Pages 1--28 from RI73-244.PDF

Maxicare Louisiana Inc 2000
A Health Maintenance Organization with a Point of Service Product

For changes
in benefits

Serving The New Orleans Slidell and Baton Rouge area see page 4

Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
JA1 Self Only
JA2 Self and Family

Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United United States States Office Office Of Of Personnel Personnel Management Management
Retirement Retirement And And Insurance Insurance Service Service

RI 73 244 1
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Maxicare Louisiana Inc 2000
Table of Contents
Introduction 3

Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4

Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 8 9
Section 5 Benefits 9 15
Point of Service benefits 16
Non FEHB benefits 17
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 18 19
Section 8 FEHB Facts 19 22
Department of Defense FEHB Demonstration Project 23 24
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits 27
Premiums 28

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Maxicare Louisiana Inc 2000
Introduction
Maxicare Louisiana Inc
1515 Poydras Street Suite 1130
New Orleans Louisiana 70112

This brochure describes the benefits you can receive from Maxicare Louisiana Inc under its contract CS2050 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

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

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

We refer to Maxicare Louisiana Inc as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

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

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

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

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

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

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

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office
changes visits

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

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

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 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 Cervical caps are now covered at a 5 copay fitting only See page 10
Primary Care office visits now require a 10 copay See page 9

Short term rehabilitative therapy now requires a 10 copay See page 11
Cardiac rehabilitation now requires a 10 copay See page 11
Vision office visits now require a 10 copay See page 15
Your share of the premium will increase by 8.6 for Self Only or 8.4 for Self and Family

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

The Louisiana Parishes of Ascension Jefferson Livingston Orleans Plaquemines St Bernard St Charles
St John the Baptist St Tammany Tangipahoa East Baton Rouge and West Baton Rouge

Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care or point of service benefits We will not pay for any other
health care services

If you or a covered family member move outside of our service area you can enroll in another plan If your
dependents live out of the area for example if your child goes to college in another state you should
consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas 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 You must share the cost of some services This is called either a copayment a set dollar amount or
for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for emergency services

After you pay 1,500 in copayments or coinsurance for self only or 3,000 for self and family enrollments
you do not have to make any further payments for certain services for the rest of the year This is called a
catastrophic limit However copayments or coinsurance for your prescription drugs and non FEHB benefits
see page 17 do not count toward these limits and you must continue to make these payments

If you choose to use the POS benefits the out of pocket expenses include a calendar year deductible of 200
for Self Only and 600 for Self and Family with a 200 deductible per family member Maxicare then pays
80 of reasonable and customary charges up to a 1 million per member per life time per POS claims

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 from a provider who
claims doesn't contract with us or you use point of service benefits If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the

year you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides my CHOICE OF PROVIDERS
health care Maxicare is pleased to offer you a choice of physician providers from whom you will receive your care In our physician handbook is a list of the providers from which you can choose Maxicare offers two types of

delivery system

HOSPITAL BASED PHYSICIAN NETWORKS There is an alternative delivery system to provide care to Maxicare members Physician networks or
individual practice associations IPA are doctors practicing in their own private offices All the doctors have
associated themselves with one specific hospital which is listed under the name of the IPA This hospital will
be the location where the majority of your hospitalizations will take place

In this type of system you first choose the IPA you wish and then you select a primary doctor from the list
that is most appropriate for you and each of your family members Each member of the family will have the
choice of his her own personal doctor within the physician network IPA

The primary care doctors will refer you to specialists who participate in the physician network The
specialists offices will be located in the community and these specialists are also on staff at the associated
hospital

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Maxicare Louisiana Inc 2000
Section 3 How to get benefits continued
Who provides my MEDICAL GROUP PRACTICES
health care When you choose a medical group as your provider you will receive the majority of your care at the medical
continued group location You will have the opportunity to choose your medical group doctor from their primary care doctors at the group The majority of the care you will receive will be in one location In most cases this will

include specialty care lab and X ray work

In the Plan's physician handbook is a description of how a medical group works how you should indicate
your preference on your provider selection card and what medical group locations are available Also in the
handbook is a description of how an IPA works how to indicate your selection on the provider selection card
and what IPAs are available

