Keystone
Health Plan 2000
Central
A Health Maintenance Organization
For changes
in benefits
see page 5
Serving The Lehigh Valley Northern Tier and Harrisburg Pennsylvania areas
Enrollment in this Plan is limited see page 6 for
enrollment requirements
Enrollment code
S41 Self only
S42 Self and family
This Plan has full accreditation with a ranking of
Commendable from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure
and
our website at http www khpc com
Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
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Keystone Health Plan Central HMO 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 11
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
Inspector General Advisory Stop Healthcare Fraud 30
Summary of benefits 31
Premiums 32
Keystone Health Plan Central HMO 2000
Introduction
Keystone Health Plan Central Inc
P O Box 898812
Camp Hill PA 17089 8812
This brochure describes the benefits you can receive from Keystone Health Plan Central under its contract
CS 2076 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 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 Keystone Health Plan Central 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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Keystone Health Plan Central HMO 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
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific
physicians hospitals and other providers that contract with us These providers coordinate your health care
services The care you receive includes preventative care such as routine office visits physical exams wellbaby
care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills
However you must pay copayments and coinsurance listed in this brochure When you receive emergency
services from non Plan providers you may have to pay for the services and submit itemized bills and your
receipts to the Plan with an explanation of the services and the identification information from your ID card
You should join an HMO because you prefer the plan's benefits not because a particular provider is
available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one
physician or group of physicians hospital or other provider will be available and or remain under contract
with us Our providers follow generally accepted medical practice when prescribing any course of
treatment
Keystone Health Plan Central HMO 2000
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of
changes 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
Changes to
this Plan Your share of Keystone Central Health Plan's non postal premium will increase by 17.1 for Self Only or 13.9 for Self and Family
Mental Health Substance Abuse Outpatient Mental Health Benefits have been
enhanced to include up to 60 outpatient visits per calendar year for serious
mental illness subject to a 25 copayment per visit Inpatient Mental Health
Benefits have been enhanced to include up to 30 days per calendar year for
serious mental illness Unused calendar inpatient days may be exchanged on a
one for two basis to secure additional outpatient benefits
Diabetic Supplies Coverage has been enhanced for equipment supplies
training and education for diabetics non insulin dependent as well as insulin
dependent Equipment and supplies include such items as blood glucose
monitors monitor supplies insulin injection aids syringes insulin infusion
devices pharmacological agents for controlling blood sugar and orthotics
Members can obtain Diabetic Supplies such as needles syringes lancets test
strips and alcohol wipes pads with any diagnosis of diabetes through the
Prescription Drug benefit prescription is required to an Express Scripts Value
Rx pharmacy and copayments apply without reimbursement option Insulin
Infusion devices and orthotics for diabetics maybe obtained through a Keystone
Health Plan Central participating Durable Medical Equipment supplier with a
referral Any equipment to exceed 100 requires prior authorization from the
plan
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Keystone Health Plan Central HMO 2000
Diabetic Eye exam Diabetes particularly diabetic retinopathy is the leading
cause of adult blindness Detection and early treatment are important in
preventing loss of vision In an effort to improve care and to encourage
members with diabetes to have a yearly eye examination Keystone Health Plan
Central will allow diabetic members one yearly self referral for a diabetic
retinopathy screening to a Keystone Health Plan Central participating
ophthalmologist or optometrist and any applicable copayment will be waived
for that visit Refractions remain a non covered service and any such charges
incurred are the responsibility of the member All eligible diabetic members
will be sent a letter each calendar year that they must take to the appointment
with the participating eye specialist
Section 3 How to get benefits
What is this
Plan's service To enroll with us you must live or work in our service area This is where our
area providers practice Our service area is
Lehigh Valley The Pennsylvania counties of Lehigh and Northampton
Harrisburg The Pennsylvania counties of Adams Berks Cumberland
Dauphin Lancaster Lebanon Perry Schuylkill and York
Northern Tier The Pennsylvania counties of Centre Columbia Juniata
Mifflin Montour Northumberland Snyder and Union
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
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
As a Keystone Health Plan Central member you have access to physician care
for urgent medical situations when you are away from home through HMO
Blue USA a nationwide network of Blue Cross and Blue Shield HMOs HMO
Blue USA is one of the largest HMO networks in the country offering coverage
in more than 200 cities If you become ill while visiting one of these cities
contact the HMO Blue USA network at 1 800 4HMO USA This number is
also found on the back of your ID card The HMO Blue USA referral
coordinator will schedule an appointment with an HMO Blue USA physician in
the area from which you are calling No office visit copayments will be
required and you will not need to file a claim
Your away from home travel isn't always measured in day trips or week
vacations That's why we also provide care when someone's away a long time
whether it's extended out of town business semesters at school or families
living apart For anyone away at least 90 days we offer Guest Membership at
an affiliated HMO near your travel destination Guest Membership allows you
or your family to enjoy the full range of benefits offered by the Host HMO
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Keystone Health Plan Central HMO 2000
For more details please contact KHPC at 1 800 622 2843 and ask to speak
with the HMO Blue USA Guest Membership Coordinator
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 You must share the cost of some services This is called either a copayment a
