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PersonalCare's HMO 2000 A Health Maintenance Organization
Serving East Central Illinois
Enrollment in this plan is limited see page 5 for requirements
Enrollment code GE1 Self only
GE2 Self and family

HMO
November 1998 to November 2001

This Plan has Commendable accreditation
from NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Services

RI 73 257 1
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PersonalCare's HMO 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16
Section 8 FEHB facts 18
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits Inside back cover
Premiums Back cover

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PersonalCare's HMO 2000
Introduction
PersonalCare's HMO 2110 Fox Drive Champaign IL 61820
This brochure describes the benefits you can receive from PersonalCare's HMO under its contract CS2042 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 PersonalCare's HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not rewritten 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
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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PersonalCare's HMO 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 you must pay copayments
and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

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

Section 2 How we change for 2000
Program wide 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 See Section 3 How to get
benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your medical
records ask your health care provider for them You may ask that a physician amend a record that is not
accurate not relevant or incomplete If the physician does not amend your record you may add a brief
statement to it If they do not provide you your records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer

Changes to this Plan Your share of the non postal premium will increase by 2.3 for Self Only or 2.3 for Self and Family
PersonalCare is no longer available in the counties of Clark Coles Cumberland Crawford Edgar Effingham or Shelby

The prescription drug copayment will change from a 5.00 copay per prescription or refill or 12.50 copay for non formulary drugs to a 5 copay per prescription unit or refill for generic drugs a 10 copay per
prescription unit or refill for brand name drugs listed on the Plan's prescription drug formulary or a 25 copay for brand name drugs not listed on the formulary

We have clarified the prescription drug benefit to show that we cover oral and injectable contraceptive drugs and devices
Periodic eye refractions will be available to all members regardless of age with a 30.00 copayment Previously eye refractions were only available to members through age 17 See page 15 for details
We no longer cover in vitro fertilization

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PersonalCare's HMO 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our service area
Plan's service is The Illinois counties of Champaign Christian DeWitt Douglas Ford Iroquois Kankakee LaSalle Livingston
area Logan Macon Marshall Menard Morgan Moultrie Piatt Sangamon Vermilion and Woodford

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

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 coinsurance a
pay for services set percentage of charges Please remember you must pay this amount when you receive services

After you pay 1,500 in copayments or coinsurance for one family member or 3,000 for two or more family
members you do not have to make any further payments for certain services for the rest of the year This is called a
catastrophic limit However copayments or coinsurance for your prescription drugs or dental services do not count
toward these limits and you must continue to make these payments

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

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider who
submit claims doesn't contract with us 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 PersonalCare's HMO is a prepaid health plan mixed model that contracts with medical groups and individual
my health care doctors in Champaign Danville Kankakee Springfield and many other central Illinois communities All family members electing coverage must enroll with a doctor within the same community Applicants may contact

PersonalCare for assistance in choosing the most conveniently located doctors Members may change chosen
doctors upon request by contacting PersonalCare at 217 366 1226 or 800 431 1211
A primary care doctor may refer you to any network specialist regardless of location or group affiliation

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

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

What do I do if First call our customer service department at 800 431 1211 If you are new to the FEHB Program we will arrange
I'm in the for you to receive care If you are currently in the FEHB Program and are switching to us your former plan will
hospital when I pay for the hospital stay until
join this Plan You are discharged not merely moved to an alternative care center or

The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

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PersonalCare's HMO 2000
Section 3 How to get benefits continued

How do I get Your primary care physician will arrange your referral to a specialist with the following exception a woman may
specialty care see her Plan gynecologist without a referral

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

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

What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive services
my specialist from your current specialist until we can make arrangements for you to see someone else
leaves the Plan

But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your
have a serious provider for up to 90 days after we notify you that we are terminating our contract with the provider unless the
illness and my termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your
provider leaves OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll
Plan leaves the in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your
Program second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice

that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will
pay for the OB GYN care you receive from your current provider until the end of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize recommending follow up care Before giving approval we consider if the service is medically necessary and if it
medical follows generally accepted medical practice
services

How do you A drug or device is considered experimental if it does not have the approval for marketing from the U S Food and
decide if a Drug Administration A drug device treatment or procedure is considered experimental or investigational if
service is published reports or written protocols show that it is undergoing clinical trials or is otherwise under study to
experimental or determine dosage toxicity or safety
investigational

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

What if I have a Call us at 800 431 1211 and we will expedite our review
serious or lifethreatening
condition
and you haven't
responded to my
request for service

What if you have If we expedite your review due to a serious or life threatening condition and deny your claim we will inform
denied my request for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's health
care and my condition benefits Contract Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening
is serious or life conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon
threatening as possible