If you have any questions regarding choosing a doctor please call our Member Services Department at
1 800 933 6294 or 1 504 523 7080

The first and most important decision each member must make is the selection of a primary care doctor The
decision is important since it is through this doctor that all other health services particularly those of
specialists are obtained It is the responsibility of your primary care doctor to obtain any necessary
authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization
Services of other providers are covered only when there has been a referral by the member's primary care
doctor with the following exceptions a qualified clinical psychologist clinical social worker optometrist
and a woman may see her physician network gynecologist for her annual routine examination without a
referral

The Plan's provider directory lists primary care doctors generally family practitioners pediatricians and
internists with their locations and phone numbers and notes whether or not the doctor is accepting new
patients Directories are updated on a regular basis and are available at the time of enrollment or upon
request by calling the Member Services Department at 1 800 933 6294 or 1 504 523 7080 you can also find
out if your doctor participates with this Plan by calling this number If you are interested in receiving care
from a specific provider who is listed in the directory call the provider to verify that he or she still
participates with the Plan and is accepting new patients Important note When you enroll in this Plan
services except for emergency benefits are provided through the Plan's delivery system the continued
availability and or participation of any one doctor hospital or other provider cannot be guaranteed

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

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

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

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

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Maxicare Louisiana Inc 2000
Section 3 How to get benefits continued
What do I do if I'm First call our customer service department at 1 800 933 6294 or 1 504 523 7080 If you are new to the
in the hospital when I FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program and are
join this Plan 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 92 nd 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 Your primary care physician will arrange your referral to a specialist
specialty 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

What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a specialist
seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us you must
when I enroll 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 receive
specialist leaves the services from your current specialist until we can make arrangements for you to see someone else
Plan

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
serious illness and my your provider for up to 90 days after we notify you that we are terminating our contract with the provider
provider leaves the unless the termination is for cause If you are in the second or third trimester of pregnancy you may
Plan or this Plan continue to see your OB GYN until the end of your postpartum care
leaves the 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 referring you to a specialist or
authorize medical recommending follow up care Before giving approval we consider if the service is medically necessary and
services if it follows generally accepted medical practice

How do you decide if Maxicare generally accepts as non experimental investigational those medical surgical and other health care
a service is procedures which have been designated as non experimental non investigational by the appropriately
experimental or recognized governmental medical or professional organizations within the United States and which have
investigational been generally accepted in the medical community as being safe and effective for use in the treatment of the condition in question In the case of prescription drugs a drug will be considered experimental if it has not

been approved by the Food and Drug Administration FDA or if the FDA has not approved the drug for the
specific route of administration dosage and except as otherwise required by law in cases of treatment for a
life threatening condition

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Maxicare Louisiana Inc 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control

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

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

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

What if I have a Call us 1 800 933 6294 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 inform OPM so
denied my request that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
for care and my Contract Division III at 1 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are
condition is serious ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
or life threatening

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial
limits 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

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Maxicare Louisiana Inc 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send to Your request must be complete or OPM will return it to you You must send the following information
OPM 1 A statement about why you believe our decision is wrong based on specific benefit provisions in this

brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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

Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan

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

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

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

after the year in which you received the disputed services or supplies

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

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

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
Privacy Act determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of

Information Act and the Privacy Act OPM may disclose this information to support the disputed claim
decision If you file a lawsuit this information will become part of the court record

Section 5 Benefits Medical and Surgical
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 office visit You pay a 2
copay per visit for laboratory tests and X rays 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 10 copay for a doctor's visit
and nothing for visits by nurses and health aides Urgent care visits after regular appointment hours you pay
a 25 copay per visit

