HealthAmerica 2000 Pennsylvania Inc
A Health Maintenance Organization
Serving Greater Pittsburgh area Central South Central and Northeast Pennsylvania
Enrollment in this Plan is limited See page 5 for requirements
Enrollment codes Greater Pittsburgh area
261 Self Only 262 Self and Family
Central South Central and Northeast Pennsylvania SW1Self Only
SW2Self and Family
This Plan has Commendable status from NCQA See the
1999 FEHB Guide for more information on NCQA
SPECIAL NOTICE TO HEALTHAMERICA ENROLLEES WHO LIVE IN
CENTRAL SOUTH CENTRAL OR NORTHEAST PENNSYLVANIA
You have a new enrollment code SW if you live in one of the following counties Adams Berks Blair
Centre Clinton Columbia Cumberland Dauphin Huntingdon Juniata Lancaster Lebanon Lycoming
Luzerne Mifflin Northumberland Perry Schuykill Snyder Union and York If you choose to remain with
HealthAmerica for 2000 you must complete a Standard Form SF 2809 to change to the new enrollment
code during open season If you don't change to the new enrollment code HealthAmerica will not provide
benefits for services that you receive from local Plan providers including primary care physicians
specialists hospitals pharmacies etc You will have to use Plan providers located in the Greater Pittsburgh
area 26 for all covered medical care
Visit the OPM website at http www opm gov insure
and
our website at http www healthamerica cvty com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service
HealthAmerica Pennsylvania Inc 2000
Table of Contents
Page
Introduction .1
Plain language .1
How to use this brochure .2
Section 1 Health Maintenance Organizations .3
Section 2 How we change for 2000 .3 4
Section 3 How to get benefits .5 7
Section 4 What to do if we deny your claim or request for service .7 8
Section 5 Benefits .9 18
Section 6 General exclusions Things we don't cover .19
Section 7 Limitations Rules that affect your benefits .20 21
Section 8 FEHB FACTS .21 24
Inspector General Advisory Stop Healthcare Fraud .24
Summary of benefits .25
Premiums .26
i
2
2
Page 3
4
HealthAmerica Pennsylvania Inc 2000
Introduction
HealthAmerica Pennsylvania Inc A Coventry HealthPlan Five Gateway Center
Pittsburgh PA 15222 1209
This brochure describes the benefits you can receive from HealthAmerica Pennsylvania Inc a Coventry HealthPlan under its contract CS2078 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 3 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 HealthAmerica Pennsylvania 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
1
3
3
Page 4
5
HealthAmerica Pennsylvania Inc 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
2
4
4
Page 5
6
HealthAmerica Pennsylvania 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 preventive
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 when you receive services you must pay copayments listed in this brochure When you receive emergency services you may have to submit claim
forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes 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 the record 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 For enrollment code SW your share of the non postal HealthAmerica Pennsylvania premium will increase
Plan by 13.7 for Self Only and 25.4 for Self and Family For enrollment code 26 your share of the nonpostal HealthAmerica Pennsylvania premium will increase by 5.4 for Self Only and 2.2 for Self and
Family
HealthAmerica has added a new enrollment code SW for enrollees who live in South Central Central and Northeast Pennsylvania Your enrollment code is SW if you live in one of following counties Adams
Berks Blair Centre Clinton Columbia Cumberland Dauphin Huntingdon Juniata Lancaster Lebanon Luzerne Lycoming Mifflin Northumberland Perry Schuylkill Snyder Union York In order to receive
the Plan's full benefits you should have switched your enrollment during open season by completing a 2809
The office visit copay has increased from 5 to 10 The copay for an office visit after posted hours has increased from 10 to 20
Transplants are only covered at facilities specifically approved and designated by the Plan HealthAmerica generally uses United Resource Networks URN for organ tissue transplants You may be required to
travel outside of the local service area for transplant services The plan provides travel and transportation assistance for patients who live more than 50 miles from the approved facility See page 9
Heart lung and lung are added to the list of covered organ tissue transplants See page 9
3
5
5
Page 6
7
HealthAmerica Pennsylvania Inc 2000
Section 2 How we change for 2000 continued
Changes to this Under the Prescription Drug Benefits your copay is 35 for all covered medications and items that are not
Plan on our prescription drug formulary When generic substitution is permissible but you or your doctor request the name brand drug you pay the price difference between the generic drug and name brand drug
continued as well as the appropriate copay generic formulary name brand formulary or non formulary per
prescription unit or refill See page 16
Prescriptions from retail pharmacies will only be dispensed for up to a 31 day supply Previously you could obtain up to a 34 day supply See page 16
We do not cover the cost of cochlear Implant devices See page 11
We cover the treatment of diabetes Medical and Surgical Benefits or Prescription Drug Benefits and serious mental illness Mental Conditions and Substance Abuse Benefits as mandated by the
Commonwealth of Pennsylvania See appropriate benefits pages for coverage details
