Pages 1--26 from Fehb-SW.PDF

For changes in
benefits see
page 3

Serving Dallas Ft Worth Area East Texas West Texas and Amarillo Area
Enrollment in this Plan is limited see page 3 for requirements

Enrollment code
V21 Self Only
V22 Self and Family

This plan has full accreditation
from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure
and
Visit this Plan's Website at http www txnylcare com

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE

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NYLCare Health Plans of the Southwest Inc 2000
Table of Contents Page

Introduction 2
Plain language 2
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 6
Section 5 Benefits 8 15
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16 17
Section 8 FEHB FACTS 18 19
Department of Defense FEHB Demonstration Project 22 23
Inspector General Advisory Stop Healthcare Fraud 23
Summary of benefits 24
Premiums 25

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NYLCare Health Plans of the Southwest Inc 2000
Introduction
NYLCare Health Plans of the Southwest Inc
4500 Fuller Drive
Irving TX 75038
800 486 3040

This brochure describes the benefits you can receive from NYLCare Southwest HMO under its contract CS 2087 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 NYLCare Southwest HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

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

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

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

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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NYLCare Health Plans of the Southwest Inc 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other
providers that contract with us These providers coordinate your health care services The care you receive includes preventative care
such as routine office visits physical exams well baby care and shots 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 premiums as low as possible OPM has set a minimum copay of 10 for all primary care office changes visits

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

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

You may review and obtain copies of your medical records on request You may ask that a physician amend
a record that is not accurate relevant or complete If the physician does not amend your record you may
add a brief statement to the record

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 Administration of Blood and Blood derivatives are covered in hospital including blood processing
Your share of the non postal premium will increase by 11.6 for Self Only and 11.3 for Self and Family

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NYLCare Health Plans of the Southwest Inc 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our service area service area is Dallas Fort Worth Area East Texas West Texas and Amarillo area

You may also enroll with us if you live or work in the following places
The Texas counties of Anderson Bowie Bosque Brown Camp Cass Coke Coleman Collin Comanche
Concho Cooke Dallas Delta Denton Ellis Erath Fannin Franklin Freestone Grayson Gregg Harrison
Henderson Hill Hood Hopkins Hunt Irion Jack Johnson Kaufman Lamar Marion Menard Montague
Morris Navarro Palo Pinto Panola Parker Potter Rains Randall Red River Rockwall Runnels Rusk
Schleicher Smith Somervell Sterling Tarrant Titus Tom Green Upshur Van Zandt Wise and Wood

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 pay You must share the cost of some services This is called either a copayment a set dollar amount or for services coinsurance a set percent of charges Please remember you must pay this amount when you receive
services
After you pay 650 in copayments or coinsurance for one family member or 1,500 per family 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 dental services vision and inpatient
mental health do not count toward these limits and you must continue to make these payments

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

Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a provider who 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 my The first and most important decision each member must make is the selection of a primary care physician health care The decision is important since it is through this doctor that all other health services particularly those of
specialists are obtained It is the responsibility of your primary care physician to obtain any necessary
authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization
Services of other providers are covered only when there has been a referral by the member's primary care
physician with the following exceptions a woman may see her Plan gynecologist for all covered
gynecological care Also dental services from a Plan dentist do not require a referral from the primary care
physician except for services relating to the accidental injury benefits

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

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

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NYLCare Health Plans of the Southwest Inc 2000
What do I do if I'm in First call our customer service department at 800 486 3040 or 972 791 3910 If you are new to the FEHB the hospital when I Program we will arrange for you to receive care If you are currently in the FEHB Program and are switching
join this Plan to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

How do I get specialty Your primary care physician will arrange your referral to a specialist care
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan The physician may have to get an authorization or approval beforehand

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

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

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

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

How do you decide if We consider a drug device procedure or treatment to be experimental if a service is There are insufficient outcomes data available from controlled clinical trials published in peer reviewed
experimental or literature to substantiate its safety and effectiveness for the disease or injury involved or investigational Approval has not been granted for marketing if required by the FDA or
A recognized national medical or dental society or regulatory agency has determined in writing that it is experimental investigational or for research purposes or
Written protocol s used by the treating facility or the protocols of any other facility studying substantially the same drug device procedure or treatment or the written informed consent used by the
treating facility or by another facility studying the same drug device procedure or treatment states that it is experimental investigational or for research purposes
Our coverage policy excludes procedures that are experimental or investigational However we have also developed a policy and process for handling issues involving the use of experimental investigational
procedures in terminally ill patients

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NYLCare Health Plans of the Southwest Inc 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording 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 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 800 486 3040 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 our review due to a serious medical condition and deny your claim we will inform OPM so denied my request for that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
care and my condition Division IV at 202 606 0737 between 8a m and 5 p m Serious or life threatening conditions are ones that is serious or life my cause permanent loss of bodily functions or death if they are not treated as soon as possible
threatening