I pay for set dollar amount or coinsurance a set percentage of charges Please
services remember you must pay this amount when you receive services Your out ofpocket expenses are limited to the copayments stated in this brochure
Do I have to You normally won't have to submit claims to us unless you receive emergency
submit claims services from a provider who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You
must submit claims by December 31 of the year after the year you received the
service Either OPM or we can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time
Who provides Keystone Health Plan Central is an Individual Practice Prepayment IPP Plan
my health Each member selects a primary care physician PCP from among the Plan's
care participating Family Practitioners Internists and Pediatricians There are currently over 1,500 primary care physicians who participate in the plan
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 Talk to your Plan physician If you need to be hospitalized your primary care
I need to go physician or specialist will make the necessary hospital arrangements and
into the supervise your care To be eligible for coverage all hospital admissions must
hospital be prior authorized through Keystone Health Plan Central
What do I do if First call our customer service department at 800 622 2843 TDD 1 800 669
I'm in the 7075 for the hearing impaired If you are new to the FEHB Program we will
hospital when I arrange for you to receive care If you are currently in the FEHB Program and
join this Plan are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 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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Keystone Health Plan Central HMO 2000
How do I get
specialty care Your primary care physician will arrange your referral to a specialist If your PCP determines that you need specialized services he or she will provide you
with a Referral form to the appropriate Participating Provider Some services
will also require Prior Authorization from KHPC If you wish to change the
Specialist to whom you have been referred contact your PCP for a new
Referral form
Your PCP will give you a Referral for Medically Necessary care The Referral
form will indicate the services to be performed by the Specialist or facility The
Specialist or facility must contact the PCP before providing additional services
not listed on the form In some cases you will be required to obtain an
additional Referral form from the PCP for the requested additional services It
is important to note that all laboratory services must be obtained using the
PCP's laboratory arrangement listed on your ID card Referrals are good only
for the Provider listed on the Referral form If you need additional services or
if you need to see another Provider you should call your PCP
Certain services require Prior Authorization by KHPC's Utilization
Management Department We recommend you consult with your Provider
prior to having services rendered to ensure that he or she has obtained the
proper Prior Authorization from KHPC for the listed services
Obstetrical and Gynecological Care Services provided to you for obstetrical
and gynecological care do not require a Referral from your PCP You are
permitted to contact your Obstetrical Gynecological Specialist directly and seek
treatment The services permitted are limited to those encompassed by and
unique to the specialty of obstetrics and gynecology including follow up care
and must be performed by a Participating OB GYN Provider If you have any
questions please contact the Specialist PCP or KHPC to ensure that your
treatment is considered to be obstetrical or gynecological The Specialist is to
notify your Primary Care Physician of all services and treatment you receive
This will ensure the continuity of your care Please note that all Prior
Authorization guidelines still apply
Retroactive Referrals are not permitted by KHPC You must obtain the
Referral form before receiving non obstetrical non gynecological and nonEmergent
services
Mental Health and Substance Abuse Treatment Management of Mental Health
and or Substance Abuse treatment is provided through a subcontract with
Magellan Behavioral Health a behavioral health managed care company that
maintains a network of qualified Mental Health care professionals who offer
care to KHPC Members or other vendor we designate
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A particular Mental Health provider group is assigned to your PCP You may
contact your PCP or our Member Service Department at 717 763 3894 or 1
800 622 2843 toll free in Pennsylvania TDD number at 1 800 669 7075 for
the hearing impaired or Magellan Behavioral Health at 1 800 688 1911 TDD
number at 1 800 409 8640 for the hearing impaired to find out which Mental
Health provider group is assigned to your PCP Magellan Behavioral Health
also offers translator services to its non English speaking Members To access
this service simply call Magellan Behavioral Health at 1 800 874 9426 The
Mental Health Provider group will be responsible for providing and or
coordinating your Mental Health Substance Abuse treatment
If you need Mental Health and or Substance Abuse services you may contact
your assigned mental health provider group directly and schedule an
appointment no PCP Referral form is needed If the outpatient nonemergency
services you receive are not from the mental health provider group
assigned to your PCP these services will NOT be covered If faced with a
crisis call your assigned mental health provider group or contact Magellan
Behavioral Health at 1 800 688 1911 TDD number at 1 800 409 8640 for the
hearing impaired The Magellan Behavioral Health Care Management Team
and your mental health care provider are available 24 hours a day seven days a
week to offer assistance and coordinate care
If you need to see a specialist frequently because of a chronic complex or
serious medical condition your primary care physician will develop a treatment
plan that allows you to see your specialist for a certain number of visits without
additional referrals Your primary care physician will use our criteria when
creating your treatment plan The physician may have to get an authorization
or approval beforehand For Members who are afflicted with a lifethreatening
degenerative or disabling disease or condition as determined by
KHPC a standing referral may be given to a specialist with clinical expertise in
treating the disease or condition or in certain cases a specialist may be
designated to provide and coordinate the Member's primary and specialty care
In order to obtain a standing referral a referral form must be obtained from the
Member's PCP The referral form provides the specialist with the ability to
perform the treatment required for a specific episode of illness for up to 90
days The specialist may refer the Member for additional services including