Under the Medical and Surgical Limited Benefits for Oral and Maxillofacial Surgery we cover the extraction of symptomatic impacted third molars when partially or totally covered by bone See page 10
4
6
6
Page 7
8
HealthAmerica Pennsylvania Inc 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice You must enroll
Plan's service in the code we have designated for your county You may enroll with us if you live in one of the following
area Pennsylvania counties Enrollment code 26 Greater Pittsburgh area Allegheny Armstrong Beaver Butler Cambria Fayette
Greene Indiana Lawrence Mercer Somerset Washington and Westmoreland
Enrollment code SW Central South Central Northeast Pennsylvania Adams Berks Blair Centre Clinton Columbia Cumberland Dauphin Huntingdon Juniata Lancaster Lebanon Luzerne Lycoming
Mifflin Northumberland Perry Schuylkill Snyder Union York
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will only pay for authorized emergency care We will not pay for any other health care
services received outside the service area You must call your Primary Care Physician PCP within 48 hours or on the first working day after you are treated and or admitted to a hospital In an emergency that
is not life threatening you must call your PCP before you receive 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 If you or a family member move you do not have to wait until Open Season to change plans Contact your
employing or retirement office
How much do I You must share the cost of some services This is called either a copayment a set dollar amount or
pay for services coinsurance a set percent of charges Please remember you must pay this amount when you receive services
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the
service Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time
Who provides my We are a mixed model HMO with physicians in individual or group practices Each HealthAmerica
health care member must choose his or her own primary care physician PCP You and each covered family member can choose his or her own PCP who specializes in family practice internal medicine or pediatrics Your
PCP will provide or coordinate all of your health care needs
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 into make the necessary hospital arrangements and supervise your care
the hospital If you have a life or limb threatening emergency go to the nearest hospital or call 911 You must call your plan physician within 24 hours of treatment A life or limb threatening emergency is a sudden illness or
injury that could lead to loss of life or limb if not treated right away Examples of such emergencies are heart attack loss of consciousness difficulty breathing poisoning drug overdose or bleeding you can't
stop
5
7
7
Page 8
9
HealthAmerica Pennsylvania Inc 2000
Section 3 How to get benefits continued
What do I do if First call our customer service department at 800 735 4404 for the Greater Pittsburgh region or 800 7888445
I'm in the in South Central Central and Northeast Pennsylvania 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 are switching to us your former plan will pay for the hospital stay until
join this Plan You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist You must receive a referral from
specialty care your primary care doctor before seeing any other doctor or obtaining special services The only exceptions are when there is a medical emergency or when your primary care doctor has designated another doctor to
see his or her patients Also a woman may self refer to a Plan obstetrician gynecologist OBGYN for all her OB GYN services including her annual routine examination limited to 1 per year up to 100 Referral
to a participating specialist is given at the primary care doctor's discretion When non Plan specialists or consultants are required your primary care physician will contact us for approval We provide benefits for
covered services only when the services are medically necessary to prevent diagnose or treat your illness or condition
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 and may have to get our authorization or approval before finalizing the
treatment plan
It is important to remember that your PCP must arrange each visit to a specialist After you visit a specialist your PCP may be able to provide you with needed follow up care If your PCP decides that the
specialist should provide follow up care your PCP must arrange the visit
What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a
am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us
specialist when I you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
enroll
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive
my specialist services from your current specialist until we make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
have a serious your provider for up to 90 days after we notify you that we are terminating our contract with the provider
illness and my unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum care
provider leaves You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
the Plan or this you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
Plan leaves the condition or are in your second or third trimester Your new plan will pay for or provide your care for up
Program 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
6
8
8
Page 9
10
HealthAmerica Pennsylvania Inc 2000
Section 3 How to get benefits continued
How do you Your physician must get our approval before doing certain medical procedures or tests or when sending
authorize you to a hospital Before giving approval we consider if the service is medically necessary and if it
