15
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FreeState Health Plan 2000
Section 5 Benefits continued
Prescription Drug Benefits
What is co vered 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 you pa y a 10 copay per generic prescription unit or
refill and a 20 copay per name brand prescription unit or refill

MAIL ORDER Prescription drugs prescribed by a Plan or referral doctor may be purchased via
mail order The supplies of drugs dispensed and the copays charged are the same as when purchased
at a Plan pharmacy Call the Plan for details on ordering by mail

GENERIC DRUGS Substitution of generic equivalents for name brand drugs will be made by
Plan pharmacies except when there is no generic equivalent of a name brand drug or when an
equivalent is available but a Plan doctor specifies only a name brand is to be used Please note
If a generic is available and the prescribing doctor does not require the brand name drug but you
get the brand name drug you pay the brand copay plus the difference in cost between the generic
and brand prescription If a generic is not available or the prescribing doctor requires the brand
name drug you pay only the brand copay

MAINTENANCE DRUGS Certain drugs are indentified as maintenance drugs on the Plan's
Maintenance List These drugs will be covered for a 90 day supply You pay one prescription
copayment of 10 for generic drugs and 20 for name brand drugs Once again you pay the difference
in cost between the generic and brand prescription as stated above in the Generic Drugs
paragraph

REQUIRED PHARMACIES You may be required to use pharmacies associated with your medical
center Call your center or primary care physician to determine which pharmacy must be
used to fill your prescription

Covered medications and accessories include
Drugs for which a prescription is required by law
Dental prescriptions when written by a Plan dentist
Oral and injectable contraceptive drugs contraceptive diaphragms and devices One copay
applies to each month's supply of oral contraceptive drugs

Implanted contraceptive drugs such as Norplant
Insulin
Insulin syringes and needles
Disposable needles and syringes needed for injecting covered prescribed medication
Diabetic supplies including acetone test alcohol swabs blood glucose control regents blood
glucose test kit glucose monitoring test supplies insulin injection device lancets swabs and
test strips you pay nothing

Smoking cessation drugs and medication

Intravenous fluids and medications for home use are covered under Medical and Surgical
Benefits

Limited Benefits Drugs to treat sexual dysfunction are subject to dosage limitations Contact the Plan for the
dosage limitations

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS

16 16
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FreeState Health Plan 2000
Section 5 Benefits continued
What is not co vered 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
Medical supplies such as dressings and antiseptics
Vitamins and nutritional substances which can be purchased without a prescription
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs
Diet agents

Other Benefits
Dental car e
What is co vered United Concordia or other dental vendor as determined by the Plan is under contract with the
Plan to provide dental benefits to Plan members The following list summarizes the dental services
provided by participating United Concordia dentists and indicates copayments where they
apply This Plan covers other dental services at varying copayment levels that are not specifically
listed below For further information regarding these services and applicable copayment levels
please call United Concordia at 800 822 3368 All dental services must be provided by participating
United Concordia dentists

Schedule of Benefits
Code Description of Services Copay

Clinical Oral Examinations
00120 Periodic Oral Evaluation 5
00140 Limited Oral Evaluation Problem Focused 5
00150 Comprehensive Oral Evaluation 6

Radiographs
00210 Intraoral Complete Series incl Bitewings 11
00272 Bitewings 2 Films 5
00330 Panoramic X Rays 11

Dental Prophylaxis
01110 Prophylaxis Cleaning Adult two per year 8
01120 Prophylaxis Cleaning Child two per year 6

Topical Fluoride Treatment
01203 Topical App Of Fluoride Tx Child exclude prophy 3
01204 Topical App Of Fluoride Tx Adult exclude prophy 3
01351 Sealant Per Tooth 3

Amalgam Restorations Including Local Anesthesia Polishing
02110 Amalgam one surface primary 27
02120 Amalgam two surfaces primary 36
02130 Amalgam three surfaces primar y 49
02140 Amalgam one surface permanent 27
02150 Amalgam two surfaces permanent 36
02160 Amalgam three surfaces permanent 49

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS

17 17
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FreeState Health Plan 2000
Section 5 Benefits continued
Resin Restoration Including Local Anesthesia
02330 Resin one surface anterior 31
02331 Resin two surfaces anterior 44
02332 Resin three surfaces anterior 58

Complete Dentures Including Routine Post Del Care
05110 Complete maxillary denture 399
05120 Complete mandibular denture 399
05130 Immediate maxillary denture 422
05140 Immediate mandibular denture 422

Partial Denture Including Routine Post Del Care
05213 Max part dent resin base incl any conv clasp rests teeth 482
05214 Mand part dent resin base incl any conv clasps rests teeth 482

