Health Net 2000
A Health Maintenance Organization
For changes
Serving Most of California in benefits 4 5
see Pages
Enrollment in this plan is limited see page 5 for requirements
Enrollment Code LB1 Self Only LB2 Self and Family
Visit the OPM web site at http www opm gov insure
and Health Net's web site at http www healthnet com
Authorized for distribution by the
United States Office of
Personnel Management Federal Employees
Health Benefits Program
HEALTH NET 2000
Table of Contents Page
Introduction
2
Plain language
2
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
10
Section 5 Benefits
13
Section 6 General exclusions Things we don't cover
24
Section 7 Limitations Rules that affect your benefits
24
Section 8 FEHB facts
26
Department of Defense FEHB Demonstration Project
30
Inspector General Advisory Stop Healthcare Fraud
31
Summary of benefits
32
Premiums
34
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HEALTH NET 2000
Introduction
Health Net
P O Box 9103
Van Nuys CA 91409 9103
This brochure describes the benefits you can receive from Health Net HMO under its contract CS2002 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 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 Health Net HMO 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
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HEALTH NET 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs
and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision
not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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HEALTH NET 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals
and other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for
illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim
forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot
change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will
be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing
any course of treatment
Section 2 How we change for 2000
Program wide 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 five
years This screening is for colorectal cancer
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HEALTH NET 2000
Changes to this Plan Your share of the premium will increase by 1.7 for Self Only or for Self and Family
The office visit copay has increased from 5 per visit to 10 per visit
There will be no office visit copay required for routine immunizations and boosters and
allergy testing and treatment including allergy serum
Unlimited self referrals are allowed for Obstetrician and Gynecological services See
page 9
After the first 48 hours the length of hospital stays related to mastectomies will be
determined solely by the physician See page 14
The prescription drug copays have increased from 5 per prescription and 10 per mail
order for a 90 day supply to 5 per prescription for generic drugs listed on the Plan's
formulary 10 per name brand drugs listed on the Plan's formulary 25 per non formulary
drugs and 10 per generic and 20 per name brand mail order drugs for a 90 day supply
Non formulary mail order drugs are covered with a 50 copay per 90 day supply Some
non formulary drugs may require prior authorization from the Plan See page 20
Diabetic supplies have increased to include test strips and lancets under the prescription
drug benefit See page 20
Benefits have been clarified for immunizations for occupational purposes to indicate that
you pay 20 of charges See page 13
Section 3 How to get benefits
What is this To enroll with us you must live or work in our Health Net service area This is where our
Plan's service area providers practice Our service area is
Full counties Alameda Butte Colusa Contra Costa Glenn Humboldt Kings Lake Los
Angeles Madera Marin Mariposa Merced Napa Orange Sacramento San Diego San
Francisco San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Sierra
Solano Sutter Ventura Yolo and Yuba counties
Partial counties El Dorado Fresno Imperial Kern Mendocino Nevada Placer Plumas
Riverside San Bernardino San Joaquin Sonoma Stanislaus Tehama Trinity and Tulare
counties The following ZIP codes are those included in these partial counties
EL DORADO
95613 14 95633 36 95664 95682 95726
95619 95643 95667 95684 95762
95623 95651 95672 95709
FRESNO
93210 93624 25 93660 93724 29 93771 80
93234 93627 28 93662 93740 41 93782
93242 93630 93664 93744 45 93784
93602 93634 93667 68 93747 93786
93605 09 93640 41 93675 93750 93790 94
93611 13 93648 52 93701 12 93755
93616 93654 93714 18 93759 62
93621 22 93656 57 93720 22 93764 65
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HEALTH NET 2000
IMPERIAL
92274 75
KERN
93203 93238 93276 93311 13 93518 19
93205 06 93240 41 93280 93380 90 93523 24
93215 17 93249 52 93283 93399 93531
93220 93255 93285 93501 02 93560 61
93222 93263 93287 93504 05 93581 82
93224 26 93268 93301 09 93516 93596
MENDOCINO
95415 95445 95449 95463 95482
NEVADA
95712 95945 46 95959 95977
95924 93949 95975
PLACER
95602 04 95658 95681 95717 95765
95631 95661 95701 95722
95648 95663 95703 95736
95650 95677 78 95713 14 95746 47
PLUMAS
95981 96105 06 96129
96103 96122 96135
RIVERSIDE
91718 20 92240 41 92501 09 92561 64
91752 92253 55 92513 19 92567
91760 92258 92521 22 92570 72
92201 03 92260 64 92530 32 92581 87
92210 11 92270 92536 92589 93
92220 92276 92539 92595 96
92223 92282 92543 46 92860
92230 92292 92548 49 92880
92234 36 92320 92551 57 92882
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HEALTH NET 2000
SAN BERNARDINO
91701 91798 92321 22 92356 59 92410 16
91708 10 92252 92324 27 92365 92418
91729 30 92256 92329 92368 69 92420
91737 92268 92333 37 92371 78 92423 24
91739 92277 78 92339 42 92382 92427
91743 92284 86 92345 47 92385 86
91758 59 92301 92350 92391 94
91761 64 92305 92352 92397 99
91784 86 92307 18 92354 92401 08
SAN JOAQUIN
95201 13 95231 95253 95304 95366
95215 95234 95258 95320 95376
95219 20 95236 37 95267 95330 95378
95227 95240 42 95269 95336 37 95385 86
