Pages 1--32 from HMO2000.PDF

Serving Most of Colorado and Nevada
For
Enrollment in this Plan is limited see page 5 for requirements changes in benefits

see page 4

Colorado area
Enrollment code L21 Self Only
L22 Self and Family

Nevada area
Enrollment code VS1 Self Only
VS2 Self and Family

Visit the OPM website at http www opm gov insure
and

this Plan's website at http www bcbsco com

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

RI 73 147 1
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HMO Colorado HMO Nevada 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 3

Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10 22
Section 6 General exclusions Things we don't cover 23

Section 7 Limitations Rules that affect your benefits 24
Section 8 FEHB FACTS 26
Inspector General Advisory Stop Healthcare Fraud 30
Summary of benefits Inside back cover

Premiums Back cover

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HMO Colorado HMO Nevada 2000
Introduction
HMO Colorado HMO Nevada
700 Broadway
Denver CO 80273

This brochure describes the benefits you can receive from HMO Colorado HMO Nevada under its contract CS2004 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 4 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the
public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked
cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical
terms you and other personal pronouns active voice and short sentences

We refer to HMO Colorado HMO Nevada as this Plan throughout this brochure even though in other legal documents you will see
a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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

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

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or 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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HMO Colorado HMO Nevada 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services or point of service benefits POS as
described on page 20 you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or
remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How We Change For 2000
Program wide To keep you premium as low as possible OPM has set a minimum copay of 10 for all primary care office changes 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 give 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 Prescription Drug Benefits section has been changed to reflect a three tiered copayment structure Please refer to page 18 for complete details on the benefit changes

For enrollment code L2 your share of the non postal premium will increase by 23.8 for Self Only or
58.0 for Self and Family

For enrollment code VS your share of the non postal premium will increase by 55.2 for Self Only or
54.4 for Self and Family

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HMO Colorado HMO Nevada 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our service area Plan's service is
area
In Colorado

Services are available from Plan providers in all counties except Eagle Gunnison Hinsdale Jackson Ouray Pitkin San Juan and Summit counties HMO Colorado strives to provide an extensive provider network and has a
Network Access Plan available to ensure that the network meets the members needs You may contact the carrier at 303 831 0161 or 800 334 6557 for a copy of this Plan

In Nevada
Services from Plan providers are available in the following counties Carson City Clark Douglas Esmeralda Eureka Humboldt Lincoln Lyon Nye Storey and Washoe counties You may contact the carrier at
800 438 5270 for a copy of this Plan

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

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 HMO
Colorado HMO Nevada is part of a national network of Blue Cross and Blue Shield HMOs HMO USA and
HMO USA Guest Membership Through HMO USA urgent care can be obtained in areas served by other Blue
Cross and Blue Shield HMOs affiliated with HMO USA Through the HMO USA Guest Membership members
become a guest member in another Blue Cross and Blue Shield HMO if they are temporarily assigned for 90 days
or more in a geographic area which has another Blue Cross and Blue Shield HMO Unlike HMO USA the Guest
Membership allows members to receive covered routine care If you would like more information about receiving
care away from home please call the Plan's member services department at 800 827 6422 in Colorado or
800 438 5270 in Nevada 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 You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance a pay for services set percentage of charges Please remember you must pay this amount when you receive services except for
emergency care

After you pay 4,400 in copayments or coinsurance for one family member or 10,500 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 Point of
Service benefits do not count toward these limits and you must continue to make these payments

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

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider who submit claims 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

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HMO Colorado HMO Nevada 2000
Who provides HMO Colorado HMO Nevada is a subsidiary of Blue Cross and Blue Shield of Colorado In Colorado the Plan my health care offers a network of multi specialty medical groups family practice centers and independently practicing doctors
located in Colorado By requiring that you choose a Plan doctor convenient for you within a 25 mile radius of where you live HMO Colorado HMO Nevada can assure that both routine and emergency health care is provided

for you and your family in an efficient and effective manner
In Nevada the Plan offers multi specialty primary medical groups PMGs and individual primary care physicians PCPs Selecting a group or physician within 25 miles of your residence or work assures routine and emergency
health care is available to you and your family

At the time of enrollment each member must select a primary care doctor or group from whom all covered nonemergency
medical services will be received Members may select a different primary care doctor or group for
each eligible family member