Adjustments to Removable Prosthesis
05410 Adjust complete denture maxillary 14
05411 Adjust complete denture mandibular 15
05421 Adjust partial denture maxillary 18
05422 Adjust partial denture mandibular 18

Repairs to Partial Dentures
05510 Repair broken complete denture base 60

Extractions Including Local Anesthesia and Routine Postoperative Care
07110 Single tooth 31
07210 Surgical removal of erupted tooth requiring elevation of mucoperisteal flap 44
07220 Removal of impacted tooth soft tissue 79
07230 Removal of impacted tooth partially bony 95
07240 Removal of impacted tooth completely 140

Orthodontics
08070 Comprehensive transitional 2,025
08080 Comprehensive adolescent 2,025
08090 Comprehensive adult 2,025

Members must select a participating provider site from which to receive care
Members may transfer participating provider sites if there is no outstanding balance at the site
Members must be referred to participating specialist sites by their participating provider site
Members are required to verify provider participation by calling Client Service before seeking
care at any new provider site

In the case of accident or emergency involving acute pain or a condition requiring immediate
treatment but not hospitalization occurring more than fifty 50 miles from the subscriber's
home and received from non Plan providers the Dental Plan covers the cost of all necessary
diagnostic and therapeutic dental procedures administered by a general dentist up to 50 for each
accident or emergency subject to the member's copayment

Questions regarding plan benefits and features should be directed to United Concordia
1 800 822 3368

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS

18 18
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FreeState Health Plan 2000
Section 5 Benefits continued
Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered only when the initiation of services is within 60 days of the accidental injury
Plan benefits for follow up care are limited to care rendered within one year of the date of the
accidental injury The need for these services must result from an accidental injury and must be
authorized by your primary care doctor You pa y 10 per visit

When general anesthesia is necessary the general anesthesia is covered under medical benefits
and the dental procedures are approved by the Plan's dental vendor

What is not co vered Orthognathic Surgery
Procedures considered to be cosmetic elective or investigative in nature are not covered
Other dental services not shown as covered
Orthodontic treatment in progress prior to the member's effective date of coverage under this
Plan

Dental accidental injuries caused by chewing

Vision car e
What is co vered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases
of the eye this Plan provides the following vision care benefits

Routine annual eye refraction including written lens prescription for eyeglasses You pa y
10 per visit when the examination for annual eye refraction is provided by a MEC Health
Care participating provider

Per 24 month period at a MEC Health Care participating provider one pair of prescription
lenses standard single vision bifocal or trifocal and frames will be covered when selected
from the designated Frame Display You pa y nothing for standard single vision or bifocal
and 45 copay for trifocal additional copays exist for lens enhancements If lenses and
frames are not selected from the designated Frame Display you will have a 40 credit toward
the frames you choose and the standard single vision or bifocal lenses are still free trifocals
have a 45 copay additional copays exist for lens enhancements If you choose contact
lenses instead of glasses you can receive a pair of replacement standard soft daily wear contact
lenses at no charge if you are a current contact lens wearer 50 copay if you are a new
contact lens wearer Contact lenses other than standard soft daily wear are available for
additional copays which vary depending on whether you are or are not a current contact lens
wearer Please note There is no out of network benefit for routine vision correction frames
and lenses

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS TO RECEIVE
STANDARD HMO BENEFITS

Point of Service Benefits
Facts about the At your option you may choose to obtain benefits covered by this Plan from non Plan doctors Fr eeState Health and hospitals whenever you need care except for the benefits listed below under What is not
Plan New Choice eligible for self referral Benefits not covered under Point of Service Benefits must either be A self referral received from or arranged by Plan doctors to be covered When you obtain covered
pr ogram non emergency medical treatment from a non Plan doctor without a referral from a Plan doctor you are subject to the deductibles coinsurance and maximum benefit stated below Members
may self refer for most services Some services shown below must be referred by your primary
care physician

19 19
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FreeState Health Plan 2000
Section 5 Benefits continued
Deductible For eligible self referral services you pay a 200 calendar year deductible for an individual and 400 for a family before the Plan pays any benefits

Coinsurance When the calendar year deductible has been met the Plan pays 80 of the allowable benefit you pay 20 of the allowed benefit If the actual charge for a covered service is more than the
allowed benefit you must also pay the difference Expenses incurred in the last month of the calendar
year which are used to satisfy the deductible will apply to the deductible of the following
calendar year