laboratory testing radiology diagnostic testing or Durable Medical Equipment
DME Laboratory services must follow the PCP's laboratory arrangement as
indicated on the referral form and the Member's identification card At the end
of the 90 day period the Member must return to the PCP for an additional
Referral form according to his or her treatment plan If the specialist deems
that the referral form should be extended without a visit to the PCP he or she
may do so in consultation with the PCP Please note that all prior authorization
guidelines will still apply
Designations of specialists to provide and coordinate the Member's primary
and specialty care must be requested in writing and shall be approved pursuant
to a treatment plan approved by KHPC in consultation with you your PCP and
as appropriate the Specialist
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What do I do if I Your primary care physician will decide what treatment you need If they
am seeing a decide to refer you to a specialist ask if you can see your current specialist If
specialist when I your current specialist does not participate with us you must receive treatment
enroll 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 Call your primary care physician who will arrange for you to see another
my specialist specialist You may receive services from your current specialist until we can
leaves the Plan make arrangements for you to see someone else
But what if I
have a serious Please contact us if you believe your condition is chronic or disabling You may
illness and my be able to continue seeing your provider for up to 90 days after we notify you
provider leaves that we are terminating our contract with the provider unless the termination is
the Plan or this for cause If you are in the second or third trimester of pregnancy you may
Plan leaves the continue to see your OB GYN until the end of your postpartum care
Program You may also be able to continue seeing your provider if your plan drops out of
the FEHB Program and you enroll in a new FEHB plan Contact the new plan
and explain that you have a serious or chronic condition or are in your second
or third trimester Your new plan will pay for or provide your care for up to 90
days after you receive notice that your prior plan is leaving the FEHB Program
If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your
postpartum care
How do you Your physician must get our approval before sending you to a hospital
authorize medical referring you to a specialist or recommending follow up care Before giving
services approval we consider if the service is
1 Appropriate and necessary for the diagnosis and or treatment of your
medical condition disease illness or injury and is essential for improving
and or maintaining your current health status
2 in accordance with accepted standards of good medical practice
3 consistent with KHPC's or its designee's clinical protocols and utilization
guidelines
4 not primarily for the convenience of you your family or physician or other
health care provider and
5 provided at the most appropriate level of service setting or supply necessary to safely diagnose or treat you When applied to hospital services
this further means that the you require care in an emergency room or as an
inpatient due to the symptoms presented or your condition and you cannot
receive safe or adequate care as an outpatient in another setting
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How do you We rely on available credible data and on the advice of the general medical
decide if a service community The general medical community includes but is not limited to
is experimental or medical consultants medical journals and governmental regulations The data
investigational from these sources is used to determine if any treatment procedure facility equipment drug drug application or drug usage device or supply is not
accepted as standard medical treatment for the condition being treated The
data is also used to determine if any such items that require federal or other
governmental agency approval were not granted such approval at the time the
services were rendered or requested
Section 4 What to do if we deny your claim or request for service
If we deny 1 Be in writing
services or won't 2 Refer to specific brochure wording explaining why you believe our
pay your claim decision is wrong and
you may ask us to 3 Be made within six months from the date of our initial denial or refusal
reconsider our We may extend this time limit if you show that you were unable to make a
decision Your timely request due to reasons beyond your control
request must
We have 30 days 1 Maintain our denial in writing
from the date we 2 Pay the claim
receive your 3 Arrange for a health care provider to give you the service or
reconsideration 4 Ask for more information
request to If we ask your medical provider for more information we will send you a copy
of our request We must make a decision within 30 days after we receive the
additional information If we do not receive the requested information within
60 days we will make our decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial
OPM to review a denial or refusal OPM will determine if we correctly applied the terms of our
denial contract when we denied your claim or request for service
What if I have a Call us at 800 622 2843 TDD number 1 800 669 7075 for the hearing
serious or life impaired and we will expedite our review
threatening
condition and
you haven't
responded to my
request for
service
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What if you have If we expedite your review due to a serious medical condition and deny your
denied my claim we will inform OPM so that they can give your claim expedited
request for care treatment too Alternatively you can call OPM's health benefits Contracts
and my Division 3 at 202 606 0755 between 8 a m and 5 p m Eastern Time Serious
condition is or life threatening conditions are ones that may cause permanent loss of bodily
serious or life functions or death if they are not treated as soon as possible
threatening
Are there other You must write to OPM and ask them to review our decision within 90 days
time limits after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must
receive your request within 120 days of the date you asked us to reconsider
your claim
2 You provided us with additional information we asked for and we did not
answer within 30 days In this case OPM must receive your request within 120
days of the date we asked you for additional information
What do I send to Your request must be complete or OPM will return it to you You must send
OPM the following information
1 A statement about why you believe our decision is wrong based on specific
benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters
operative reports bills medical records and explanation of benefits EOB
forms
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 Those who have a legal right to file a disputed claim with OPM are