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 there has been a referral by the member's primary care doctor or when you use POS benefits with the following exception a woman may see her Plan gynecologist for her annual routine examination without
a referral
Note Primary care doctors in metropolitan areas are associated with specific specialists and hospitals Please check
with your primary care doctor to find out where you may be referred

The Plan's provider directory lists primary care doctors generally family practitioners pediatricians and internists with their locations and phone numbers and notes whether or not the doctor is accepting new patients
Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Customer Service Department at 303 831 0161 in the Metropolitan Denver area or 800 334 6557 from elsewhere
in the state In Nevada call 800 438 5270 You can also find out if your doctor participates with this Plan by calling this number If you are interested in receiving care from a specific provider who is listed in the directory
call the provider to verify that he or she still participates with the Plan and is accepting new patients Important note When you enroll in this plan services except for emergency benefits or POS benefits are provided through
the Plan's delivery system the continued availability and or participation of any one doctor hospital or other provider cannot be guaranteed

If you enroll you will be asked to let the Plan know which primary care doctor s you've selected for you and each
member of your family by sending a selection form to the Plan If you need help choosing a doctor call the Plan
Members may change their doctor selection by notifying the Plan 30 days in advance

If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered services until the
Plan can arrange with you for you to be seen by another participating doctor

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

What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will make the need to go into necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our customer service department at 303 831 0161 or 800 334 6557 in Colorado or 800 438 5270 in I'm in the Nevada If you are new to the FEHB Program we will arrange for you to receive care If you are currently in the
hospital when I FEHB Program and are switching to us your former plan will pay for the hospital stay until join this Plan
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
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HMO Colorado HMO Nevada 2000
How do I get Your primary care physician will arrange your referral to a specialist Except in a medical emergency or when a specialty care primary care doctor has designated another doctor to see his or her patients or when you choose to see the Plan's
POS benefits you must receive a referral from your primary care doctor before seeing another doctor or obtaining special services Referral to a participating specialist is given at the primary care doctor's discretion if non Plan

specialist or consultants are required the primary care doctor will arrange appropriate referrals

When you receive a referral from your primary care doctor you must return to the primary care doctor after the
consultation All follow up care must be provided or authorized by the primary care doctor Do not go to the
specialist for a second visit unless your primary care doctor has arranged for and the Plan has issued an
authorization for the referral in advance

If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary
care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits
without additional referrals Your primary care physician will use our criteria when creating your treatment plan

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

What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive services my specialist from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your have a serious provider for up to 90 days after we notify you that we are terminating our contract with the provider unless the
illness and my termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your provider leaves OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll Plan leaves the
in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your Program
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 Reimbursement for services requires that your physician gets our approval before sending you to a hospital authorize referring you to a specialist or recommending follow up care Before giving approval we consider if the service
medical is medically necessary and if it follows generally accepted medical practice The only exception a woman may services see her Plan gynecologist for her annual routine examination without a referral

How do you The criteria for determining whether a product or procedure is not experimental or investigational is as follows decide if a
1 The technology must have final approval from the appropriate government regulatory bodies service is

experimental or 2 The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes investigational
3 The technology must improve the net health outcome which means that the technology's benefit effects on health outcomes should outweigh any harmful effects on health outcomes

4 The technology must be as beneficial as any established alternatives and
5 The research and experimental stage of development must be completed and the improvement in net health outcome must be attainable outside the investigational settings

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HMO Colorado HMO Nevada 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

What if you have If your condition is serious or life threatening call us We will work with you to expedite the denied my request review of your claim Serious or life threatening conditions are ones that may cause permanent
for care and my loss of bodily functions or death if they are not treated as soon as possible condition is serious
or life threatening
When may I ask You may ask OPM to review a denial after you ask us to reconsider our initial denial or refusal OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim
denial or request for service
What if I have a Call us at 303 831 0161 in the Metropolitan Denver area or 800 334 6557 from elsewhere in the serious or life state In Nevada call 800 438 5270
threatening condition and you haven't
responded to my request for service

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

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

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HMO Colorado HMO Nevada 2000
What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information

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

If you want OPM to review different claims you must clearly identify which documents apply to
which claim

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

Where should I mail Send you request for review to Office of Personnel Management Office of Insurance Programs my disputed claim to Contracts Division IV P O Box 436 Washington DC 20044

OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies

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

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

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record

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HMO Colorado HMO Nevada 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 but no additional copay for laboratory tests and x rays when part of an office 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 nothing for doctors house calls or for home visits by nurses and health aides Office visits occurring after hours or on
weekends holidays require a 20 copay per visit
The following services are included
Preventive care including well baby care and periodic check ups

Mammograms for women are covered as follows for women age 35 through age 39 one
mammogram during these five years and for women age 40 and over one mammogram
per calendar year In addition to routine screening mammograms are covered when
prescribed by a Plan doctor as medically necessary to diagnose or treat an illness

Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays copay waived when other
services provided

Outpatient surgery not performed in a doctor's office you pay a 25 copay
Complete obstetrical maternity care for all covered females including prenatal
delivery and postnatal care by a Plan doctor you pay the 100 hospital admission copay New mothers may at their option remain in the hospital up to 48 hours after a

regular delivery and up to 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during
pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's
hospital confinement for maternity will be covered under either a Self Only 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 family planning services including the fitting of a diaphragm
costs related to inserting and removing a Norplant device and professional charges
related to fitting inserting or removing an IUD or cervical cap The cost of the device is
included If such devices are not provided by a Plan provider benefits are available under
the Prescription Drug Benefit in this brochure

Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy
serum

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung single lung double lung kidney and liver transplants
allogeneic donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following conditions
acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple
myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and varian
germ cell tumors Treatment for breast cancer multiple myeloma and epithelial ovarian
cancer must be preapproved by the Plan's Medical Director and performed in a PlanCare

must be received from or arranged by Plan doctors to receive standard HMO benefits 10 10
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HMO Colorado HMO Nevada 2000
approved facility 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 their procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure Coverage includes all stages of reconstruction of the breast on which the mastectomy was

performed and surgery and reconstruction of other breasts to produce a symmetrical appearance Treatment of physical complications of mastectomy including
lymphedemas is also a covered benefit
Breast Prosthesis including the surgical bra used for an external prosthesis and necessary replacement protheses and bras are covered benefits

Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides including home IV therapy when
prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need

Depo Provera injections by the member's primary care physician for the purpose of birth
control

All necessary medical or surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers at no additional cost to you

Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical procedures and hospitalization for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures

involving the teeth or intra oral areas surrounding the teeth are not covered including any medical or dental care involved in the 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 may decide whether to have breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to produce
a symmetrical appearance
Cryosurgery for localized prostrate cancer is considered to be an appropriate treatment and is a covered benefit when medically necessary You pay 10 copay in office 25 copay on an
outpatient basis and 100 copay on an inpatient basis This surgical procedure is still considered to be experimental and investigational for salvage therapy and is not covered for
local failures after radical prostatectomy external beam irradiation and brachytherapy
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement
can be expected and services are provided within six months of illness or injury onset you pay a 10 copay per visit Speech therapy is limited to treatment of 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

Treatment of congenital defects and birth abnormalities for children up to age 5 without regard to standard improvement will be entitled to this benefit
Osteopathic manipulation is covered for up to six treatments per year when performed by the member's primary care physician or a Plan provider You pay a 10 copay per visit

Care must be received from or arranged by Plan doctors to receive standard HMO benefits 11 11
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HMO Colorado HMO Nevada 2000
Diagnosis and treatment of infertility is covered you pay a 10 copay per visit Artificial insemination is covered as follows you pay a 10 copay for each of six attempts one attempt
per monthly cycle After that you pay 50 of charges for each additional attempt Fertility drugs are not covered Other assisted reproductive technology ART procedures such as invitro
fertilization and embryo transfer are not covered One ultrasound for infertility regardless of the number of attempts

Supplies equipment and appliances including oxygen are covered the Plan will pay a total of 1,000 per member per calendar year you pay all charges thereafter for the
following oxygen and oxygen equipment orthopedic appliances crutches rental or purchase of durable medical equipment medical supplies and prostheses when authorized by a primary
care doctor

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Chiropractic services
Homemaker services
Foot orthotics
Blood and blood derivatives not replaced by the member
Long term rehabilitative therapy
Custodial care
Transplants not listed as covered
Cardiac rehabilitation
Genetic counseling and testing
Services related to refractive keratoplasty surgery to correct nearsightedness including
radial keratotomy or any procedure designed to correct farsightedness or astigmatism

Medical supplies and devices available over the counter
Air conditioners humidifiers and purifiers biofeedback equipment exercise equipment
whirlpools and self help devices