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial 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 do not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information

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NYLCare Health Plans of the Southwest Inc 2000
What do I send to Your request must be complete or OPM will return it to you You must send the following information OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this
brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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

Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's
representative They must send a copy of the person's specific written consent with the review request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs Contract my disputed claim to Division IV 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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NYLCare Health Plans of the Southwest Inc 2000
Section 5 Benefits
Medical and Surgical Benefits
What is Covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no additional
copay for laboratory tests and X rays no charge for well baby visits routine immunizations and boosters a female enrollee's well woman exam and health assessments Within the Service Area house calls will be

provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a 10 copay for a doctor's house call or home visits by nurses and health aides

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 for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women age 50
through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms are covered when prescribed by the doctor as
medically necessary to diagnose or treat your illness Routine immunizations and boosters
Consultations by specialists Diagnostic procedures such as laboratory tests and X rays delivery
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean 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 the infant requiring definitive treatment will be covered only if the
infant is covered under a Self and Family enrollment Voluntary sterilization and family planning services you pay a 25 copay for elective tubal ligation or
vasectomy procedures in addition to the office visit or hospital copayment You pay 25 for the insertion and or removal of IUD and diaphragm
Diagnosis and treatment of diseases of the eye Allergy testing and treatment including testing and treatment materials such as allergy serum is provided
you pay a 25 copay for each test session The insertion of internal prosthetic devices such as pacemakers and artificial joints
External breast prosthesis and surgical bras after a mastectomy Cornea heart kidney liver single lung double lung heart lung and pancreas transplants allogeneic
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 testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian
cancer Related medical and hospital expenses of the donor are covered when the recipient is covered by the 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 Durable medical equipment such as standard wheelchairs and hospital beds are rented or purchased at the
Plan's option you pay nothing The repair replacement or maintenance of durable medical equipment is not covered
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Home health services of nurses and health aides when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
Rehabilitative Therapy External breast prosthesis and surgical bras after a mastectomy

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Southwest Inc 2000
Limited benefits
Oral and maxillofacial Provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip
surgery 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
shortening of the mandible or maxillae for cosmetic purposes correction of malocclusion and any
dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive Provided to correct a condition resulting from a functional defect or from an injury or surgery that has
surgery produced a major effect on the member's appearance and if the condition can reasonably be expected to be corrected by such surgery

Prosthetic devices Prosthetic devices such as artificial limbs and external lenses following cataract removal are covered for the initial device only Repair and periodic maintenance are excluded Replacements are not covered
unless due to the physical growth of a child You pay nothing

Diagnosis and Diagnosis and treatment of infertility is covered you pay 10 per visit The following types of artificial
treatment of infertility insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination IUI artificial insemination is covered only when using the patient's spouse's

sperm you pay 50 of charges for each artificial insemination service The 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 are not covered

Cardiac rehabilitation Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is covered you pay a 10 copay for each outpatient session

Hearing aids Hearing aids are covered following diagnosis of hearing deficiencies when ordered by a Plan doctor including audiometry initial placement of necessary hearing aid device s one 1 audiogram per year
if needed and replacement of the hearing aid device s every four 4 years if medically necessary up to
800 max per unit You pay nothing

Diabetic Supplies Diabetic Supplies at local Participating Pharmacy Lifescan Inc One Touch glucose monitor You pay nothing 1 every 5 years Blood and urine test strips 30 day supply for Lifescan Inc One Touch
monitor only You pay a 10 copay Lancets 30 day supply You pay a 10 copay Lancet devices 1
per year You pay a 10 copay Injection aids 1 per year You pay a 10 copay Mail Service
Pharmacy Blood and urine test strips 90 day supply for Lifescan monitor only You pay a 10
copay Lancets 90 day supply You pay 10 copay

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
Homemaker services
Orthopedic devices such as braces and foot orthotics
Refractions and eye exercises
Corrective eyeglasses and frames or contact lenses including the fitting of the lenses
Mechanical organ replacement devices

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Southwest Inc 2000
Hospital Extended Care Benefits
What is covered Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are

hospitalized under the care of a Plan doctor You pay a 275 copay per admission and a 100 copay
per outpatient surgical visit up to annual copay maximum 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 60 consecutive days per medical condition 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 a 25 copay
per day up to annual copay maximum All necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing

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

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a 25 copay per service
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need
procedures for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization
would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a
condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate
See page 12 for non medical Substance Abuse Benefits

What is not covered Personal comfort items such as telephone and television 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
emergencies what they all have in common is the need for quick action