the request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are
acting as the enrolled person's representative They must send a copy of
the person's specific written consent with the review request
Where should I Send your request for review to Office of Personnel Management Office of
mail my Insurance Programs Contract Division III P O Box 436 Washington D C
disputed claim 20044
to OPM
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What if OPM OPM's decision is final There are no other administrative appeals If OPM
upholds the agrees with our decision your only recourse is to sue
Plan's 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 Federal law governs your lawsuit benefits and payment of benefits The
apply if I file a Federal court will base its review on the record that was before OPM when
lawsuit 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 Chapter 89 of title 5 United States Code allows OPM to use the information it
and the collects from you and us to determine if our denial of your claim is correct
Privacy Act The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom
of Information Act and the Privacy Act OPM may disclose this information to
support the disputed claim decision If you file a lawsuit this information will
become part of the court record
Section 5 Benefits
What is Plan physicians and other Plan providers provide a comprehensive range of covered preventive diagnostic and treatment services including all necessary office
visits you pay a 10 copay per visit You pay a 20 copay per visit for visits
to a physician's office after normal hours 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 a physician's house call or for home visits
by nurses and health aides
The following services are included and are subject to the office visit copay
unless otherwise indicated
Preventive care including well baby care and periodic check ups Mammograms are covered as follows for women age 35 through 39 one
mammogram during these five years for women ages 40 and over one
mammogram every year All female members age 40 and over may self refer to
a participating provider for an annual screening mammogram In addition to
routine screening mammograms are covered when prescribed by the physician
as medically necessary to diagnose or treat your illness
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Routine immunizations and boosters copayment waived for children up to age 18
Consultations by specialists Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor office visit copayments
are waived for obstetrical 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 and family planning services Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum excluding poison ivy injections
The insertion of internal prosthetic devices such as pacemakers and artificial joints breast prosthesis and surgical bras as well as their replacement
Cornea heart heart lung kidney liver lung single or double and pancreas
transplants allogeneic donor bone marrow transplants autologous bone
marrow transplants autologous stem cell and peripheral stem cell support for
the following conditions acute lymphocytic or non lymphocytic leukemia
advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced
neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and
testicular mediastinal retroperitoneal and ovarian germ cell tumors
Transplants are covered when approved by the Medical Director Related
medical and hospital expenses of the donor are covered when the recipient is
covered by this Plan
Dialysis Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity Orthopedic devices such as braces foot orthotics
Prosthetic devices such as artificial limbs and intraocular lenses following cataract removal
Standard durable medical equipment DME such as wheelchairs and hospital beds
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
Home Health Care when provided by home health care personnel in the member's home if located within the service area and referred by the PCP and
prior authorized by KHPC Private duty nursing will be covered only if
specifically prior authorized Homemaker services and other non medical
services are not covered
Limited benefits
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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provided for non dental 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 the treatment of
temporomandibular joint TMJ pain dysfunction syndrome The member is
entitled to oral surgery services for the extraction of impacted teeth when
partially or totally covered by bone Such services must be recommended by an
oral surgeon and approved by Keystone Health Plan Central Services will be
fully covered and may be provided to the member on an outpatient or when
medically necessary inpatient basis
Mastectomy and Breast Cancer Reconstructive Surgery is covered
including medically necessary hospitalization and home health care when a
member is discharged within 48 hours following admission for a mastectomy
Coverage is provided for initial and subsequent artificial prosthetic devices
inserted during reconstructive surgery and for all stages of mastectomy
including lymphedemas which are pursuant to an order of the participating
physician Coverage for reconstructive surgery to be performed on one or both
breasts following a mastectomy to re establish symmetry or alleviate functional
impairment as a result of the mastectomy is also covered Coverage for
prosthetic devices inserted during reconstructive surgery and reconstructive
surgical procedures themselves are limited to such procedures performed within
six years of the date of the mastectomy
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
Short term rehabilitative therapy physical speech occupational orthoptic
cardiac respiratory and urinary incontinence therapy is provided on an
inpatient or outpatient basis for up to 60 consecutive days per condition if
significant improvement can be expected based on the treatment plan
prescribed you pay nothing 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
Infertility counseling testing and services including artificial insemination
but excluding in vitro fertilization will be covered when prior authorized by
KHPC Infertility services are subject to a copayment of 50 of the cost of
treatment which includes the cost of injectables related to infertility services
administered and or dispensed by the physician's office Infertility services are
available to both male and female members Infertility services are not covered
if the present condition of infertility is due whether wholly or partially to
either party having undergone a voluntary sterilization procedure and or an
unsuccessful reversal of a voluntary sterilization procedure whether either
party is a KHPC member or not Other services that are not covered
under infertility are cost of donor sperm reversal of voluntary sterilization and