SONOMA
94922 23 95401 09 95433 95448 95476
94926 28 95416 95436 95450 95486 87
94931 95419 95439 95452 95492
94951 55 95421 95441 42 95462
94975 95425 95444 95465
94999 95430 31 95446 95471 73
STANISLAUS
95230 95316 95326 95360 61 95380 82
95307 95319 95328 95363 95386 7
95313 95323 95350 58 95367 68
TEHAMA
96021 and 96055
TRINITY
95526
TULARE
93201 93235 93265 93286 93646 47
93207 08 93237 93267 93291 92 93666
93218 19 93244 93270 72 93603 93670
93221 93247 93274 75 93615 93673
93223 93256 58 93277 79 93618
93227 93260 61 93282 93631
Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care We will not pay for any other
health care services
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HEALTH NET 2000
If you or a covered family member move outside of our service area you can enroll in
another plan If your dependents live out of the area for example if your child goes to
college in another state you should consider enrolling in a fee for service plan or an HMO
that has agreements with affiliates in other areas When a dependent resides outside of the
service area including a child under a Medical Court Order coverage will be limited to
emergency services only If you or a family member move you do not have to wait until
Open Season to change plans Contact your employing or retirement office
How much do I pay for You must share the cost of some services This is called either a copayment a set dollar
services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for medically necessary medical or surgical care
received in a hospital or extended care facility and rehabilitation therapy
After you pay 1,500 in copayments or coinsurance for one family member or 4,500 for
two or more family members you do not have to make any further payments for the rest of
the year with Health Net This is called a catastrophic limit However copayments or
coinsurance for your prescription drugs do not count toward these limits and you must
continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are
responsible for informing us when you reach the limits
Do I have to submit You normally won't have to submit claims to us unless you receive emergency services
claims from a provider who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of
the year after the year you received the service Either OPM or we can extend this deadline if
you show that circumstances beyond your control prevented you from filing on time
Who provides my Health Net is a Mixed Model MMP HMO and has an extensive network of over 600
health care contacting physician groups and 415 hospitals conveniently located in the communities
where you work and live Over 36,000 primary care and referral specialist physicians are
affiliated with Health Net through our contracting physician groups
A Health Net member must select a contracting physician group within a 30 mile radius of
his or her home or work site Although all members may choose their own primary care
doctor and contracting physician group we encourage family members to choose their
primary care doctors within the same physician group This helps Plan administration and
will strengthen your family's doctor patient relationships
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HEALTH NET 2000
Members may transfer to another contracting physician group by notifying Health Net of
their request to transfer Call 1 800 522 0088 You may change physician groups during open
season upon change of address when you exercise the once a month transfer option or upon
approval of Health Net All transfers will become effective on the first day of the month
following Health Net's receipt of the transfer provided such request is received by the 14th
of the month Such requests will not be honored if you are more than three months pregnant
confined to a hospital in a surgery follow up period not yet released by the surgeon or
receiving treatment for an illness if the treatment is not complete
What do I do if my Call us We will help you select a new one
primary care physician
leaves the Plan
What do I do if I 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 Member Services department at 1 800 522 0088 If you are new to the FEHB
the hospital when I join Program we will arrange for you to receive care If you are currently in the FEHB Program
this Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Your primary care physician will arrange your referral to a specialist or other health care
care provider with the following exceptions a woman may see her participating gynecologist at
anytime and members may self refer to a participating chiropractor as described on page 15
If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician will develop a treatment plan that allows you to see
your specialist for a certain number of visits without additional referrals Your primary care
physician will use our criteria when creating your treatment plan
What do I do if I am Prior to enrolling call our Member Services Department at 1 800 522 0088 to see if your
seeing a specialist when I current specialist is affiliated with Health Net through one of our contracting physician
enroll groups This may help you to choose a physician group more suitable for your specific needs
Your primary care physician will decide what treatment you need If they decide to refer you
to a specialist ask if you can see your current specialist If your current specialist does not
participate with us you must receive treatment from a specialist who does Generally we will
not pay for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see someone else
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But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to
serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating
provider leaves the Plan our contract with the provider unless the termination is for cause If you are in the second or