Pre authorization Pre authorization from the Plan is required for certain services as shown below when not of an emergency nature You or your physician must call the Plan for authorization If you do not call
for authorization you risk having to pay 40 of the allowed benefit after the deductible and take
the chance that the procedure is not a covered benefit

Out of Pocket This Self Referral Program has an out of pocket maximum based on deductible and coinsurance maximum payments Once out of pocket expenses for deductibles and coinsurance reach 2,000 per member
or 4,000 per family the Plan will pay 100 of the allowed benefit for the remainder of the
calendar year Coinsurance amounts for failure to obtain pre authorization do not contribute
toward the out of pocket maximum

Although self referral benefits are available for some services you should remember that the outof
pocket costs are lower through the standard HMO benefit

An allowed benefit is the acceptable charge that the Plan uses to calculate the reimbursement to a
health care provider that is not under contract with the Plan The member is responsible for any
amount that exceeds the allowed benefit determined by the Plan plus the stated coinsurance payment

Benefits under the Self Referral Program are subject to the definitions limitations and exclusions
shown elsewhere in this brochure The Plan determines the medical necessity of services
and supplies provided to prevent diagnose or treat an illness or condition

Medical and surgical benefits
What is eligible f o r At your option you can choose to self refer for the following services instead of getting a referr a l
s e l f re f e r ra l from your primary care physician You pay 20 of the allowed benefit after deductible

Physician office home or hospital visits
Specialist care and consultation
Allergy testing and treatment
Maternity annual pap smears and pelvic exams
Diagnostic laboratory and x ray tests
Surgical procedures pre authorization required
Periodic physical exams immunizations and well child care
Physical speech or occupational therapy
Home health care pre authorization required
Durable medical equipment prosthetics and orthopedic devices pre authorization required
Hearing and vision exams
Family planning and sterilizations
Dialysis chemotherapy radiation therapy and inhalation therapy
Infertility services pre authorization required
20 20
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FreeState Health Plan 2000
Section 5 Benefits continued
What is not eligib l e The following services must be provided by or referred to specialists by your primary care
for self r e f e r ra l physician or the Plan You cannot self refer for the following services

Health education services
Dental care benefits
Emergency and urgent care benefits

Hospital extended care benefits
What is eligible You can choose to be admitted for an inpatient hospital stay through self referral You must
for self referral notify the Plan in advance of any self referral admission and the admission must be pre authorized
by the Plan You pay 20 and any charges above the allowed benefit after the 200
deductible is satisfied If pre authorization is not obtained you pay 40 of the allowed benefit
after the deductible To obtain pre authorization call 410 528 7029 or 800 898 9903 In addition
to the services noted above the following require pre authorization

Inpatient hospitalization
Skilled nursing facility
Hospice care

Mental conditions substance abuse benefits

What is eligible for You can choose to self refer for inpatient hospital and outpatient care You must call the Plan to
Point of Service benefits obtain a pre authorization prior to receiving any self referral services You pay 20 and any
charges above the allowed benefit after the deductible is satisfied for all covered services except
out patient care Outpatient care will be covered after the deductible You pay 20 of the allowed
benefit and any charges above the allowed benefit per visit for visits 1 through 5 you pay 35 of
the allowed benefit and any charges above the allowed benefit per visit for visits 6 through 30
you pay 50 of the allowed benefit and any charges above the allowed benefit per visit thereafter
for the remainder of the calendar year

If pre authorization is not obtained for inpatient care you pay 40 of the allowed charges after
the deductible To obtain pre authorization of inpatient or outpatient care call 1 800 245 7013

Emer gency car e
What is eligible for Emergency services will be treated as a standard HMO benefit and only provided through the
self referral HMO delivery system Please refer to the section in this brochure covering emergency benefits

Other co vered benefits
What is eligible for Prescriptions written as a result of a self referral to a doctor are eligible for a 10 generic
self referral copayment and 20 brand copayment for a 34 day supply as long as they are filled at a Plan participating
pharmacy Please note At a Plan participating pharmacy if a brand name prescription
is selected over a generic and the prescribing doctor does not require the brand name drug you
pay the brand copayment plus the difference in cost between the generic and brand prescription
If a non participating pharmacy is used you pay 20 of the allowed benefit after deductible

How to file claims Call the Client Services Department at 410 654 8670 or 800 445 6036 for claim forms and submit your claims to

CFS Health Group Inc
FEP New Choice Claims
P O Box 308
Owings Mills MD 21117 0308 21 21
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FreeState Health Plan 2000
Section 5 Benefits continued