embryo transfer
Chiropractic services are limited to acute care severe and sudden onset within
Oral and 1 week of the accident or injury and are provided for up to two weeks
maxillofacial Services are limited to X rays consultations and manipulation Chronic
surgery is problems and routine maintenance are not covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Keystone Health Plan Central HMO 2000
What is not Physical examinations that are not necessary for medical reasons such as covered 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
Transplants not listed as covered Blood and blood derivatives not replaced by the member
Hearing aids Long term rehabilitation services
Homemaker services Eye exercises and eyeglasses contact lenses or the fitting of contact lenses
Refractions including lens prescriptions Charges for missed appointments and charges for completion of insurance
forms
Radial keratotomy
What is covered
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit
when you are hospitalized under the care of a Plan doctor You pay nothing All
necessary services are covered including
Semi private room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or
private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended Care The Plan provides a comprehensive range of benefits with no dollar or day limit
when full time skilled nursing care is necessary and confinement in a skilled
nursing facility is medically appropriate as determined by a Plan doctor and
approved by the Plan You pay nothing All necessary services are covered
including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or
arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the
home or hospice facility up to a maximum of 7500 Services include inpatient
and outpatient care and family counseling these services are provided under
the direction of the 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 Medically necessary ambulance services are covered when required in
Service connection with emergency services or when ordered or referred by the
primary care physician and prior authorized by KHPC or its designee in
connection with non emergency care
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Keystone Health Plan Central HMO 2000
Limited Benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor
procedures determines there 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
detoxification emergency care 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 pages
20 21 for
non medical substance abuse benefits
What is not Personal comfort items such as telephone and television covered 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
What is a An emergency service is any health care service provided after the sudden onset medical of a medical condition that manifests itself by acute symptoms of sufficient
emergency severity or severe pain such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of
immediate medical attention to result in
1 Placing the health of the person or with respect to a pregnant woman the
health of the woman or her unborn child in serious jeopardy
2 Serious impairment to bodily functions or
3 Serious dysfunction of any bodily organ or part
Emergency transportation and related emergency services provided by a
licensed ambulance service shall also be considered emergency services
Emergencies within the In the event you experience a condition requiring Emergency Services you
service area should attempt to contact your PCP If you cannot contact your PCP at the time of the injury or condition you should seek medical care from the most readily
available source In such cases you should notify your PCP or KHPC within
48 hours of receiving the care or as soon as possible thereafter
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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To be covered by follow up care recommended by non Plan providers must be approved by the
this Plan any 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 25 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency
results in admission to the hospital the emergency room copayment is waived
Emergencies Emergencies outside the service area are subject to the ongoing Non outside the Participating Provider provisions set forth below the charges for Medically
service area Necessary Emergency Services received outside the service area are covered only if in the determination of KHPC
You could not have anticipated the need for such services prior to leaving the service area and
Delaying the care until you could be expected to return to the care of the PCP might significantly jeopardize your health or life
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 would be transferred when medically
feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan
providers must be approved by the plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency
results in admission to the hospital the emergency room copayment is waived
What is Emergency care at a doctor's office or an urgent care center covered Emergency care as an outpatient or inpatient at a hospital including
doctors services
Ambulance service approved by the Plan
What is not Elective care or non emergency care covered
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
Providers your emergency care upon receipt of their claims Claims for non Plan Providers 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 unless the claim is denied If it
is denied you will receive notice of the decision including the reasons for the
denial and the provisions of the contract on which denial was based If you
disagree with the Plan's decision you may request reconsideration in
accordance with the disputed claims procedure described on pages 11 14
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Keystone Health Plan Central HMO 2000
Mental conditions
What is To the extent shown below the Plan provides the following services necessary covered for the diagnosis and treatment of acute psychiatric conditions including the
treatment of mental illness or disorders
Diagnostic evaluation Psychological testing brief testing to establish a diagnosis
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services
Outpatient Up to sixty 60 visits for Serious Mental Illness are covered per calendar year care when provided by a Participating Provider and determined to be Medically
Necessary by KHPC or its designated agent and appropriate for short term
evaluation and or crisis intervention In addition unused calendar year
Inpatient Serious Mental Illness days may be exchanged on a one for two basis
to secure additional Outpatient visits for Serious Mental Health Illness
Outpatient Electro Convulsive Therapy will be counted against the patient's
Inpatient mental health benefit on a one session for one Inpatient day basis
You pay a 25 copayment for each covered visit all charges thereafter
For other than Serious Mental Illness up to twenty 20 Outpatient mental