or this Plan leaves the third trimester of pregnancy you may continue to see your OB GYN until the end of your
Program 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 In
addition authorization by the Plan may be required for some formulary and non formulary
prescription drugs
How do you decide if a The Plan's Medical Policy Committee determines what procedures and services are
service is experimental experimental investigational using published peer review medical and surgical literature The
or investigational procedure or service will be evaluated based on its health effects safety quality and cost
effectiveness In some cases the Plan uses an independent medical review for expert
evaluation and determination of coverage
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
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When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or
to review a denial refusal OPM will determine if we correctly applied the terms of our contract when we denied
your claim or request for service
What if I have a Call us at 1 800 522 0088 and we will expedite our review
serious or life
threatening condition
and you haven't
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request for inform OPM so that they can give your claim expedited treatment too Alternatively you can
care and my condition call OPM's health benefits Contract Division IV at 202 606 0737 between 8 a m and 5
is serious or life p m Serious or life threatening conditions are ones that may cause permanent loss of bodily
threatening functions or 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
limits our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your
request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within
30 days In this case OPM must receive your request within 120 days of the date we
asked you for additional information
What do I send to 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
Anyone enrolled in the Plan
The estate of a person once enrolled in the Plan and
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
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What address should Send your request for review to Office of Personnel Management Office of Insurance
I send my disputed Programs Contracts Division IV P O Box 436 Washington D C 20044
claim to
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our
the 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will
file a lawsuit base 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
Privacy 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
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HEALTH NET 2000
Section 5 Health Net Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan
doctors and other Plan providers This includes all necessary office visits you pay a 10
copay per visit Within the Service Area house calls will be provided if in the judgment of
the Plan doctor such care is necessary and appropriate you pay a 20 copay for a doctor's
house call and a 20 a day copay after day 30 for home visits by nurses and health aides
The following services are included
Preventive care including well baby care office visit copay waived for infant through 30
days of life routine physicals periodic checkups and vision and hearing exams
Mammograms are covered as follows for women age 35 through age 39 one mammogram
during these five years for women age 40 through 64 one mammogram every year and for
women age 65 and above one mammogram every two years In addition to routine screening
mammograms are covered when prescribed by the doctor as medically necessary to diagnose
or treat your illness
Routine immunizations and boosters you pay nothing
Immunizations for occupational and foreign travel purposes you pay 20 of charges
Consultations by specialists
Diagnostic procedures including laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor office visit copays 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 cesarean 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 you pay a 150 copay for females and a 50 copay for males and
family planning services including contraceptive devices
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including allergy serum you pay nothing
The insertion of internal prosthetic devices such as pacemakers and artificial joints
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HEALTH NET 2000
Cornea heart heart lung kidney liver lung single and double 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 nonHodgkin's
lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal and
ovarian germ cell tumors selective congenital genetic diseases chronic myelogenous
leukemia aplastic anemia breast cancer epithelial ovarian cancer and multiple myeloma
when determined to be medically necessary and appropriate by Health Net Treatment for
breast cancer multiple myeloma and epithelial ovarian cancer may be provided as part of a
peer reviewed non random clinical trial approved under the guidelines of the National
Institutes of Health Food and Drug Administration or Veterans Administration 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 After the first 48 hours the length of stay will be determined solely by the
physician Surgical reconstruction of a breast as the result of a mastectomy including surgery
to restore symmetry also includes breast prosthesis and treatment of physical complications
at all stages of mastectomies including lymphodomas
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces
Prosthetic devices such as breast prostheses surgical bras and artificial limbs and lenses
following cataract removal
Durable medical equipment such as wheelchairs and hospital beds
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness you pay a 20 copay after the 30th visit
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
Blood blood plasma blood factors and blood derivatives
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization
procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including but
not limited to treatment of fractures and excision of tumors and cysts All other procedures
involving the teeth or intra oral areas surrounding the teeth are not covered including any
dental care involved in treatment of temporomandibular joint TMJ pain dysfunction
syndrome Orthognathic surgery will be provided to correct the malposition or improper
development of the upper or lower jaw to correct a present functional disorder
Reconstructive surgery will be provided to correct a condition resulting from a functional
defect or injury that has produced a major effect on the member's appearance and the
condition can reasonably be expected to be corrected by such surgery A patient and her
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HEALTH NET 2000
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
Rehabilitative therapy will be covered for physical speech occupational and respiratory
you pay nothing Continued significant improvement must appear to be likely for services to
be covered Speech therapy is limited to treatment of certain speech impairments of organic
origin Occupational therapy is limited to services that assist the member to achieve and
maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility including artificial insemination and fertility drugs
for covered services are covered on an inpatient or outpatient basis you pay 50 of
charges The following type s of artificial insemination are covered intravaginal
insemination IVI intracervical insemination ICI and intrauterine insemination IUI you
pay 50 of the charges Cost of donor sperm ova or their collection or storage is not
covered Other assisted reproductive technology ART procedures such as in vitro
fertilization and embryo transfer including any related service or supply e g associated
fertility drugs are not covered
Foot orthotics are covered only when they have been incorporated into a cast splint brace
or strapping of the foot
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial
infarction is provided at a Plan facility for up to 60 consecutive days you pay nothing
Chiropractic services are available to members up to 20 visits per calendar year you pay a
10 copay per visit without referral from a Primary Care Physician Chiropractic appliances
are covered up to a maximum plan payment of 50 This benefit is available through the
chiropractors who participate in Health Net's Chiro Net network
What is not covered Physical examinations that are not necessary for medical reasons such as those required for
obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Hypnotherapy
Experimental or Investigational services
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HEALTH NET 2000
Hospital Care Extended Care Benefits
What is Covered
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit when you
are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
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
Blood blood plasma blood factors and blood derivatives
Extended care The Plan provides a comprehensive range of benefits up to 100 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 for up to 210 days 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
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there
procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will
cover the hospitalization but not the cost of the professional dental services Conditions for
which hospitalization would be covered include hemophilia and heart disease the need for
anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification diagnosis treatment of medical conditions and medical management of withdrawal
symptoms acute detoxification if the Plan doctor determines that outpatient management is
not medically appropriate See page 19 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
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HEALTH NET 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
Emergencies within the If you are in an emergency situation please call your contracting physician group In extreme
service area emergencies if you are unable to contact your medical group contact the local emergency
system i e 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 unless it was not reasonably
possible to do so It is your responsibility to ensure that the Plan has been notified in a timely
manner
If you need to be hospitalized the Plan must be notified within 48 hours or on the first
working day following your admission unless it was not reasonably possible to notify the
Plan within that time If you are hospitalized in non Plan facilities and Plan doctors believe
care can be better provided in a Plan hospital you will be transferred when medically feasible
with any ambulance charges covered in full Benefits are available for care from non Plan
providers in a medical emergency only if delay in reaching a Plan provider would result in
death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been
covered if received from Plan providers
You pay A 35 copay per emergency room visit or urgent care center visit if the urgent care center is not operated by the member's selected contracting physician group a 10 office visit copay
applies at your physician group's urgent care center if the emergency results in admission to
a hospital the copay is waived
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HEALTH NET 2000
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 by a Plan hospital you will be transferred when medically feasible with
any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers
You pay A 35 copay per hospital emergency room visit or urgent care center visit if the emergency
results in admission to a hospital the copay is waived
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
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
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your