Non FEHB Benefits The benefits described on this page are neither offered nor guaranteed under the contract with Availa ble to Plan the FEHB Program but are made available to all enrollees and family members of this Plan
Member s 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 POS maximum
benefits or out of pocket maximums These benefits are not subject to the FEHB disputed
claims procedures

Expanded dental benefits Freestanding non group dental coverage Just Dental High Option FreeState Health Plan offers a freestanding non group dental plan called Just Dental High Option This dental plan

is administered by United Concordia You must enroll in Just Dental High Option during the
same time that the FEHB Open Season is going on

This freestanding product offering means that even though Just Dental High Option is
available through FreeState Health Plan Inc you do not need to enroll in FreeState's FEHB
Health Plan to benefit from Just Dental High Option's comprehensive services Just Dental
High Option is a tru ly stand alone plan your enrollment will be independent of your FEHB
Health Plan enrollment

You will benefit from attractive discounts on all types of dental procedures from office visits
and routine cleanings to lab and x ray services and specialty care

For more information please call Just Dental United Concordia at 800 822 3368 Upon
request we will promptly send to you a pamphlet including specific enrollment procedures
dental services and fees participating providers and an application form

Please keep in mind that your application for enrollment requires your annual prepayment for
the first twelve month coverage period you will have the option to renew your Just Dental
coverage thereafter

The 2000 Annual Premiums for Just Dental High Option are
Individual 160.00
Parent Child 239.00
Husband Wife 277.00
Family 402.00

Expanded vision car e Any FreeState Health Plan Inc member utilizing a MEC Health Care provider will receive a 20 discount on lenses frames or contacts if purchased through this Plan provider

Medicare Prepaid Plan Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in a Plan through Medicare As indicated on page 23 annuitants and former spouses
with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll
in a Medicare prepaid plan when one is available in their area They may then later reenroll in
the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare
Part A may join this Medicare prepaid plan but will probably have to pay for hospital
coverage in addition to the Part B premium Before you join the plan ask whether the plan
covers hospital benefits and if so what you will have to pay Contact your retirement system
for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan
Contact us at 410 356 8123 or 800 275 3802 for information on the Medicare prepaid
Plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by
the Plan without dropping your enrollment in this Plan's FEHB plan call 410 356 8123 or
1 800 275 3802 for information on the benefits available under the Medicare HMO

These non FEHBP benefits are not part of the FEHBP contract

22 22
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FreeState Health Plan 2000
Section 6 General Exclusions Things We Don't Co ver
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 co ver Services drugs or supplies that are not medically necessary the following
S e rvices 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 see Point of Service 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 Benefits
Medicar e Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us

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

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

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

For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the
Medicare Choice plan offered by this Plan see page 22

23 23
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FreeState Health Plan 2000
Section 7 Limitations Rules That Affect Your Benefits continued
Other group insurance When anyone has coverage with us and with another group health plan it is called double coverag e coverage You must tell us if you or a family member has double coverage You must also send
us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners'Guidelines

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

We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances be yond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary
care
When others ar e When you receive money to compensate you for medical or hospital care for injuries or illness r esponsible 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 Go vernment Agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for

24 24
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FreeState Health Plan 2000
Section 8 FEHB F ACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients'Bill of Rights which gives you the right to information about your
health plan its networks providers and facilities You can also find out about care management which includes medical practice
guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you

If you want specific information about us call 410 654 8670 800 445 6036 410 998 5768 TDD 800 828 3196 TDD or write to
CareFirst BlueCross BlueShield FreeState Health Plan 10455 Mill Run Circle 01 780 Owings Mills MD 21117 You may also
contact us by fax at 410 998 5809 or visit our website at www carefirst com

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

When your enrollment ends and
The next Open Season for enrollment

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

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your and premiums effecti ve 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 co verage ar e Self Only coverage is for you alone Self and Family coverage is for you your spouse and your availa ble for my famil y unmarried dependent children under age 22 including any foster or step children your
and me employing or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
which is also authorized by your employing or retirement office
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 No new enrollment for m
is necessary

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

25 25
25 Page 26 27
FreeState Health Plan 2000
Section 8 FEHB FACTS continued
Are my medical and claims We will keep your medical and claims information confidential Only the following will have records confidential access to it

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 member s
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 Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if m y You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or
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 spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices

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

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

Key points about TCC You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
26 26
26 Page 27 28
FreeState Health Plan 2000
Section 8 FEHB FACTS continued
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

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

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

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

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

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

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

How can I con vert to You may convert to an individual policy if individual co verag e
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
did not pay your premium you cannot convert