medical services follows generally accepted medical practice We only cover medically necessary services and supplies
How do you We gather appropriate information to determine whether a procedure service or supply is experimental or
decide if a service investigational The gathered information includes all appropriate medical records reviews of current
is experimental or medical and scientific evidence publications as well as information from government regulatory bodies Appropriate medical professionals participate in the extensive evaluation process to determine whether a
investigational procedure is is not considered experimental or investigational After the determination is made you will be notified of our decision You can obtain a copy of our Experimental Procedures Determinations Policy by
contacting HealthAmerica's Member Services Department
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 in 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
OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request for
denial service
What if I have a Call our customer service department at 800 735 4404 for the Greater Pittsburgh region or 800 788 8445
serious or life in South Central Central and Northeast Pennsylvania We will expedite our review
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 we deny your claim we will inform
denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's health
for care and my benefits Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
condition is
serious or life
threatening
7
9
9
Page 10
11
HealthAmerica Pennsylvania Inc 2000
Section 4 What to do if we deny your claim or request for service continued
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time limits denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send to Your request must be complete or OPM will return it to you You must send the following 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 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 OPM review to Office of Personnel Management Office of Insurance Programs
mail my disputed Contract Division 3 P O Box 436 Washington D C 20044
claim
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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review
if I 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
the 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
8
10
10
Page 11
12
HealthAmerica Pennsylvania Inc 2000
Section 5 Medical and Surgical Benefits
What is covered Our Plan doctors and other Plan providers provide a comprehensive range of preventive diagnostic and treatment services This includes all necessary office visits You pay a 10 office visit copay for office
visits but no additional costs for laboratory tests and X rays Within the service area house calls will be provided if in the judgement of our Plan doctor such care is necessary and appropriate you pay a 10
copay for a doctor's house call and nothing for home visits by nurses and licensed therapists For office visits after posted appointment hours you pay a 20 copay per visit
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows if you are a woman age 35 through age 39 one mammogram during these five years if you are a woman age 40 through 49 one mammogram every one or two
years if you are a woman age 50 through 64 one mammogram every year and if you are a woman age 65 and above one mammogram every two years In addition to screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness You pay nothing
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays You pay nothing
Complete obstetrical maternity care if you are a covered female including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care The mother at her option may
remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If you terminate your enrollment during
pregnancy benefits will not be provided after your coverage under our Plan has ended Ordinary nursery care of your newborn child during the covered portion of your hospital confinement for
maternity will be covered under either a Self Only or Self and Family enrollment Other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and
Family enrollment
Voluntary sterilization family planning services and the full range of FDA approved contraceptive devices You pay a 10 copay for diaphragms fitting only you pay a 50 copay for vasectomies and
you pay a 100 copay for tubal ligation
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell
support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer when authorized for payment by our Plan's Medical Director in accordance with policies and procedures based on criteria established by our Medical
Executive Committee and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical and hospital expenses of the donor are covered if the expenses are not covered by the
donor's insurance Transplant services may be provided at a participating Center of Excellence as determined by us and all transplants must be performed at hospitals specifically approved and
designated by us to perform these procedures The Plan provides limited travel and transportation assistance for patients who live more than 50 miles from the approved facility Contact customer
service for information
If you undergo a mastectomy you may at your option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure You pay nothing
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces when ordered by a Plan physician and authorized in accordance with our policies and procedures
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
9
11
11
Page 12
13
HealthAmerica Pennsylvania Inc 2000
Section 5 Medical and Surgical Benefits continued