non Plan 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
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 10
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HEALTH NET 2000
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below this 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 50 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year
you pay a 30 copay per visit for each covered visit all charges thereafter
There is a 30 charge for missed appointments if the visit is not canceled for good cause at
least 24 hours before the appointment Group therapy sessions count as one half of a private
office visit you pay a 15 copay for each covered visit
Inpatient care Up to 60 days of hospitalization each calendar year you pay nothing for the first 60 days all charges thereafter
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 Services for the psychiatric aspects
are provided in conjunction with the mental conditions benefit shown above Outpatient visits
to Plan providers for treatment are covered as well as inpatient services necessary for
diagnosis and treatment The mental conditions benefit visit day limitations apply to any
covered substance abuse care
What is not covered Treatment that is not authorized by a Plan doctor
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HEALTH NET 2000
Prescription Drug Benefits
What is covered Prescription Drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy
will be dispensed for up to a 30 day supply For each prescription unit or refill you pay a 5
copayment for generic drugs and 10 copayment for brand name drugs When generic
substitution is permissible i e a generic drug is available and the prescription order does not
state do not substitute or dispense as written in the prescribing doctor's handwriting but
you request the brand name drug you pay the difference between the generic and the brand
name drug as well as the 10 copayment per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug
formulary Non formulary drugs are covered when prescribed by the Plan doctors For each
non formulary prescription unit or refill you pay 25 for a 30 day supply
Maintenance drugs may be obtained through a mail order prescription drug program for up to
a 90 day supply per order You pay a 10 copayment for Generic Drugs and a 20 copayment
for brand name drugs that are listed in the Plan's formulary For non formulary drugs you pay
50 The prescribed supply may not always be an appropriate drug treatment plan according
to FDA or the Plan's usage recommendations If this is the case the amount of medication
dispensed may be reduced
Some Formulary and Non formulary drugs may require prior authorization from the Plan For
a copy of the Plan's drug formulary contact the Plan at 1 800 522 0088 or visit the Plan's
web site at www healthnet com
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral contraceptive drugs
Insulin with a copay charge applied to each vial
Diabetic supplies such as blood glucose monitoring strips and lancets
Disposable hypodermic needles and syringes needed for injecting covered prescribed
medication including insulin
Contraceptive devices such as diaphragms and IUDs
Intravenous fluids and medication for home use implantable drugs such as Norplant and
some injectable drugs such as Depo Provera are covered under Medical and Surgical
Benefits
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HEALTH NET 2000
Limited benefits Fertility drugs associated with covered services under the diagnosis and treatment of infertility including artificial insemination are covered under Medical and Surgical Benefits
you pay 50 of charges Fertility drugs associated with procedures not covered under the
infertility treatment benefit such as in vitro fertilization and embryo transfer are not covered
Drugs to treat sexual dysfunction are limited Contact the Plan for dosage limits at
1 800 522 0088 You pay 50 of charges up to the dosage limits and all charges above that
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Anorectics appetite suppressants except for treatment of morbid obesity
Smoking cessation products
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HEALTH NET 2000
Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth are covered The need for these services must result from an accidental injury not biting
or chewing You pay nothing at the dentist's office and a 35 copayment at the emergency
room
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of
diseases of the eye annual eye refractions to provide a written lens prescription may be
obtained from Plan providers you pay a 10 copay per visit
What is not covered Eye exercises
Eyeglasses contact lenses or the fitting of contact lenses
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HEALTH NET 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are
made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included
in the FEHB premium any charges for these services do not count toward any FEHB deductibles or out of pocket maximums
These benefits are not subject to the FEHB disputed claims procedure
Optional Eyewear The Vision One Discount Program is being extended to you by Health Net No extra
Coverage premiums or deductibles are required The plan offers you savings of up to 20 on eyewear
at stores you already know including Sears Montgomery Ward JC Penney stores and
selected Pearle Vision locations For more information on this program contact Health Net's
Member Services department at 1 800 522 0088
Optional Dental For a small monthly premium as a supplement to your Federal Employees Health Benefits Benefits program Health Net Members have the option to join the Denticare Dental Plan Please note
new Members must complete a Denticare application form and agree to pay its monthly
premiums in order to be enrolled in a dental plan
Denticare's Managed The Denticare plan offers Members a broad spectrum of dental coverage at a lower outof