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Southwest Inc 2000
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies if you 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 must notify the Plan within 48 hours
unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been
timely notified

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

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

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by
the Plan or provided by Plan providers

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

You pay 20 per urgent care center visit 75 per emergency room visit for emergency care services which are covered benefits of this Plan If the emergency results in admission to a hospital inpatient services are
subject to the hospital admission copay of 275 per admission and the emergency care copay is waived
Emergencies outside the service area Benefits are available for any medically necessary health service that is immediately required because of
injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If a
Plan doctor believes care can be better provided 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 care services to the extent the services would have been covered if received from Plan providers

You pay 20 per urgent care center visit 75 per emergency room visit for emergency care services which are covered benefits of this Plan If the emergency results in admission to a hospital inpatient services are
subject to the hospital admission copay of 275 per admission and the emergency care copay is waived
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service if approved by the Plan
What is not covered Elective care or non emergency care Emergency care provided outside the Service Area if the need for care could have been foreseen
before departing the Service Area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the Service Area

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Southwest Inc 2000
Filing claims for non Plan 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 6 7

Mental Conditions Substance Abuse Benefits
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 treatment of mental illness or disorders
Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 25 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay 50 of actual charges for first 30 days all charges thereafter These charges do not apply to the annual copayment maximum
Serious Mental Illness A Serious Mental Illness means the following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual Schizophrenia paranoid and other
psychotic disorders bipolar disorders hypomanic manic depressive and mixed major depressive
disorders single episode or recurrent schizo affect disorders bipolar or depressive pervasive
developmental disorders obsessive compulsive disorders depressed in childhood and adolescence

Outpatient Services up to a maximum of 60 office visits of 50 minutes each including group and
individual treatment during a calendar year You pay a 10 copay per visit

Inpatient Services for a maximum of 45 days of inpatient treatment during a calendar year You pay a
275 copay per admission

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance Abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical
non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for
any other illness or condition and to the extent shown below the services necessary for diagnosis and
treatment
Outpatient care All necessary outpatient visits to Plan providers for treatment you pay a 10 copay for each covered visit

Inpatient care All necessary care you pay a hospital admission copay of 275 per admission
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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NYLCare Health Plans of the Southwest Inc 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained from a Plan pharmacy will be dispensed for up to a 30 day supply You pay a 5 copay for generic drugs or a 10 copay for name
brand drugs per prescription unit or refill Prescription drugs obtained through the Home Delivery
Pharmacy Service will be dispensed for up to a 90 day supply you pay a 5 copay for generic drugs or
a 10 copay for name brand drugs per prescription unit or refill Injectables except insulin aerosol
inhalers and inhalant solutions are available only through the Home Delivery Pharmacy Service

When generic substitution is permissible i e a generic drug is available and the prescribing doctor
does not require the use of a name brand drug but you request the name brand drug you pay the price
difference between the generic and name brand drug as well as the 5 copay per prescription unit or
refill

Drugs purchased as a result of a medical emergency that occurs outside the Plan's service area will be
reimbursed for up to a 10 day supply minus the applicable copay

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary The
Plan's has an open formulary with few restrictions on prescription medications The Plan's clinical
staff and its Pharmacy and Therapeutics Committee evaluate drugs impartially for quality and cost
effectiveness Non formulary drugs will be covered when prescribed by a Plan doctor

Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs diaphragms and cervical caps that require a prescription
Insulin
Disposable needles and syringes needed for injecting covered prescribed medication including insulin

Intravenous fluids and medications for home use
Implanted time release medications such as Norplant are covered You pay 50 of charges and charges for voluntary removal of this device before its removal is medically indicated

Limited Benefits Drugs to treat sexual dysfunction are covered Contact the Plan for dose limits
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches
Fertility drugs

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Southwest Inc 2000
Other Benefits
Dental care What is covered

The following list identifies the dental services provided by participating Plan dentists in their offices and indicates copayments
where they apply Any unlisted procedures and services and procedures and services provided by Plan Specialist dentist will be
charged to the member at 75 of the dentist's usual and customary fees

You Pay ROOT CANAL THERAPY by Primary Dentist DIAGNOSTIC PREVENTIVE by Primary Dentist per tooth

Initial periodic oral examination Nothing 1 canal 170
Treatment Plan Nothing 2 canals 200
Oral cancer exam Nothing 3 canals 260
Visual aids Nothing
Consultations Nothing ORAL SURGERY by Primary Dentist You Pay
X rays per tooth
Bitewing 2 Surgical extraction erupted tooth 40
Other X rays one each 36 months Nothing Surgical extraction soft tissue impaction 55
Full Mouth 6 Surgical extraction partial bony impaction 75
Panoramic 12 Surgical extraction full bony impaction 100 Prophylaxis cleaning every 6 months Nitrous Oxide per 1 2 hour 10