health care visits per calendar year when provided by a Participating Provider
and determined to be Medically Necessary by KHPC or its designated agent
and appropriate for short term evaluation and or crisis intervention are covered
Outpatient Electro Convulsive Therapy will be counted against the patient's
Inpatient mental health benefit on a one session for one Inpatient day basis
You pay a 25 copayment for each covered visit all charges thereafter
Inpatient care For Serious Mental Illness Medically Necessary Inpatient mental health care services in a Participating facility are covered Benefit is limited to thirty 30
Inpatient days per Member in a calendar year In addition unused calendar
year Inpatient Serious Mental Illness days may be exchanged on a one for two
basis to secure additional Outpatient visits for Serious Mental Health Illness
Outpatient Electro Convulsive Therapy will be counted against the patient's
Inpatient mental health benefit on a one session for one Inpatient day basis
You pay nothing for the first 30 days of hospitalization for serious mental
illness all charges thereafter
For other than Serious Mental Illness Medically Necessary Inpatient mental
health care services in a Participating facility are covered Benefit is limited to
thirty 30 Inpatient days per Member in a calendar year Outpatient Electro
Convulsive Therapy will be counted against the patient's Inpatient mental
health benefit on a one session for one Inpatient day basis You pay nothing
for the first 30 days of hospitalization for other than serious mental illness all
charges thereafter
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Keystone Health Plan Central HMO 2000
What is not Care for psychiatric conditions that in the professional judgment of Plan covered doctors are not subject to significant improvement through relatively
short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and
appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse
What is This Plan provides medical and hospital services such as acute detoxification covered 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 Up to 60 visits per calendar year for rehabilitation and counseling services care lifetime maximum of 120 visits You pay nothing for the first course of
treatment course of treatment determined by Plan doctor you pay a 25
copayment per full visit a 15 copayment per partial visit during subsequent
treatment courses all charges after 60 visits per year or 120 per lifetime Up to
30 outpatient visits per calendar year may be exchanged on a 2 for 1 basis to
secure up to 15 additional non hospital residential alcohol abuse treatment
days which are in addition to the annual and lifetime max
Inpatient care Up to 30 days per calendar year for rehabilitation services lifetime maximum of 90 days You pay nothing during benefit period all charges thereafter
Outpatient Up to 30 visits per calendar year for counseling and treatment you pay a 25 care copayment per visit for each covered visit all charges thereafter
Inpatient care One 28 day confinement up to 33 days if treatment includes detoxification per calendar year for substance abuse rehabilitation lifetime maximum of two
confinements You pay nothing during benefit period all charges thereafter
What is not Rehabilitation services in an acute care hospital except for alcohol abuse covered Treatment that is not provided by a Plan doctor or authorized by Magellan
Behavioral Health or other vendor that we designate
20 CARE MUST BE RECEIVED FROM AND ARRANGED BY PLAN DOCTORS
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Keystone Health Plan Central HMO 2000
What is Prescription drugs prescribed by a Plan Primary Care Physician PCP or a covered specialist to whom the PCP makes a referral and obtained at a participating
pharmacy are dispensed for up to a 90 day supply You pay a 10 copayment
for up to a 30 day supply or a 20 copayment for up to a 60 day supply or a
30 copayment for up to a 90 day supply per prescription unit or refill for
generic drugs or for brand name drugs when the prescribing doctor requires a
brand name drug A valid Plan ID card must be presented at the pharmacy
when obtaining prescription drugs
Mail Order Prescription drugs may be obtained through the Plan's mail order
pharmacy and will be dispensed for up to a 90 day supply You pay a 20
copayment per prescription unit or refill regardless of days supply
Generic Enforcement Generic drugs will be substituted for brand name drugs
when permissible whether obtained at a participating pharmacy or through the
mail order pharmacy If you request a brand name drug when generic
substitution is permissible and the prescribing doctor does not require the brand
name drug you pay the 10 copayment plus the cost difference between the
brand name drug and its generic equivalent
Formulary Drugs are prescribed by Plan doctors and dispensed in accordance
with the Plan's drug formulary Non formulary drugs will not be covered
unless there is plan approval through the non formulary consideration process
Covered Drugs for which a prescription is required by law medications Prescription contraceptive drugs and devices
and Insulin accessories Diabetic supplies such as syringes needles glucose test strips
include lancets etc Disposable needles and syringes needed to inject covered
prescribed medication Compounded preparations containing at least one prescription drug
Limited Medications used to treat either infertility or sexual dysfunction will be benefits dispensed subject to dose or quantity limitations Call the Plan for specific
limitations Must be prescribed by Plan doctors and obtained at a participating
pharmacy You pay 50 of the cost
What is not Drugs available without a prescription or for which there is a nonprescription covered equivalent available
Drugs obtained at a non participating pharmacy except for emergencies 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 Smoking cessation drugs
Weight control drugs Blood and blood products
Dental applications including fluoride
Venom and desensitization serums
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 21
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Keystone Health Plan Central HMO 2000
Dental care
Accidental Restorative services and supplies necessary to promptly repair but not replace injury benefit sound natural teeth The need for services must result from an accidental
injury Services must be sought within 24 hours of the accident unless it is not
feasible due to medical conditions for services to be covered You pay
nothing Accidental dental injuries caused by chewing are not covered
22 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Keystone Health Plan Central HMO 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family Members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums
These benefits are not subject to the FEHB disputed claims procedure
Vision Care