Dental Care Plan pocket cost to the Member You are able to individually choose a general dentist from
Option DHMO a network of credentialed dentists and may change this selection monthly Once you are
enrolled your selected dentist will provide diagnostic and preventive services at no charge
to the Member and other dental services at a significantly reduced fee
To receive more information about enrolling in the Denticare Dental Plan simply complete
and return the postage paid card included in your Health Net information kit or call 1 800
999 2848
Medicare Prepaid Plan This Plan offers Medicare recipients the opportunity to enroll in the Plan Health Net
Enrollment Seniority Plus program through Medicare As indicated on page 24 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 Health Net Seniority Plus but will have to pay for Medicare Part A
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 1 800 935 6565 for information on the Health Net Seniority Plus Medicare
prepaid plan and the cost of that enrollment If you are eligible for Medicare and are
interested in enrolling in a Medicare HMO sponsored by Health Net without dropping your
enrollment in Health Net's FEHB plan call 1 800 935 6565 for information on the benefits
available under the Medicare HMO
Benefits on this page are not part of the FEHB contract
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HEALTH NET 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it
unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible selfreferred
services
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the
fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not covered under this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the
payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in
a Medicare Choice plan when one is available in your area For information on suspending
your FEHB enrollment and changing to a Medicare Choice plan contact your retirement
office If you later want to re enroll in the FEHB Program generally you may do so only at
the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you
may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program
and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the
Medicare Choice plan offered by this Plan call us at 1 800 596 6565 or see page 23
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HEALTH NET 2000
Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage 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 beyond Under certain extraordinary circumstances we may have to delay your services or be unable
our control to provide them In that case we will make all reasonable efforts to provide you with
necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or
responsible for injuries illness 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
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HEALTH NET 2000
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency
Agencies directly or indirectly pays for
If you have a If you have a malpractice claim because of services you did or did not receive from a plan
malpractice claim provider such claim shall not include this Plan only the provider subject to the allegation
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
information about your the right to information about your health plan its networks providers and facilities You can
HMO 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 web site www opm gov lists the specific types of information that
we must make available to you
If you want specific information about us call 1 800 522 0088 or write to Health Net P O
Box 10348 Van Nuys CA 91410 0348 You may visit our web site at www healthnet com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to
information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the FEHB need to make an informed decision about
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 benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
effective January 1 Annuitants premiums begin January 1
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HEALTH NET 2000
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been
I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not
meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and
are available for me and your unmarried dependent children under age 22 including any foster or step children your
my family 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
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
This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal
actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose
your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election
Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
What if I paid a deductible Your old plan's deductible continues until our coverage begins
under my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had
before you enrolled in this Plan solely because you had the condition before you enrolled
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HEALTH NET 2000
When you lose 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 spouse If you are divorced from a Federal employee or annuitant you may not continue to get
coverage benefits under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating
a divorce contact your ex spouse's employing or retirement office to get more information
about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC
For example you can receive TCC if you are not able to continue your FEHB enrollment
after you retire You may not elect TCC if you are fired from your Federal job due to gross
misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay
premiums from the 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
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HEALTH NET 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