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Maxicare Louisiana Inc 2000
Section 5 Benefits Medical and Surgical continued
What is covered The following services are included and are subject to the office visit copay unless stated otherwise
continued Preventive care including well baby care and periodic check ups

Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women age 50

through 64 one mammogram every year and for women age 65 and above one mammogram every two
years In addition to routine screening mammograms are covered when prescribed by the doctor as
medically necessary to diagnose or treat your illness
Routine immunizations and boosters excluding those required for foreign travel only
Therapeutic injections you pay 50 of charges
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48 hours after a regular

delivery and 96 hours after a 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 family planning services you pay a 5 copay for diaphragms fitting only a 5 copay for cervical caps fitting only a 100 copay for a vasectomy and a 200 copay for a tubal ligation

Hearing tests
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney liver lung single or double heart lung 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 Treatment for breast cancer multiple myelomas and epithelial ovarian cancer
may be provided in a non randomized clinical trial when approved by the Plan's medical director using
eligibility criteria for National Cancer Institute NCI sponsor clinical trials If no such trials are underway
in the Plan's area regular Plan transplant benefits will be provided using Plan eligibility criteria Related
medical and hospital expenses of the donor are covered when the recipient is covered by this Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy
Growth hormones therapy including the cost of growth hormones you pay 50 of charges
Surgical treatment of morbid obesity
Prosthetic devices such as artificial limbs which are implanted and lenses following cataract removal breast prostheses and surgical bras as well as their replacement you pay 50 of charges

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

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Maxicare Louisiana Inc 2000
Section 5 Benefits Medical and Surgical continued
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

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an
injury or surgery that has produced a major effect on the member's appearance and if the condition can
reasonably be expected to be corrected by such surgery A patient and her attending physician may decide to
have breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed
to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or
outpatient basis for up to two months per illness or injury if significant improvement can be expected within
two months you pay a 10 copay per visit Speech therapy is limited to treatment of certain speech
impairments of organic origin Occupational therapy is limited to services that assist the member to achieve
and maintain self care and improved functioning in other activities of daily living You pay 50 of charges
per outpatient visit

Diagnosis and treatment of infertility is covered you pay 50 of charges The following types of artificial
insemination are covered intravaginal insemination IVI intrauterine insemination IUI and intracervical
insemination ICI you pay 50 of charges Cost of donor sperm is not covered Fertility drugs are covered
under the Prescription Drug Benefit Other assisted reproductive technology ART procedures such as in
vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided
for up to 60 days If physical therapy is to be received you pay a 10 copay per outpatient visit If
occupational therapy is to be received you pay 50 of charges per outpatient visit

Health education classes are reimbursed up to 50 per year toward the cost of attending approved classes in
nutrition and other health education topics

Durable medical equipment such as wheelchairs and hospital beds are provided up to a maximum benefit
of 750 per member per contract year You pay 20 of charges

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
Transplants not listed as covered
Blood
Hearing aids
Long term neuromuscular rehabilitative therapy
Chiropractic services
Oxygen for home use and equipment
Dental care and appliances
Treatment of malocclusion prognathism and temporomandibular joint disease TMJ
Homemaker services

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Maxicare Louisiana Inc 2000
Section 5 Benefits Hospital and Extended Care
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
Extended care The Plan provides a comprehensive range of benefits for up to 100 days when full time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu of hospitalization You pay nothing All
necessary services are covered including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are provided under the direction
of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of
approximately six months or less

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

Limited benefits
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of
detoxification medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 14 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
Hospitalization for dental care and treatment

Benefits Emergency
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency 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 lifethreatening
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

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Maxicare Louisiana Inc 2000
Section 5 Benefits Emergency continued
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if you are
the service area unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan

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

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

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

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the
Plan or provided by Plan providers except as covered under POS benefits