What is covered Prosthetic devices such as artificial limbs lenses following cataract removal breast
continued prosthesis surgical bra when ordered by a Plan physician and authorized in accordance with our policies and procedures
Durable medical equipment such as wheelchairs and hospital beds when ordered by a Plan physician and authorized in accordance with our policies and procedures
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 our Plan doctors and other Plan providers at no additional cost to you
Limited benefits Oral and maxillofacial surgeryis 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 your oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts and extractions of impacted third molars when partially or totally covered by
bone All other procedures involving your 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
Reconstructive surgerywill be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on your appearance and if the condition can
reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and whether surgery on the other
breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant improvement can be
expected within two months you pay nothing Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist you in achieving and
maintaining self care and improved functioning in other activities of daily living
Self referred annual preventive gynecological examinationsare limited to one per year from a Plan OB GYN
Diagnosis and treatment of infertilityis covered you pay a 300 copay or 50 of the cost of the service whichever is less for you and each of your covered dependents The following types of artificial
insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI you pay a 300 copay or 50 of the cost of the service whichever is less for you and
each of your covered dependents cost of donor sperm is not covered Fertility drugs are not covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer
gamete intrafallopian transfer GIFT zygote intrafallopian transfer ZIFT and ovum harvest are not covered
Cardiac rehabilitationfollowing a heart transplant bypass surgery or a myocardial infarction is provided up to 60 consecutive days or 15 visits whichever is greater per cardiac event You pay nothing
Chiropractic carefor diagnosis and medically necessary treatment of acute musculoskeletal disorders is limited to 15 visits per member per year up to 1000 You pay 10 per visit
Enteral Formulais covered when medically necessary for treating specific metabolic disorders phenylketonuria branched chain phenylketonuria galactosemia and homocystinuria It must be
administered under the direction of a Physician You pay nothing
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
10
12
12
Page 13
14
HealthAmerica Pennsylvania Inc 2000
Section 5 Medical and Surgical Benefits continued
Limited benefits Diabetes Treatmentis covered if prescribed by a Plan physician and it complies with our polices and
continued procedures Plan approved blood glucose monitors insulin infusion devices and orthotics are covered in full You pay nothing We also cover outpatient diabetes self management training and education
including nutritional therapy for persons with diabetes if prescribed by a Plan Physician Selfmanagement training and education includes 1 visits medically necessary upon the diagnosis of diabetes
2 visits where a Plan physician identifies and diagnoses a significant change in the patient's symptoms or conditions that necessitates changes in a patient's self management and 3 where a licensed physician
identifies that a new medication or therapeutic process relating to the person's treatment or diabetes management is medically necessary You pay a 10 copay per visit Insulin syringes pharmacological
agents injection aids and monitor supplies for controlling blood sugar are covered under the Prescription Drug Benefits subject to applicable copays and the Plan's prescription drug formulary
What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining
covered 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
Hearing aids and Cochlear Implants
Homemaker services
Replacement of orthopedic or external prosthetic devices
Long term rehabilitative therapy
Organ transplantation services and supplies related to organ donation unless the recipient is a Plan member
Foot orthotics disposable supplies or dental appliances
Blood and blood derivatives not replaced by you
Foot care services except when required to treat manifestations of systemic disease causing circulatory problems such as diabetes or peripheral vascular disease
Section 5 Hospital Extended Care Benefits
What is covered
Hospital care We provide 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 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 We provide a comprehensive range of benefits for up to 100 days per calendar year when full time skilled
care nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are
covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility Services include inpatient and outpatient care and family counseling Hospice 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
11
13
13
Page 14
15
HealthAmerica Pennsylvania Inc 2000
Section 5 Hospital Extended Care Benefits continued
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
service
Limited benefits
Inpatient We cover hospitalization for certain dental procedures when a Plan doctor determines there is need for
dental hospitalization for reasons totally unrelated to the dental procedure Although we will cover the