Deluxe equipment such as motor driven wheelchairs when standard equipment is determined to be adequate by the Plan

Cost of repairs that exceed the rental price of a replacement unit

Care must be received from or arranged by Plan doctors to receive standard HMO benefits 12 12
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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 a 100 copay per inpatient admission
up to an annual hospital copayment maximum of one copay per Self Only and three per Self and Family enrollment 300 This maximum is separate and in addition to the copayment

maximum of 100 300 for mental conditions admissions This copay is waived if a member is re admitted as an inpatient within 72 hours of a discharge for the original diagnosis or
complications related to the original diagnosis All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically
necessary the doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units
Mastectomies may be performed on an inpatient basis with a 48 hour stay allowed if
desired by the patient

Maternity stays at the option of the mother may be up to 48 hours for a regular delivery
and up to 96 hours for a caesarean delivery

Extended care The Plan provides a comprehensive range of benefits for up to 30 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 a 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 This

benefit is limited to an initial period of three months Should the patient survive past the initial three month period the Plan will provide up to two additional three month periods but
will not provide more than nine months of hospice care per member

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 procedures is a need for hospitalization or reasons totally unrelated to the dental procedure the Plan will
cover the hospitalization and costs of services related to the medical condition costs related to the dental procedures are not covered Conditions for which hospitalization would be

covered include hemophilia and heart disease the need for anesthesia by itself is not such a condition unless anesthesia is needed for a child under specific conditions You pay a 100
copay per admission up to annual maximum

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 Benefits for detoxification services usually limited to three to five

days do not include rehabilitation or long term care You pay a 100 copay per admission up to annual maximum See page 17 or nonmedical substance abuse benefits

Care must be received from or arranged by Plan doctors to receive standard HMO benefits
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HMO Colorado HMO Nevada 2000
What is not covered Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member

Custodial care rest cures domiciliary or convalescent care

Care must be received from or arranged by Plan doctors to receive standard HMO benefits 14 14
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HMO Colorado HMO Nevada 2000
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you emergency 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

Urgent care Situations that are not life threatening but require prompt medical attention to prevent serious deterioration in the health of an individual

Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme service area emergencies if you are unable to contact your doctor contact the local emergency system
e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You

or a family member should notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been notified timely

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

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

You pay 50 per hospital emergency room visit or 20 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital inpatient services are subject to the hospital admission copay of 100 and the emergency care 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

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 20 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital inpatient services are subject to the hospital admission copay of 100 and the emergency care 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 doctor's services

Ambulance service approved by the Plan

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HMO Colorado HMO Nevada 2000
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 providers emergency care upon receipt of their claims Physician claims should be submitted on the
HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification
information from your ID card to the applicable address
COLORADO MEMBERS HMO Colorado
700 Broadway HB0642
Denver CO 80273
NEVADA MEMBERS HMO Nevada
P O Box 173690 Denver CO 80217 5270

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

16 16
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HMO Colorado HMO Nevada 2000
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental
illness or disorders

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

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay per visit for each covered visit all charges thereafter
Outpatient visit maximums do not apply to members receiving treatment for the following diagnoses schizophrenia schizo affective disorder bipolar affective disorder major

depressive disorder specific obsessive compulsive disorder panic disorder attention deficit disorder or Gilles de la Tourette's syndrome

Inpatient care Up to 45 days of hospitalization each calendar year you pay 100 per admission up to the mental conditions hospital copayment maximum of 100 per Self Only and 300 per Self and
Family enrollment for covered days all charges thereafter This copayment maximum is separate from and in addition to the 100 300 copayment maximum for other hospital

admissions The hospital copay will be waived if a member is re admitted as an inpatient within 72 hours of a discharge with the original diagnosis or complications related to the
original diagnosis Inpatient day limitations do not apply to members receiving treatment for the following diagnoses schizophrenia schizo affective disorder bipolar affective disorder
major depressive disorder specific obsessive compulsive disorder panic disorder attention deficit disorder or Gilles de la Tourette's syndrome

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation
unless determined by a Plan doctor to be necessary and appropriate

Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

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

Outpatient care Up to 20 visits to a Plan provider each calendar year you pay a 10 copay per visit for visits one through five and a 25 copay per visit for visits six through twenty
Inpatient care Up to two 28 day substance abuse rehabilitation intermediate care programs per member per lifetime in an alcohol detoxification or rehabilitation center approved by the Plan you pay
nothing during the benefit period all charges thereafter