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

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

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

How can I get a Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage of Group Health Plan that indicates how long you have been enrolled with us You can use this certificate when getting
Coverage 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 27
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FreeState Health Plan 2000
Section 8 FEHB FACTS continued
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

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

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 areas
Commonwealth of Puerto Rico
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 plan brochures
enrollment instructions and forms The toll free phone number for the IPC is 1 877 DOD FEHB
1 877 363 3342

You may select coverage for yourself self only or for you and your family self and family during
the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following
the Open Season that you enrolled

If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact
the IPC to find out how to enroll and when your coverage will begin

28 28
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FreeState Health Plan 2000
Department of Defense FEHB Demonstration Project continued
DoD has a web site devoted to the Demonstration Project You can view information such as
their Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area
locations and zip code lists at www tricare osd mil fehbp You can also view information about
the demonstration project including The 2000 Guide to Federal Employees Health Benefits
Plans Participating in the DoD FEHBP Demonstration Project on the OPM web site at
www opm gov

Am I eligible for Temporary See Section 8 FEHB Facts for information about TCC Under this Demonstration Project the Continuation of Co verag e only individual eligible for TCC is one who ceases to be eligible as a member of family under
TCC your self and family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title
10 United States Code For these individuals TCC begins the day after their enrollment in the
DoD FEHBP Demonstration Project ends TCC enrollment terminates after 36 months or the
end of the Demonstration Project whichever occurs first You your child or another person
must notify the IPC when a family member loses eligibility for coverage under the DoD FEHBP
Demonstration Project

TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel
your coverage or your coverage is terminated for any reason TCC is not available when the
demonstration project ends

Do I ha ve the 31 Da y These provisions do not apply to the DoD FEHBP Demonstration Project Extension and
Right To Convert

29 29
29 Page 30 31
FreeState Health Plan 2000
Inspector General Advisory Stop Health Care F r aud
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 410 654 8670 or 800 445 6036 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

30 30
30 Page 31 32
FreeState Health Plan 2000
Summary of Benefits for F reeState Health Plan Inc 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
AND SERVICES AVAILABLE AS POS BENEFITS ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN
DOCTORS

Benefits Plan pays pr ovides Page
Inpatient car e 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 12 13

Extended care All necessary services up to 100 days per calendar year You pay nothing 13
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 365 days
Substance abuse of inpatient care per year You pay nothing 15

Outpatient car e 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 a 10 per office visit nothing
per house call by a doctor You pay nothing for prenatal care and well child
care for children under age 5 .9 11

Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions Unlimited outpatient visits per year You pay a 15 copay per visits 1 5
Subtance Abuse a 25 copay per visit for visits 6 30 and a 35 copay per visit
thereafter for the remainder of the year 15

Emer gency car e Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital or urgent care

center for each emergency room visit and any charges for services that
are not covered benefits of this Plan 13 14

Prescription drugs Drugs prescribed by a Plan doctor or Plan dentist and obtained at a Plan pharmacy You pay a 10 generic copay and 20 brand name copay

per prescription unit or refill 16 17
Dental car e Accidental injury benefit you pay a 10 copay per visit Preventive dental care you pay variable copays for most services 17 19

Vision car e One refraction annually You pay a 10 copay per visit 19
Point of Service Services of out of network doctors and hospitals Not all benefits are covered You pay deductibles and coinsurance and a maximum benefit
applies After your coinsurance and deductible expenses reach a maximum
of 2,000 per Self or 4,000 per Self and Family enrollment per calendar
year covered benefits will be provided at 100 of the allowed benefit for
the remainder of the calendar year Coinsurance amounts for failure to obtain
pre authorization do not contribute toward the out of pocket maximum 19

Out of pocket limit Your out of pocket expenses covered under this Plan and authorized by Plan providers are limited to the stated copayments which are required
for a few benefits 6

31 31
31 Page 32
FreeState Health Plan 2000
2000 Rate Information for
Fr eeState Health Plan

N on-Postal r ates 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 r ates 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 e mployee but not a member of a special postal
e mployment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service
E mployees 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
Pl ans

Non Postal Pr emium Postal Pr emium A Postal Pr emium B
Biweekly Monthl y Biweekly Biweekly
Type of Code Gov't Your Your Gov't Your Your USPS Your Your USPS Your Your
Enrollment Share Share Share Share Share Share Share Share Share Share Share Share

Self Only LD1 78.83 46.07 46.07 170.80 99.82 99.82 93.06 31.84 31.84 93.26 31.64
Self and Family LD2 175.97 108.82 108.82 381.27 235.78 235.78 207.74 77.05 77.05 201 .02 83.77 32

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