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 convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage
or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement
office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will
not have to answer questions about your health and we will not impose a waiting period or
limit your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan
Certificate of Group Coverage that indicates how long you have been enrolled with us You can use this certificate
Health Plan Coverage when getting health insurance or other health care coverage You must arrange for the other
coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting
periods limitations or exclusions for health related conditions based on the information in the
certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in
other FEHB plans you may request a certificate from them as well
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HEALTH NET 2000
Department of Defense FEHB Demonstration Project
What is the Department of Defense DoD and FEHB Program Demonstration Project
1 The National Defense Authorization Act for 1999 Public Law 105 261 established the DoD FEHBP Demonstration Project
It allows some active and retired military members and their dependents to enroll in the FEHB Program The demonstration
will last for 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 You may enroll if
You are an active or retired military member and are eligible for Medicare
You are a dependent of an active or retired military member and are eligible for Medicare
You are a former spouses of an active or retired military member who has not remarried or
You are a survivor dependent of a deceased active or retired military member and
You live in one of the eight geographic demonstration areas
2 If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you are not eligible to
enroll under the DoD FEHBP Demonstration Project
Where Are The Demonstration Areas
Dover AFB DE Dallas TX
Commonwealth of Puerto Rico Humboldt County CA area
Fort Knox KY Naval Hospital Camp Pendleton CA
Greensboro Winston Salem High Point NC 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
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
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HEALTH NET 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 1 800 522 0088 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
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HEALTH NET 2000
Summary of Benefits for Health Net 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and
exclusions we set forth in this 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 CHIROPRACTIC CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED
BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services
without dollar or day limit Includes in hospital doctor
care room and board general nursing care private
room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of
operating room intensive care and complete maternity
care You pay nothing .16
Extended All necessary services for up to 100 days per calendar
Care year You pay nothing .16
Mental Diagnosis and treatment of acute psychiatric conditions
Conditions for up to 60 days of inpatient care per year You pay nothing .19
Substance Covered under Mental Conditions .19
Abuse
Outpatient care Comprehensive range of services such as diagnosis and
treatment of illness or injury including specialist's care
preventive care including well baby care periodic
checkups and routine immunizations laboratory tests
and X rays complete maternity care You pay a 10
copay for office visits a 20 copay per house call by a
doctor copays are waived for maternity care .13
Home health All necessary visits by nurses and health aides You pay
care nothing for the first 30 days and you pay a 20 a day
copay starting on day 31 .16
Mental Up to 50 outpatient visits per year You pay a 30 copay
Conditions per visit There is a 30 charge for missed appointments
if the visit is not cancelled for good cause at least 24 hours
before the appointment Group therapy sessions count as
one half of a private office visit you pay 15 for each
covered visit .19
Substance Covered under Mental Conditions .19
Abuse
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HEALTH NET 2000
Emergency care Reasonable charges for services and supplies required because of a medical emergency
You pay a 35 copay per emergency room visit
or non Plan urgent care center visit and any
charges for services that are not covered by this Plan 17
Prescription drugs Drugs prescribed by a Plan doctor and obtained at
a participating pharmacy You pay a 5 copay for
generic drugs and 10 copayment for name brand
drugs per prescription or refill For Non formulary
drugs you pay 25 For mail order drugs up to a
90 day supply you pay a 10 copay for generic drug
and 20 for name brand drugs For non formulary
mail order drugs you pay a 50 copay 20
Dental care Accidental injury benefit you pay nothing at a dentist's office or a 35 copay at the emergency room
22
Vision care One refraction annually you pay a 10 copay per visit 22
Out of pocket limit Copayments are required for a few benefits however
after your out of pocket expenses reach a maximum of
1,500 per Self Only or 4,500 per Self and Family
enrollment per calendar year covered benefits will be
provided at 100 percent This copay maximum does
not include prescription drugs .8
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HEALTH NET 2000
2000 Rate Information for Health Net
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to an 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 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 Benefit
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 California
Self Only LB1 61.28 20.42 132.77 44.25 72.51 9.19 72.51 9.19
Self and Family LB2 145.04 48.35 314.26 104.75 171.63 21.76 171.63 21.76
34 8214 10 99 35