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

Care must be received from or arranged by Plan doctors to receive standard HMO benefits
17 17
17 Page 18 19
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor listed on the Plan's drug formulary and obtained at a Plan Pharmacy will be dispensed for up to a 34 day supply You pay a 5
copay for Generic drugs 15 copay for Brand Name drugs and 30 copay per prescription or
refill for formulary drugs If a formulary generic is available to the pharmacy and either the
covered member of provider requests the brand name equivalent drug the member will be
responsible for paying the 15 copay plus the cost difference between the brand name and
generic drugs Emergency prescriptions are reimbursable at 100 of charges minus the copay
Non formulary drugs may be covered only when the prescribing physician submits
documentation of medical necessity and receives approval from the Plan prior to the member
obtaining the drug

HMO Colorado administers a drug formulary which is developed by our Pharmacy and
Therapeutics P T committee The P T committee is comprised of physicians and
pharmacists and meets quarterly to evaluate drugs for formulary consideration Formulary
exceptions are handled on a cases by case basis Providers may request coverage of nonformulary
drugs by presenting evidence of medical necessity for the use of the non formulary
drug The medical director or pharmacy direction makes the determination on non formulary
coverage exceptions based on the evidence provided by the prescriber

Maintenance drugs by mail You may receive up to a 90 day supply of maintenance drugs through the mail by using the Plan's Managed Prescription Mail Service Program You pay one
copay for a 30 day supply and two copays for either a 60 day or 90 day supply If a formulary generic is available to the pharmacy and either the covered member of provider requests the
brand name equivalent drug the member will be responsible for paying the 15 copay plus the cost difference between the brand name and generic drugs For more information on how to
receive maintenance drugs by mail call the Plan's Customer Service Department at 303 831 0161 in the metropolitan Denver area and 800 334 6557 elsewhere in the state In
Nevada call 800 438 5270

Covered medications and Drugs for which a prescription is required by Federal law accessories include
Insulin disposable needles and syringes and blood glucose test strips and supplies

Prescription oral contraceptives and contraceptive devices purchased from a plan pharmacy
Limited Benefit Intravenous fluids and medication for home use covered implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits

Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay 5 copay up to the dosage limits and all charges above that

What is not covered Drugs not listed in the Plan's formulary Exceptions to this exclusion may be provided by HMO Colorado upon receipt of documentation of medical necessity from the prescribing
provider

Drugs available without a prescription or for which there is a marketed non prescription equivalent available

Drugs obtained at a non Plan pharmacy except for emergencies
Nutritional substances
Medical supplies such as dressings and antiseptics
Therapeutic devices or appliances such as support garments
Fertility drugs
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation
Appetite suppressants

Care must be received from or arranged by Plan doctors to receive standard HMO benefits 18 18
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HMO Colorado HMO Nevada 2000
Other Benefits
Dental care
What is covered This Plan provides the following program of dental services through participating Plan dentists The emphasis is on prevention with preventive and diagnostic dental services
provided with no copayment

The following dental services are provided by participating Plan dentists You pay nothing up to annual benefit allowance of 750 If a provider or member needs to verify enrollment or
has questions or concerns please call 800 231 2583 for both Colorado and Nevada In Nevada providers and members should mail all claims to Blue Cross and Blue Shield of
Nevada 555 Middle Creek Parkway MS 420 Colorado Springs CO 80921 3634

DIAGNOSTIC PREVENTIVE
Initial Oral Examination Prophylaxis cleaning at six month intervals

Periodic oral examination Fluoride treatment to age 19 at six month intervals at six month intervals
Emergency oral examination Oral hygiene instructions during regular office hours
Full mouth X rays Consultation one per year if necessary
Panoramic X ray one per year if necessary
Intra oral periapical X ray s
Bitewing X ray s at six month intervals

Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are covered when care is rendered within 72 hours of the accident The need for these
services must result from an accidental injury not biting or chewing occurring while the member is covered under the FEHB Program You pay a 50 copay per visit

What is not covered Other dental services not shown as covered
Dental care received later than 72 hours after an accident

Care must be received from or arranged by Plan doctors to receive standard HMO benefits 19 19
19 Page 20 21
Point of Service Benefits
Facts about Point of At your option you may choose to obtain benefits covered by this Plan from any doctor or Service hospital whenever you need care except for the benefits listed below under What is not
covered Benefits not covered under Point of Service Benefits must either be received from or arranged by Plan doctors to be covered When you obtain covered 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