procedures hospitalization we will not cover 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 Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment
inpatient of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan
detoxification doctor determines that outpatient management is not medically appropriate See page 15 for nonmedical substance abuse benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care Blood and blood derivatives not replaced by the member
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
12
14
14
Page 15
16
HealthAmerica Pennsylvania Inc 2000
Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
medical endangers your life or could result in serious injury or disability and requires immediate medical or
emergency surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially
life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that we may determine are medical emergencies what they all
have in common is the need for quick action
Emergencies If you are in an emergency situation please call your primary care doctor In extreme emergencies if you
within the are unable to contact your doctor contact the local emergency system e g the 911 telephone system or
service area 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 us You or a family member must notify us within 48 hours unless it was
not reasonable to do so It is your responsibility to ensure that we have been timely notified
If you need to be hospitalized we must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify us within that time If you are hospitalized
in non Plan facilities and 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
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 the Plan providers
We pay Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per emergency room visit or urgent care center visit for emergency care services that are covered benefits of this Plan If the emergency results in admission to a hospital we waive the copay
Emergencies Benefits are available for any medically necessary health service that is immediately required because of
outside the injury or unforeseen illness
service area If you need to be hospitalized we must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify us 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
We pay Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per emergency room visit or urgent care center visit for emergency care services that are covered benefits of this Plan If the emergency results in admission to a hospital we waive the copay
What is covered Emergency care at a doctor's office or urgent care center Emergency care as an outpatient or inpatient at a hospital including doctor's services
Ambulance service approved by the Plan
13
15
15
Page 16
17
HealthAmerica Pennsylvania Inc 2000
Section 5 Emergency Benefits continued
What is not Elective care or nonemergency 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 With your authorization we will pay benefits directly to the providers of your emergency care upon receipt
for non Plan of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to
providers pay for the services submit itemized bills and your receipts to us along with an explanation of the services and the identification information from your ID card
We will send payment to you or the provider if you did not pay the bill unless we deny benefits for the claim If we deny benefits we will send you a written notice of our decision including the reasons for the
denial and the provisions of the contract on which we based our denial If you disagree with us you may ask us to reconsider our decision in accordance with the disputed claims procedure described on page 7
Section 5 Mental Conditions Substance Abuse Benefits
Although referral from your PCP is not required you must call 1 800 627 1894 in Greater Pittsburgh and 1 800 332 1024 in Central South Central and Northeast Pennsylvania prior to obtaining services The Plan or mental health managed care vendor will determine
and authorize the number of visits based on the medical necessity of treatment
Mental
Conditions
What is To the extent shown below we provide the following services necessary for the diagnosis and treatment of
covered acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year
care you pay a 20 copay for each individual visit and a 10 copay for each group visit all charges thereafter
Inpatient Up to 30 days of hospitalization each calendar year Inpatient mental health days may be exchanged on a
care one for two basis to secure up to 60 transitional partial hospitalization days or on a one for four basis to secure up to 120 intensive outpatient sessions You pay a 25 copay per day for the first five 5 days per
admission to inpatient hospital or partial hospitalization facility and nothing day 6 through 30 inpatient or day 6 through 60 partial hospitalization or you pay 25 for the first ten 10 days of intensive outpatient
sessions and nothing session 11 through 120 all charges thereafter The copay will be waived on the first five 5 days of partial hospitalization if transferred from an inpatient facility
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
covered 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 shortterm psychiatric condition
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
14
16
16
Page 17
18
HealthAmerica Pennsylvania Inc 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
Serious Mental Serious Mental Illness means any of the following mental illnesses as defined by the American Psychiatric
Illness Association in the most recent edition of the Diagnostic and Statistical manual Schizophrenia Bipolar Disorder Obsessive Compulsive Disorder Major Depressive Disorder Panic Disorder Anorexia Nervosa