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

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PersonalCare's HMO 2000
Section 4 What to do if we deny your claim or request for service continued
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 for review to Office of Personnel Management Office of Insurance Programs Contract
my disputed claim to Division 3 P O Box 436 Washington D C 20044
OPM

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your
the Plan's denial only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year
after the year in which you received the disputed services or supplies

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will 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

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PersonalCare's HMO 2000
Section 5 Benefits

Medical and Surgical Benefits
A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and
other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no
additional copay for laboratory tests and X rays Services rendered by a nurse practitioner or physician
assistant that would otherwise be provided by a Plan doctor you pay a 10 copay per visit Within the
service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate you pay nothing for doctor's house calls or for home visits by nurses and health aides

The following services Preventive well baby care and child care You pay nothing for the first year after the first year you pay
are included a 10 copay per visit

Preventive care including periodic checkups and physical examinations

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 insulin and injections for allergies are covered in full You pay nothing Other prescribed injectables which you administer yourself such as Betaseron Pergonal and Imitrex you
pay 50 of the 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 covered in full 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 enrollment in the Plan is terminated during pregnancy benefits will not be
provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during
the covered portion of the mother's hospital confinement for maternity will be covered under either a
Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will
be covered only if the infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of infertility is covered you pay a 10 copayment per office visit The following types of artificial insemination are covered intravaginal insemination IVI intracervical
ICI and intrauterine IUI cost of donor sperm is not covered Fertility drugs and infertility services
as mandated by the State of Illinois are covered

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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PersonalCare's HMO 2000
Section 5 Benefits continued
The following services Cornea heart heart lung lung single or double pancreas kidney and liver transplants allogeneic
are included donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's

lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma and testicular mediastinal
retroperitoneal and ovarian germ cell tumors and breast cancer multiple myeloma and epithelial
ovarian cancer 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
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics initial device only you pay 20 of charges
Prosthetic devices such as artificial limbs and lenses following cataract removal initial device only breast prostheses surgical bras and replacements you pay 20 of charges

Durable medical equipment such as wheelchairs and hospital beds initial equipment only you pay 20 of charges
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your primary care doctor and approved by PersonalCare 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 except where noted

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
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 10 per outpatient 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

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility on an inpatient or outpatient basis for up to two months per condition if significant
improvement can be expected within two months you pay nothing
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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PersonalCare's HMO 2000
Section 5 Benefits continued
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 and blood derivatives not replaced by the member
Hearing aids
Long term rehabilitative therapy
Chiropractic services
Homemaker services
In vitro fertilization

Hospital Extended Care Benefits
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay a 100 copay per inpatient admission 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 120 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are
covered including

Bed board and general nursing care

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

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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PersonalCare's HMO 2000
Section 5 Benefits continued

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
procedures hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered

include hemophilia and heart disease the need for anesthesia by itself is not such a condition You pay
100 copay per inpatient admission

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

substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Blood and blood derivatives not replaced by the member

Custodial care rest cures domiciliary or convalescent care

Emergency Benefits
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 life
threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe
There are many other acute conditions that the Plan may determine are medical emergencieswhat they all
have in common is the need for quick action

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

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

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

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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PersonalCare's HMO 2000
Section 5 Benefits continued

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

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

You pay 50 or 50 of covered charges whichever is less per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services

Ambulance service approved by the Plan

What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen before
leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area

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 page 7

Mental Conditions and Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Members must have a referral from their PCP to see a mental health specialist

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year group sessions may be substituted on a two to one basis for each unused outpatient visit upon approval by
the primary care doctor and the Plan's Medical Director you pay a 20 copay for each covered visit all
charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year you pay 100 copay per admission for the first 30 days all charges thereafter Inpatient days can be exchanged for outpatient treatment at the rate of two day
treatments for each inpatient day

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PersonalCare's HMO 2000
Section 5 Benefits continued
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 non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any
other illness or condition and to the extent shown below the services necessary for diagnosis and treatment
Members must have a referral from their PCP to receive substance abuse services

Outpatient care Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for each covered visit all charges thereafter

These substance abuse benefits may be combined with the outpatient mental conditions benefit shown
above provided such treatment is necessary as a mental conditions service and is approved by the Plan to
permit an additional 20 outpatient visits per calendar year with the applicable mental conditions benefit
copayments

Inpatient care Benefits are provided for substance abuse rehabilitation intermediate care programs in an alcohol detoxification or rehabilitation center approved by the Plan you pay a 100 copay per hospital admission for
up to 30 days of treatment per calendar year all charges thereafter Inpatient days can be exchanged for
outpatient treatment at the rate of two day treatments for each inpatient day