Provider Choices Participating Provider A provider who has an agreement with Blue Cross and Blue Shield of Colorado Nevada BCBSCONV to accept as payment in full the Plan's payment plus the
member's deductible copayment and penalty amounts if any When a participating provider is used the member does not file a claim form

Nonparticipating Provider Providers and facilities that do not have an agreement with BCBSCONV Members are responsible for paying all billed charges to the non Plan provider
including any amount greater than the Plan's maximum allowable fee Members must pay applicable deductibles coinsurance and penalty amounts Members may have to file their
own claim forms
To receive a Participating Provider Directory call the Plan's Customer Service Department at 303 831 0161 or 800 334 6557 in Colorado or 800 438 5270 in Nevada

What is covered Covered services are paid after you have satisfied the calendar year deductible of 250 per Self Only enrollment and 500 per Self and Family enrollment After the deductible is met
the Plan will pay 70 percent of the first 2,500 of the maximum allowable fee per Self Only enrollment or the first 5,000 of the maximum allowable fee per Self and Family enrollment

and 100 percent of the maximum allowable fee thereafter

Care must be received from or arranged by Plan doctors to receive standard HMO benefits 20 20
20 Page 21 22
Precertification
Precertification ensures that benefits are provided for medically necessary care The precertification process must be completed and the deductible must be satisfied for you to
receive full POS benefits for all non emergency admissions rehabilitative services durable medial equipment and home health care Please note Failure by you to precertify these
services from a non participating provider will result in an additional obligation of 20 percent for a total of 50 percent coinsurance on the part of the member

To precertify services you must call the Plan's Health Services Department at 800 526 4662 in Colorado Mountain Time and 800 626 4666 in Nevada Pacific Time between the hours
of 8 a m and 4 30 p m

Coinsurance The member pays 30 percent of the maximum allowable fee and all charges above the maximum allowable fee except where noted

Maximum Benefit Covered POS services are limited to 1,000,000 per member per lifetime
What is not covered The POS Benefit does not cover ambulance service inpatient and outpatient mental conditions and substance abuse hospice care diagnosis and treatment of infertility organ
transplants skilled nursing facility care and preventive care services except an annual gynecological examination

How to obtain benefits Participating and Non participating Blue Cross and Blue Shield of Colorado Nevada providers should file your claims promptly to the applicable address
COLORADO PROVIDERS HMO Colorado
700 Broadway HB0642
Denver CO 80273
NEVADA PROVIDERS HMO Nevada
P O Box 173690 Denver CO 80217 3690

Care must be received from or arranged by Plan doctors to receive standard HMO benefits 21 21
21 Page 22 23
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB
premium and any charges for these services do not count toward any FEHB deductibles point of service maximum benefits or out ofpocket maximums These benefits are not subject to the FEHB disputed claims procedures

Medicare prepaid plan enrollment This Plan offers Medicare recipients in Colorado the opportunity to enroll in the Plan through Medicare without payment of an FEHB
premium As indicated on page 28 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 303 831 3000 for information on the Medicare prepaid plan and
the cost of that enrollment
If you are Medicare eligible and interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan call 303 831 3000 for information on the benefits available under the Medicare HMO

The above Medicare Product is not available from this Plan in Nevada
Added values for Colorado and Nevada FEP enrollees HMO Colorado HMO Nevada has contracted with Cole Vision to provide a large network where you may obtain a discounted vision
exam and other services such as frames and lenses at a substantial discount This replaces the exam once every two years and allows you to obtain routine exams whenever you wish For information on the nearest provider in your area please call 800 804 4384 Of
course if you need eye treatment because of a medical condition you should obtain a referral from your PCP just as you have in the past

HealthAdvantage is an educational and self help program to assist you in management of your own health conditions A 24 hour 800 number is available providing round the clock health information and counseling from an RN You will receive the number
with your enrollment information
Added values for Colorado FEP enrollees only A voluntary comprehensive dental program is available which provides coverage in addition to the benefits shown on page 19 of this
brochure Coverage is available for certain oral surgery endodontics restorative periodontal and prosthodontic services There is a separate annual premium you must pay if you choose to take this additional coverage
For more information please call 800 231 2583

22
Benefits on this page are not part of the FEHB contract 22
22 Page 23 24
HMO Colorado HMO Nevada 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 or hospitals 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
Expenses you incurred while you were not enrolled in this Plan