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

You pay 50 of charges up to a 50 copay per hospital emergency room visit or up to a 25 copay per urgent care center visit for emergency services which are covered benefits of this Plan If the emergency results in
admission to a hospital the emergency care copay is waived

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

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

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the
Plan or provided by Plan providers except as covered under POS benefits

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

You pay 50 of charges up to a 50 copay per hospital emergency room visit or up to a 25 copay per urgent care center visit for emergency services which are covered benefits of this Plan If the emergency results in
admission to a hospital the emergency care copay is waived

What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or nonemergency care except as covered under POS benefits Emergency care provided outside the service area if the need for care could have been foreseen before
leaving the service area except as covered under POS benefits
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area except as covered under POS benefits

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Maxicare Louisiana Inc 2000
Section 5 Benefits Emergency continued
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency care upon
providers receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation

of the services and the identification information from your ID card Payment will be sent to you or the
provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the
decision including the reasons for the denial and the provisions of the contract on which denial was based If
you disagree with the Plan's decision you may request reconsideration in accordance with the disputed
claims procedure described on pages 8 9

Benefits Mental Conditions and Substance Abuse
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 To receive
referrals for mental health call 1 800 933 6294

Diagnostic evaluation
Psychological testing you pay 50 of charges
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 5 copay for the first visit a 30 copay per visit for visits 2 through 40 all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 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 that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric 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 benefits 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
and copayments apply to any covered substance abuse care

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

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Maxicare Louisiana Inc 2000
Section 5 Benefits Prescription Drug
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 or one commercially prepared unit i e one inhaler one vial ophthalmic
medication or insulin You pay a 7 copay per prescription unit or refill for generic drugs or a 12 copay
per prescription unit or refill for name brand drugs when generic substitution is not permissible When
generic substitution is permissible i e a generic drug is available and the prescribing doctor does not require
the use of a name brand drug but you request the name brand drug you pay the price difference between the
generic and name brand drug as well as the 12 copay per prescription unit or refill for name brand drugs

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary procedure
Nonformulary drugs will be covered when prescribed by a Plan doctor

Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs and contraceptive devices
Insulin with a copay charge applied to each 30 day supply
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent glucose monitors and acetone test tablets

Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use provided under home health services at no charge

Limited benefits Clomidphene and serophene for infertility Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Implanted time release medications such as Norplant
Drugs prescribed for weight loss

Benefits Other
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 for members of all ages which include the written lens prescription may be obtained
from Plan providers You pay a 10 copay per visit

What is not covered Eyeglasses contact lenses or the exams for fitting of contact lenses Eye exercises

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Maxicare Louisiana Inc 2000
Maxicare's Point of Service benefit Maxi Choice
Facts about this Members may use non Plan providers of their choice
Plan's POS option

What is covered Members may choose to receive services from any doctor or hospital without a referral This option is available each time a member seeks medical attention Some of the same services are covered as when a
participating provider is used see What is not covered below However covered benefits including hospital
care are paid on a fee for service basis when services are received from non Plan providers or from Plan
providers without a referral Benefit payments will be subject to a 200 deductible for Self Only or 600 for
Self and Family enrollment The Plan pays 80 of the Reasonable and Customary R C charges You
are responsible for 20 of the applicable charges and all charges in excess of the R C charges

Maximum benefit All benefits under the POS plan are limited to a total maximum payment by the Plan of 1,000,000 per member per lifetime

Precertification The purpose of precertification is to insure that benefits are provided only for medically necessary care This
requirement for precertification process must be completed in order to receive benefits for covered healthcare expenses after
benefits any applicable deductibles and coinsurance A telephone call must be made to Maxicare by you or your doctor 14 days prior to any hospital admission or outpatient procedure In an emergency Maxicare must be

notified within 48 hours or at the earliest reasonable time The toll free number is 1 800 933 6294 within
Louisiana only or 1 504 523 8229 All hospital admissions and outpatient procedures must be precertified
as outlined above If precertification is not obtained benefits are reduced by an additional 20