Bulimia Nervosa Schizo Affective Disorder and Delusional Disorder When you have a condition that qualifies as serious mental illness we provide the following benefits
Outpatient Up to 60 visits per year you pay a 20 copay for each individual marital and family visit or 10 copay
care for each group visit all charges thereafter Group visits are counted as one half of a visit 15 minute medication checks you pay a 10 copay per visit
Inpatient Up to 30 days of hospitalization each calendar year Inpatient mental health days may be exchanged on a
Care one for two basis to secure up to 60 transitional partial hospitalization days or on a one for four basis to secure up to 120 intensive outpatient sessions You pay a 25 copay per day for the first five 5 days per
admission to inpatient hospital or partial hospitalization facility and nothing day 6 through 30 inpatient or day 6 through 60 partial hospitalization or you pay 25 for the first ten 10 days of intensive outpatient
sessions and nothing session 11 through 120 all charges thereafter The copay will be waived on the first five 5 days of partial hospitalization if transferred from an inpatient facility
What is not Treatment not authorized by a Plan doctor
covered
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 and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care Up to 60 outpatient visits per calendar year with a lifetime maximum of 120 visits to Plan providers for treatment you pay nothing for each covered visit all charges thereafter
These outpatient visits on the basis of 30 visits only can be exchanged on a two for one basis to secure up to fifteen 15 additional days in an Alcohol Detoxification or Rehabilitation Center
Inpatient care Up to 30 days in an Alcohol Detoxification or Rehabilitation Center approved by the Plan with a lifetime maximum of 90 days you pay nothing during the benefit period all charges thereafter
What is not Treatment that is not authorized by a Plan doctor
covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
15
17
17
Page 18
19
HealthAmerica Pennsylvania Inc 2000
Section 5 Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan Participating retail pharmacy will be dispensed up to a 31 day supply or 100 unit supply whichever is less or one
commercially prepared unit i e one inhaler one can one vial ophthalmic medication or insulin Selected products or prescription drugs may require prior approval from the Plan You pay a 5 copay per generic
formulary drug or refill and a 10 copay per name brand formulary drug when generic substitution is not permissible and 35 copay for a non formulary drug at a retail pharmacy When generic substitution is
permissible but you or your doctor request the name brand drug you pay the price difference between the generic drug and name brand drug as well as the appropriate copay per prescription unit or refill In any
event your prescription drug copay will never exceed the retail price of the drug
Mail Order You can get a 90 day supply of plan approved maintenance medications for one copayment through our mail order pharmacy Maintenance medications are those drugs that are needed for long term or chronic
conditions such as high blood pressure The mail order quantity shall not exceed 3 commercially prepared units or the amount required for ninety 90 consecutive days whichever is less Selected products or
prescription drugs may require prior approval from the Plan and may not be available by mail order
Prescription Drugs are prescribed by Plan doctors and dispensed in accordance with our prescription drug formulary
Drug Formulary Nonformulary drugs will be covered when prescribed by a Plan doctor subject to the 35 non formulary copay
Our Prescription Drug Formulary is a list of drugs and other items that we approve for your use and which will be dispensed through Participating pharmacies to members We periodically review and modify our
formulary The list of approved drugs is available for review in the participating physician's office You may also obtain the list by contacting the Plan's Member Services Department or the plans web site at
www healthamerica cvty com
Covered medications and accessories include
Drugs for which a prescription is required by law
Full range of FDA approved prescriptions for birth control including but not limited to oral contraceptives Depo Provera and contraceptive diaphragms
Insulin with a copay charge applied to each vial
Plan approved diabetic supplies and pharmacological agents or devices used to assist in insulin injection injection aids including insulin syringes and needles blood glucose test strips and lancets
Selected injectables as specified by the Plan Imitrex Glucagon and Bee Sting Kits
Disposable needles and syringes needed to inject covered medication
Intravenous fluids and medications for home use some injectable drugs diabetic equipment glucose monitors and some FDA approved contraceptive devices are covered under Medical and Surgical
Benefits
Limited Benefits Sexual dysfunction drugs have dispensing limitations For complete details please call the Member Services phone number shown on your ID card
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
16
18
18
Page 19
20
HealthAmerica Pennsylvania Inc 2000
Section 5 Prescription Drug Benefits continued
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available
covered Drugs obtained at a non Plan pharmacy except for out of area emergencies Vitamins and minerals both OTC and legend except legend prenatal vitamins and liquid or chewable