23 23
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HMO Colorado HMO Nevada 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us

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

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

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

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

Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines

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

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

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures

24 24
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HMO Colorado HMO Nevada 2000
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws

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

Medicaid We pay first if both Medicaid and this Plan cover you

Other We do not cover services and supplies that a local State or Federal Government agency directly or Government indirectly pays for
Agencies

25 25
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HMO Colorado HMO Nevada 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website www opm gov lists the specific types of information that we must make
available to you

If you want specific information about us call write or fax to
COLORADO NEVADA
800 334 6557 or 303 831 0161 800 438 5270
HMO Colorado HMO Nevada
700 Broadway P O Box 173690
Attn CS0414 Denver CO 80217 3690
Denver CO 80273
Fax 303 839 8566 Fax 303 764 7088
You may also visit our website at www bcbsco com

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

When your enrollment ends and
The next Open Season for enrollment

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

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1 When you retire you can usually stay in the FEHB Program Generally you must have been
What happens when enrolled in the FEHB Program for the last five years of your Federal service If you do not meet I retire this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section

26 26
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HMO Colorado HMO Nevada 2000
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your
available for me and employing or retirement office authorizes coverage for Under certain circumstances you may my family also get coverage for a disabled child 22 years of age or older who is incapable of self support

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

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

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

Are my medical and We will keep your medical and claims information confidential Only the following will have claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

OPM when reviewing a disputed claim or defending litigation about a claim

27 27
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HMO Colorado HMO Nevada 2000
Information Information for for new new members 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 Your old plan's deductible continues until our coverage begins deductible under my
old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled

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

28 28
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HMO Colorado HMO Nevada 2000
How do I enroll in If you are leave Federal service your employing office will notify you of your right to enroll TCC 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

How can I convert You may convert to an individual policy if to individual
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or coverage 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 If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when
Health Plan getting health insurance or other health care coverage You must arrange for the other coverage 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

29 29
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HMO Colorado HMO Nevada 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 800 334 6557 or 303 831 0161 in Colorado or 800 438 5270 in Nevada 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
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HMO Colorado HMO Nevada 2000
Summary of Benefits for HMO Colorado HMO Nevada 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 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 a 100

copay per admission up to an annual hospital copay maximum of 100 per Self Only and 300 per Self and Family enrollment 13 14

Extended care All necessary services for up to 30 days per year You pay nothing 13
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 45 days of Inpatient care per year You pay a 100 copay per admission up to an annual mental conditions

hospital copay maximum of 100 per Self Only and 300 per Self and Family enrollment this copayment maximum is separate from and in Addition to the annual
hospital copay maximum 13
Substance abuse Two 28 day treatment programs per lifetime You pay nothing 17
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or Injury care 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 copay per office visit nothing per house call by a doctor 10 12

Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions Up to 20 outpatient visits per year You pay 10 copay per visit 17
Substance abuse Counseling visits with Plan providers You pay a 10 copay per visit for Visits 1 5 and a 25 copay for visits 6 20 17

Emergency Reasonable charges for services and supplies required because of a medical emergency care You pay a 50 copay to the hospital for each emergency room visit and any charges for
services that are not covered by this Plan 15 16
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You may pay a drugs 5 15 30 copay per prescription unit or refill plus the difference in cost if a name

brand drug is prescribed when a generic is available 18
Dental care Accidental injury benefits you pay a 50 copay per visit Diagnostic and Preventive dental care you pay nothing up to 750 annual Plan benefit per Person 19

Vision care No current benefit
Out of pocket Copayments are required for a few benefits however the Plan has set a Maximum of maximum 4,400 per Self Only or 10,500 per Self and Family enrollment per calendar year for
total copays you must pay for services covered by the Plan This copay maximum does not include the cost of prescription drugs 5

31 31
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2000 Rate Information for
HMO Colorado HMO Nevada

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

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

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

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share
Share Share Share Share Share Share Share

Most of Nevada Self Only
VS1 78.83 36.51 170.80 79.10 93.06 22.28 93.26 22.08
Self and Family VS2 175.97 99.53 381.27 215.65 207.74 67.76 201.02 74.48

Most of Colorado Self Only L21 77.49 25.83 167.90 55.96 91.70 11.62 91.70 11.62
Self and Family L22 175.97 82.37 381.27 178.47 207.74 50.60 201.02 57.32

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