The following information must be provided to Maxicare Louisiana
Your Maxicare ID number from membership card
Your name birth date and phone number only if Maxicare ID number is unavailable
Name and telephone number of physician
Hospital name and location
Reason for hospitalization
Proposed treatment or surgery
Number of planned days of confinement

Deductible The calendar year deductible only applies to POS claims and is the amount of covered expenses an individual must incur before the Plan pays benefits that are subject to the deductible The deductible subject to
reasonable and customary charges is 200 per Self Only enrollment or 600 per Self and Family enrollment
with a maximum of 200 per family member and is not reimbursable by the Plan This deductible applies
to all benefits except prescription drugs purchased at a Plan pharmacy Copayments under Maxicare's
Prepaid Plan cannot be used to meet the calendar year deductible

Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductibles You are required to pay 20 of the reasonable and customary charges on benefits for covered
services obtained from non Plan providers The Plan will pay 80 of the reasonable and customary charges
up to the total maximum benefit Charges for covered services that exceed the R C charges and or the
lifetime maximum benefits are the responsibility of the member All inpatient hospital admissions and
surgeries must be precertified or benefits will be reduced by an additional 20

What is not covered Physical examinations Prescription drugs Routine pediatric care Personal comfort items
Immunizations Cosmetic surgery
Dental care Eyeglasses
Outpatient mental health Organ transplants
Substance abuse

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Maxicare Louisiana Inc 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 outof
pocket maximums These benefits are not subject to the FEHB dispute claims procedure

What is covered
Vision care You are eligible to receive substantial discounts on eyeglasses contact lenses and nonprescription
items such as sunglasses and
contact lens solutions Please read the flyer that
describes your extra Vision Care benefit This
discount enriches our routine Vision Care
coverage which includes an eye exam from your
Plan provider

Dental care You are eligible to receive substantial discounts on dental care including diagnostic and
preventative restorative crowns endodontics
peridontics prosthodontics and orthodontics
Please read the accompanying flyer that
describes Dental Care benefits available through
this program

Benefits on this page are not part of the FEHB Contract
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Maxicare Louisiana Inc 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 self referred services see Point of Service benefits

Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term

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

Other group When anyone has coverage with us and with another group health plan it is called double coverage You
insurance coverage 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

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Maxicare Louisiana Inc 2000
Section 7 Limitations Rules that affect your benefits continued
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide them
beyond our control 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 illness that another
responsible for person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment
injuries 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 determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

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

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

If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it must
malpractice claim go to binding arbitration Contact us about how to begin our binding arbitration process

Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to
information about information about your health plan its networks providers and facilities You can also find out about care
your HMO 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 1 800 933 6294 or 1 504 532 7080 or write to Maxicare
Louisiana Inc at 1515 Poydras Street Suite 1130 New Orleans Louisiana 70112 You may also contact us
by fax at 1 504 571 5978

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Maxicare Louisiana Inc 2000
Section 8 FEHB Facts continued
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees
information about Health Benefits Plans brochures for other plans and other materials you need to make an informed decision
enrolling in the about
FEHB Program When you may change your enrollment

How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

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

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums effective premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the
I retire 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried
coverage are dependent children under age 22 including any foster or step children your employing or retirement office
available for me and authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22
my family 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 access to it
claims records
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

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Maxicare Louisiana Inc 2000
Section 8 FEHB Facts continued
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 Your old plan's deductible continues until our coverage begins
deductible under my
old plan