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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PersonalCare's HMO 2000
Section 5 Benefits continued
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31 day supply or 100 unit supply whichever is less or one commercially prepared unit i e one
inhaler one vial ophthalmic medication or insulin Generic substitutes will be dispensed whenever generic
equivalents are available Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's
drug formulary A formulary is a group of drugs PersonalCare prefers its members to use These drugs are
selected by a Pharmacy Therapeutics Committee which includes physicians and pharmacists They
review studies outcomes literature and expert opinions to decide if the drugs are safe and effective and add
the most useful and cost effective drugs They may also remove old drugs as new more effective drugs
become available Nonformulary drugs will be covered when prescribed by the Plan doctor You pay a 5
copay per prescription unit or refill for generic drugs 10 copay per prescription unit or refill for brand
name drugs listed on the Plan's prescription drug formulary and a 25 copay for brand name drugs not listed
on the formulary

Covered medications and accessories include
Drugs for which a prescription is required by law
Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets

Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits

Oral and injectable contraceptive drugs and contraceptive devices
Limited benefits Sexual dysfunction drugs have dispensing limitations Contact the Plan for details
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
Smoking cessation drugs and medications including nicotine patches

Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair and replace sound natural teeth due to
benefit traumatic injury within thirty 30 days of the injury The need for these services must result from an accidental injury You pay nothing

Vision care
What is covered Eye refractions for all members to provide a written lens prescription for eyeglasses may be obtained
through Cole Vision's Vision One Exam Plus Program Cole Vision has a large network of providers in
the optical departments of major retailers such as Sears JC Penney and participating Pearle Vision Centers
Call 800 799 0259 to find the provider nearest you You pay a 30 copay per visit Cole Vision also has
a discount program for frames and lenses

What is not covered The fitting of contact lenses Eye exercises

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PersonalCare's HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your
Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
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 re enroll in the FEHB Program generally
you may do so only at the next Open Season

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

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

For information on Medicare Choice plans contact your local Social Security Administration SSA office or
request it from SSA at 1 800 638 6833

Other group When anyone has coverage with us and with another group health plan it is called double coverage You must tell
insurance us if you or a family member has double coverage You must also send us documents about other insurance if we
coverage 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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PersonalCare's HMO 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 In
beyond our 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 person
responsible for caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds
injuries 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 We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays
Government for
Agencies

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PersonalCare's HMO 2000
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the 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 800 431 1211 or write to 2110 Fox Drive Champaign IL
61820 You may also contact us by fax at 217 366 5410

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 FEHB about
Program When you may change your enrollment

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

When your enrollment ends and
The next Open Season for enrollment

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

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

What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the
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 my authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22
family and me 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

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PersonalCare's HMO 2000
Section 8 FEHB Facts continued
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

Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809
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 enrolled
conditions in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when
my 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

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PersonalCare's HMO 2000
Section 8 FEHB Facts continued
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
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 You may convert to an individual policy if
to individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay
coverage 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

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PersonalCare's HMO 2000
Section 8 FEHB Facts continued

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 how long you have been enrolled with us You can use this certificate when getting health insurance or
Group Health Plan other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan
Coverage Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well

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PersonalCare's HMO 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 431 1211 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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PersonalCare's HMO 2000
Summary of Benefits for PersonalCare's HMO 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth
in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your
enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this
brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes 11
care 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 100 copay per
admission

Extended care All necessary services up to 120 days per calendar year You pay nothing 11

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per 14 conditions year You pay 100 copay per admission

Substance Up to 30 days in a substance abuse treatment program You pay 100 copay per admission 14 abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury 9
care including specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10

copay for office visits and nothing for house calls by a doctor

Home health All necessary visits by nurses and health aides You pay nothing 10 care

Mental Up to 20 outpatient visits per year You pay a 20 copay per visit 13 conditions
Substance Up to 20 outpatient visits per year You pay a 20 copay per visit 14 abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You 12 pay a 50 or 50 of charges whichever is less to the hospital for each emergency room visit
and any charges for services that are not covered by this Plan

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per 15 prescription unit or refill for generic drugs 10 copay per prescription unit or refill for brand
name drugs listed on the Plan's prescription drug formulary and a 25 copay for brand name
drugs not listed on the formulary

Dental care Accidental injury benefit You pay nothing 15
Vision care Periodic eye refractions including lens prescriptions for all members You pay a 30 copay 15 per visit

Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses 5 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 dental services

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PersonalCare's HMO 2000
2000 Rate Information for
PersonalCare's HMO Health Plan

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

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

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

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

Self Only GE1 59.21 19.73 128.28 42.76 70.06 8.88 70.06 8.88
Self and GE2 152.27 50.75 329.91 109.97 180.18 22.84 180.18 22.84
Family

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