Various vision centers within our service area offer discounts to Keystone Health Plan Central Members Details can be found
in the Wellness Services and Eyecare Discounts section of the Participating Physicians Pharmacies and Hospitals Directory
Members should present their Plan identification card to obtain services
Fitness Discount Programs
Area health clubs smoking cessation programs and weight reduction programs offer discounts to Keystone Health Plan Central
Members Members will find a list of participating organizations in the Wellness Services and Eyecare Discounts section of the
Participating Physicians Pharmacies and Hospitals Directory Members present their Plan identification card to obtain
discounts
NurseLink
Keystone Health Plan Central is pleased to offer you a unique service that gives you access to professional health information
whenever you need it 24 hours a day 7 days a week NurseLink gives you access to a registered nurse or to our health
information library which contains over 1,100 health related topics By using the NurseLink directory you can hear prerecorded
information about many health topics by simply using 4 digit topic codes Please call 717 763 3894 or 800 622
2843 TDD number 1 800 669 7075 for the hearing impaired for additional information about NurseLink
NOTE NurseLink is intended to be a resource for information that does not replace the care or advice of your physician You
should always contact your PCP immediately in an Urgent or Emergent medical situation
KHPC offers several special wellness programs that are listed below Information on any of these programs can be obtained
by calling Member Services at 800 622 2843 TDD number 1 800 669 7075 for the hearing impaired
Taking Lifetime Control Diabetes Program
Special Deliveries High Risk Maternity Management Program
Take AIM Asthma Program
Gift of Good Health Mammography Management Program
Free and Clear Smoking Cessation Program
Medicare Choice prepaid plan enrollment
This plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 4 annuitants
and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare
Choice prepaid plan when one is available in their area They may then later re enroll in the FEHB Program Most Federal
annuitants have Medicare Part A Those without Medicare Part A may join this Medicare Choice prepaid plan but will
probably have to pay for hospital coverage in addition to the Medicare 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 changes to a Medicare Choice prepaid plan Contact us at 800 990 4201 for
information on the Medicare Choice prepaid plan and the cost of that enrollment
If you are Medicare eligible and are interested in a Medicare Choice HMO sponsored by this Plan without dropping your
enrollment in this Plan's FEHB plan call 800 990 4201 for information on the benefits under the Medicare Choice HMO
Benefits on these pages are not part of the FEHB contract
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Keystone Health Plan Central HMO 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 enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and
we will coordinate the payments On occasion you may need to file a Medicare
claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and
also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage
and enroll in a Medicare Choice plan when one is available in your area For
information on suspending your FEHB enrollment and changing to a
Medicare Choice plan contact your retirement office If you later want to reenroll
in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service
area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the
FEHB Program and your benefits will not be reduced We cannot require you
to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security
Administration SSA office or request it from SSA at 1 800 638 6833 For
information on the Medicare Choice plan offered by this Plan see page 23
Plan specific
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Keystone Health Plan Central HMO 2000
Other group When anyone has coverage with us and with another group health plan it is
insurance called double coverage You must tell us if you or a family member has double
coverage 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 Under certain extraordinary circumstances we may have to delay your services
beyond our or be unable to provide them In that case we will make all reasonable efforts
control to provide you with necessary care
When others When you receive money to compensate you for medical or hospital care for
are responsible injuries or illness that another person caused you must reimburse us for
for injuries 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 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 determines 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
Keystone Health Plan Central HMO 2000
Other Government Agencies We do not cover services and supplies that a local state or Federal
Government agency directly or indirectly pays for
Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to
information about your health plan its networks providers and facilities You can also find out about care
management which includes medical practice guidelines disease management programs and how we
determine if procedures are experimental or investigational OPM's website www opm gov
lists the
specific types of information that we must make available to you
If you want specific information about us call 800 622 2843 TDD number 1 800 669 7075 for the hearing
impaired or write to P O Box 898812 Camp Hill PA 17089 8812 You may also contact us by fax at
717 972 0094 or visit our website at www khpc com
Where do I get Your employing or retirement office can answer your questions and give you a
information Guide to Federal Employees Health Benefits Plans brochures for other plans
about and other materials you need to make an informed decision about
enrolling in the When you may change your enrollment
FEHB How you can cover your family members
Program 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
The benefits in this brochure are effective on January 1 If you are new to this
When are my plan your coverage and premiums begin on the first day of your first pay
benefits and period that starts on or after January 1 Annuitants premiums begin January 1
premiums
effective
What happens
when I retire
When you retire you can usually stay in the FEHB Program Generally you
must have been enrolled in the FEHB Program for the last five years of your
Federal service If you do not meet this requirement you may be eligible for
other forms of coverage such as Temporary Continuation of Coverage which
is described later in this section
26
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Keystone Health Plan Central HMO 2000
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Keystone Health Plan Central HMO 2000
What types of
coverage are Self Only coverage is for you alone Self and Family coverage is for you your