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

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 If you are divorced from a Federal employee or annuitant you may not continue to get benefits under your
spouse coverage former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or

retirement office to get more information about your coverage choices

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

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

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

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

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Maxicare Louisiana Inc 2000
Section 8 FEHB Facts continued
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You
TCC 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 Coverage that indicates
Certificate of Group how long you have been enrolled with us You can use this certificate when getting health insurance or other
Health Plan health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new
Coverage 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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Maxicare Louisiana Inc 2000
Department of Defense FEHB Demonstration Project
What is the The National Defense Authorization Act for 1999 Public Law 105 261 established the DoD FEHBP
Department of Demonstration Project It allows some active and retired uniformed service members and their dependents to
Defense DoD and enroll in the FEHB Program The demonstration will last for three years beginning with the 1999 Open
FEHB Program Season for the year 2000 Open Season enrollments will be effective January 1 2000 DoD and OPM have
Demonstration set up some special procedures to successfully implement the Demonstration Project noted below
Project Otherwise the provisions described in this brochure apply

Who is eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for Medicare
You are a qualified former spouse of an active or retired uniformed service member and you have not remarried or

You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas

If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you are
not eligible to enroll under the DoD FEHBP Demonstration Project

Where are the Dover AFB DE
demonstration areas Commonwealth of Puerto Rico Fort Knox KY

Greensboro Winston Salem High Point NC
Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA

When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information Processing Center
IPC in Iowa to provide you with information about how to enroll IPC staff will verify your eligibility and
provide you with FEHB Program information plan brochures enrollment instructions and forms The tollfree
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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Maxicare Louisiana Inc 2000
Department of Defense FEHB Demonstration Project continued
Am I eligible for See Section 8 FEHB Facts for information about TCC Under this Demonstration Project the only
Temporary individual eligible for TCC is one who ceases to be eligible as a member of family under your self and
Continuation of family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does
Coverage TCC not qualify to enroll as an unremarried former spouse under title 10 United States Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP Demonstration Project ends TCC

enrollment terminates after 36 months or the end of the Demonstration Project whichever occurs first You
your child or another person must notify the IPC when a family member loses eligibility for coverage under
the DoD FEHBP Demonstration Project

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

Do I have the 31 day These provisions do not apply to the DoD FEHBP Demonstration Project
extension and right to
convert

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Maxicare Louisiana Inc 2000
Notes

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Maxicare Louisiana Inc 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 1 800 933 6294 or 1 504 523 7080 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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Maxicare Louisiana Inc 2000
Summary of Benefits for Maxicare Louisiana 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 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 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 12

Extended care All necessary services up to 100 days per calendar year You pay nothing 12
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 14

Substance abuse Covered under mental conditions benefit 14
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 Xrays
complete maternity care You pay a 10 copay per office visit a 2
copay for laboratory tests and X rays in addition to the office visit copay a
10 copay per house call by a doctor You pay a 25 copay per urgent care
visit after regular appointment hours 9

Home health care All necessary visits by nurses and health aides You pay nothing 10
Mental conditions Up to 40 outpatient visits per year You pay a 5 copay for the first visit and a 30 copay for subsequent 39 visits 14

Substance abuse Covered under mental conditions benefit 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 of charges up to a 50 copay to the hospital for

each emergency room visit and any charges for services that are not
covered benefits of this Plan 12 14

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 7 copay for generic drugs and a 12 copay for name brand drugs per

prescription unit or refill 15
Dental care Non FEHB benefits available 17
Vision care One refraction annually You pay a 10 copay 15
Point of Service Services of non Plan doctors and hospitals Not all benefits are covered
benefits You pay deductibles and coinsurance and a maximum benefit applies 16

Out of pocket Copayments are required for a few benefits however after your out ofpocket
maximum expenses reach a maximum of 1,500 per Self Only or 3,000 per Self and Family enrollment per calendar year covered benefits will be

provided at 100 This copay maximum does not include prescription
drugs or non FEHB benefits 5

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Maxicare Louisiana Inc 2000
2000 Rate Information for
Maxicare Louisiana

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

Baton Rouge New Orleans areas
Self Only JA1 61.15 20.38 132.49 44.16 72.36 9.17 72.36 9.17

Self and Family JA2 142.01 47.34 307.70 102.56 168.05 21.30 168.05 21.30

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