legend pediatric vitamins
Medical supplies such as dressings and antiseptics
Contraceptive devices except diaphragms
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation
Drugs used for the primary purpose of treating infertility including those given in connection with artificial insemination
Oral dental preparations and fluoride rinses
Drug therapy for weight loss e g Xenical
Section 5 Other Benefits
Dental care
What is covered
Accidental Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are
Injury Benefits covered The need for these services must result from an accidental injury Covered services must be rendered within 24 hours of the accident You pay nothing
What is not Orthodontia and all other dental related services
covered Services provided by non participating dentists Other dental services shown as not covered
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of disease of the eye annual eye refractions to provide a written lens prescription for all members may be obtained from Plan
providers You pay a 15 copay per visit
What is not Corrective lenses or frames
covered Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
17
19
19
Page 20
21
HealthAmerica Pennsylvania 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 but are made available to all enrollees and family members who are 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
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 6 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage
and enroll in a Medicare prepaid plan when one is available in their area They may then later reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join the Medicare prepaid plan but will probably have
to pay for hospital coverage in addition to the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping your FEHB enrollment and
changing to a Medicare prepaid plan Contact us at 1 800 470 4272 for information on the Medicare prepaid plan and the cost of that enrollment The Health Care Financing Administration has not approved all of the counties in this Plan's service area for participation
in the Medicare HMO Call the Plan to find out if your county is included
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan call 1 800 470 4272 for information on the benefits available under the Medicare HMO
HealthAmerica Dental Plan Federal HealthAmerica dental is an optional dental benefit available when you enroll in HealthAmerica's HMO It is available at no cost when you choose HealthAmerica's HMO medical option For more information
please reference the HealthAmerica Dental brochure
Eligibility and Enrollment To apply for federal HealthAmerica dental coverage you must be enrolled in the HealthAmerica HMO medical option and you must complete a dental enrollment form
Plan Features Preventive Services including exam cleaning and Xrays restorative and orthodontics
Value Added Services
Vision Coverage All HealthAmerica members automatically qualify for a 20 20 vision benefit which provides a 20 discount off the normal retail price for lenses frames and contact lenses at Plan participating vision providers
Health Education Classes Classes include Weight Management Diabetic Education Prenatal Education Stress Management and Smoking Cessation
Health Club Discounts HealthAmerica members are eligible for discounted initiation fees and discounted monthly membership fees at Plan participating health clubs
To obtain an approved listing of programs available refer to your provider directory or call our customer service department at 800 735 4404 for the Greater Pittsburgh region or 800 788 8445 in South Central Central and Northeast Pennsylvania
BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT
18
20
20
Page 21
22
HealthAmerica Pennsylvania 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
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
19
21
21
Page 22
23
HealthAmerica Pennsylvania Inc 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to 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 18
Other group When anyone has coverage with us and with another group health plan it is called double coverage You
insurance must tell us if you or a family member has double coverage You must also send us documents about other
coverage insurance if we ask for them When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is less
We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control
When others 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
injuries 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
20
22
22
Page 23
24
HealthAmerica Pennsylvania Inc 2000
Section 7 Limitations Rules that affect your benefits continued
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers Compensation
Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly or
Government indirectly pays for
Agencies
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 the Plan's Member Services Department in Greater Pittsburgh at 412 553 5575 or 800 735 4404 or you may write to 60 Boulevard of the Allies Five Gateway Center Pittsburgh Pennsylvania 15222 or contact the
Member Services Department in South Central Central and Northeast Pennsylvania at 717 540 6315 or 800 788 8445 or you may write to 2575 Interstate Drive Harrisburg Pennsylvania 17110 9339 You may also visit our website at www healthamerica cvty com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information Employees Health Benefits Plans brochures for other plans and other materials you need to make an
about enrolling informed decision about
in the FEHB When you may change your enrollment