available for spouse and your unmarried dependent children under age 22 including any
my family and foster or step children your employing or retirement office authorizes coverage
me for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support which is also
authorized by your employing or retirement office
If you have a Self Only enrollment you may change to a Self and Family
enrollment if you marry give birth or add a child to your family You may
change your enrollment 31 days before to 60 days after you give birth or add
the child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member
Your employing or retirement office will not notify you when a family member
is no longer eligible to receive health benefits nor will we Please tell us
immediately when you add or remove family members from your coverage for
any reason including divorce No new enrollment form is necessary
If you or one of your family members is enrolled in one FEHB plan that person
may not be enrolled in another FEHB plan
Are my We will keep your medical and claims information confidential Only the
medical and following will have access to it
claims records OPM this Plan and subcontractors when they administer this contract
confidential 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
Identification We will send you an Identification ID card Use your copy of the Health
cards 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 Your old plan's deductible continues until our coverage begins
a deductible
under my old
plan
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Keystone Health Plan Central HMO 2000
Pre existing We will not refuse to cover the treatment of a condition that you or a family
conditions member had before you enrolled in this Plan solely because you had the condition before you enrolled
What happens You will receive an additional 31 days of coverage for no additional premium
if my when
enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends 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 If you are divorced from a Federal employee or annuitant you may not
former spouse continue to get benefits under your former spouse's enrollment But you may
coverage 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 You can pick a new plan
about TCC 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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Keystone Health Plan Central HMO 2000
How do I If you leave Federal service your employing office will notify you of your right
enroll in TCC to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days
after your child is no longer an eligible family member That office will send
you information about enrolling in TCC You must enroll your child within 60
days after they become eligible for TCC or receive this notice whichever is
later
Former spouses You or your former spouse must notify your employing or
retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse
information about enrolling in TCC Your former spouse must enroll within 60
days after the event which qualifies them for coverage or receiving the
information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your
former spouse notifies your employing or retirement office within the 60 day
deadline
How can I You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled
coverage your coverage or did not pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law
or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual
coverage is available You must apply in writing to us within 31 days after you
receive this notice However if you are a family member who is losing
coverage the employing or retirement office will not notify you You must
apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program
however you will not have to answer questions about your health and we will
not impose a waiting period or limit your coverage due to pre existing
conditions
How can I get
a Certificate of If you leave the FEHB Program we will give you a Certificate of Group Health
Group Health Plan Coverage that indicates how long you have been enrolled with us You
Plan can use this certificate when getting health insurance or other health care
Coverage 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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Keystone Health Plan Central HMO 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 800 622 2843 TDD 1 800 669 7075 for the hearing impaired 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
Keystone Health Plan Central HMO 2000
Summary of Benefits for Keystone Health Plan Central 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth
in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your
enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this
brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general
nursing care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 16
Extended care All necessary services no dollar or day limit You pay nothing 16
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of
inpatient care per year You pay nothing 19 20
Substance abuse For alcoholism up to 30 days per year for abuse rehabilitation lifetime
maximum of 90 days For other substance abuse one 28 day confinement
per year for rehabilitation lifetime maximum of two confinements You
pay nothing 20 21
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays
complete maternity care You pay 10 per office visit or 20 for house calls
by a doctor 13
Home health care All necessary visits per calendar year by nurses and health aides You pay
nothing 14
Mental conditions Up to 60 outpatient visits per year You pay a 25 copay per visit 19 20
Substance abuse For alcoholism up to 60 visits per year for rehabilitation lifetime maximum
of 120 visits you pay nothing for the first course of treatment then a 25
copay per full visit or a 15 copay per partial visit For other substance abuse
up to 30 visits per year You pay a 25 copay per visit 20 21
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each emergency room
visit and any charges for services that are not covered by this Plan 17 18
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 10 copay per prescription generic or brand oral contraceptives included
per 30 day supply generic enforcement 3 times copay for 90 day supply
Mail order maintenance drugs oral contraceptives included 90 day supply
generic enforcement 21 22
Dental care Accidental injury benefit you pay nothing 22
Vision care No current benefit
Out of pocket maximum Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for a few benefits 13
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Keystone Health Plan Central HMO 2000
2000 Rate Information for
Keystone Health Plan Central
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
Self Only S41 78.83 29.47 170.80 63.85 93.06 15.24 93.26 15.04
Self and Family S42 175.97 86.32 381.27 187.03 207.74 54.55 201.02 61.27
33 33