Program 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 premiums begin January 1
effective
21
23
23
Page 24
25
HealthAmerica Pennsylvania Inc 2000
Section 8 FEHB FACTScontinued
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in
when I retire the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is
described later in this section
What types of 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 my authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
family and me 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 We will keep your medical and claims information confidential Only the following will have access to it
and claims OPM this Plan and subcontractors when they administer this contract
records This Plan and appropriate third parties such as other insurance plans and the Office of Workers
confidential Compensation Programs OWCP when coordinating benefit payments and subrogating claims Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809
cards 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
conditions enrolled in this Plan solely because you had the condition before you enrolled
22
24
24
Page 25
26
HealthAmerica Pennsylvania Inc 2000
Section 8 FEHB FACTScontinued
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment Your enrollment ends unless you cancel your enrollment or
in this Plan You are a family member no longer eligible for coverage
ends 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 former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse
coverage 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
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC You
in 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
23
25
25
Page 26
27
HealthAmerica Pennsylvania Inc 2000
Section 8 FEHB FACTScontinued
How can I You may convert to an individual policy if
convert to Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay
individual your premium you cannot convert
coverage 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
Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving
Group Health this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health
Coverage 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
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 800 735 4404 for the Greater Pittsburgh region or 800 788 8445 in South Central Central and Northeast Pennsylvania 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
24
26
26
Page 27
28
HealthAmerica Pennsylvania Inc 2000
Summary of Benefits for HealthAmerica Pennsylvania 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
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital
Care 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 paynothing .11
Extended All necessary services up to 100 days per calendar year You paynothing .11
Care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per
Conditions year You paya 25 copay per day for the first 5 days and nothing for days 6 through 30 .14
Serious Diagnosis and treatment of serious mental illness for up to 30 days of hospitalization per year
Mental Illness You paya 25 copay per day for the first 5 days and nothing for days 6 through 30 .15
Substance Up to 30 days in an Alcohol Detoxification or Rehabilitation Center per contract year 90 days per
Abuse lifetime You paynothing .15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including
Care specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You paya 10 copay per
office visit or house call by a doctor You paya 20 copay per office visit after posted appointment hours .9 10
Home Health All necessary visits by nurses health aides and licensed therapists You paynothing .10
Care
Mental Up to 20 outpatient visits per year You paya 20 copay for each individual visit and 10 copay
Conditions for each group visit .14
Serious Up to 60 visits per year You paya 20 copay for each individual marital and family visit or
Mental Illness 10 copay for each group visit .15
Substance Up to 60 visits per contract year 120 visits per lifetime You paynothing .15
Abuse
Emergency Reasonable charges for services and supplies required because of a medical emergency You paya
Care 25 copay to the hospital for each emergency room visit within or outside the service area and any charges for services that are not covered by this Plan .13 14
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan retail or mail order pharmacy up to a 31
Drugs day supply You paya 5 copay per formulary generic drug prescription unitor refill or a 10 copay per formulary name brand drug per prescription unit or refill or a 35 copay per nonformulary
drug prescription unit or refill .16
Dental Care Accidental injury benefit You paynothing .17
Vision Care One refraction annually including lens prescription for all members You paya 15 copay per visit .17
Out of pocket Your out of pocket expenses for benefits covered under this Plan are limited to the stated
Maximum copayments which are required for a few benefits .5 25
27
27
Page 28
HealthAmerica Pennsylvania Inc 2000
2000 Rate Information for HealthAmerica Pennsylvania
Non Postal ratesapply 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 ratesapply 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 Gov't Your Gov't Your
Enrollment Share Share Share Share Share Share Share Share
Greater Pittsburgh area
Self Only 261 65.72 21.90 142.38 47.46 77.76 9.86 77.76 9.86
Self and 262 170.86 56.95 370.19 123.40 202.18 25.63 201.02 26.79
Family
Central South Central and Northeast Pennsylvania
Self Only SW1 70.91 23.64 153.65 51.21 83.91 10.64 83.91 10.64
Self and SW2 175.97 69.85 381.27 151.34 207.74 38.08 201.02 44.80
Family
26 28