Child to age 15 5 Local Anesthetic Nothing
Adult age 15 8
PERIODONTICS by Primary Dentist gum treatment per quadrant

Oral hygiene instruction Nothing Osseous surgery per quadrant 280
Occlusal Adjustment Limited 60
Occlusal Adjustment Complete 130
Fluoride treatment once each 6 months Nothing Periodontal scaling and root planing per quadrant 70
Sealant treatment per tooth 7
MAJOR DENTISTRY by Primary Dentist
NON ROUTINE and EMERGENCY DENTISTRY

X rays single per film 3 Crown and Bridge per unit
All gold is charged at market price
Non routine or emergency office visit Porcelain veneer crown with non precious 235
During regular office hours 9 Full cast crown non precious 225
Not during regular office hours 15 Inlay -2 surfaces 175
Missed appointment w o 24 hour notice 15 Inlay -3 surfaces 200
Re cement crown bridge 10
FILLINGS by Primary Dentist Post for crown 60 Silver Stainless steel crown 60

1 surface 10 Full Dentures upper or lower
2 surfaces 15 Only A D A approved materials used 235 plus lab fee
3 or more surfaces 18 Partial Dentures upper or lower 320 plus lab fee
Composite resin white anterior teeth only
1 surface 18
2 surfaces 21 ORTHODONTICS 75 of Dentist's Usual and
3 or more surfaces 26 customary fee
INFECTION CONTROL by Primary Dentist 6 per visit
COSMETIC by Primary Dentist Acid etch bonding for repair of incisal edge 50

Patient pays 20 in advance of treatment The balance is to be paid in
equal monthly installments during course of treatment Treatment scheduled
for more than 24 months is to be paid at 65.00 per month

Accidental injury benefit
Dental and orthodontic services following an accidental dental injury The need for these services must directly result from an
accidental injury not chewing or biting Treatment must be sought within 48 hours of the accidental injury and coverage may
extend for no longer than 60 consecutive days further treatment must be approved by the Plan You pay the appropriate doctor's
office visit hospital admission or emergency care copayments

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Southwest Inc 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure

Vision benefits Enrollees are entitled to the following vision benefits from Plan optometrists One 1 eye examination for eyeglasses every 12 months you pay a 10 copay
Eyeglass lenses and frames available at discount prices
Contact lenses and materials are also available at discount prices and
One 1 eye examination for contact lenses every 12 months you pay a 20 copay

Medicare prepaid plan This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As
enrollment indicated on page 16 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 this 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 our
Government Programs Department NYLCare 65 at Metro 972 791 4601 or 972 650 5500 or
toll free 800 435 2113 for information on the Medicare prepaid plan and the cost of that enrollment
The service area is different for this Medicare prepaid plan

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 please call Metro 972 791 1119 or
toll free 800 572 5080 for information on the benefits available under the Medicare HMO

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT

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NYLCare Health Plans of the Southwest 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

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 NYLCare Southwest please call 800 572 5080

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NYLCare Health Plans of the Southwest Inc 2000
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

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

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NYLCare Health Plans of the Southwest Inc 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
information about right to information about your health plan its networks providers and facilities You can also find
your HMO out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website

www opm gov lists the specific types of information that we must make available to you

If you want specific information about us call 800 486 3040 or write to NYLCare Southwest
4500 Fuller Drive Irving Texas 75038 You may also contact us by fax at 972 650 5610 or visit
our website at www txnylcare com

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

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

When your enrollment ends and
The next Open Season for enrollment

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

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

What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been
retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of

Coverage which is described later in this section

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NYLCare Health Plans of the Southwest Inc 2000
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for my retirement office authorizes coverage for Under certain circumstances you may also get coverage
family and me for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled
in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access
claims records to it
confidential OPM this Plan and subcontractors when they administer this contract

This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Program 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
cards SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter If you enrolled through Employee Express you can

request a confirmation letter from their Help line at 912 757 3030

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

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NYLCare Health Plans of the Southwest Inc 2000
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
spouse coverage your spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's

employing or retirement office to get more information about your coverage choices

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

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

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

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

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NYLCare Health Plans of the Southwest Inc 2000
How do I enroll in If you are leave Federal service your employing office will notify you of your right to enroll under
TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline

How can I convert You may convert to an individual policy if
to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not have
to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of
Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate

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

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NYLCare Health Plans of the Southwest Inc 2000
Department of Defense FEHB Demonstration Project
What is the Department of Defense DoD and FEHB Program Demonstration Project
The National Defense Authorization Act for 1999 Public Law 105 261 established the DoD FEHBP Demonstration Project It
allows some active and retired uniformed service members and their dependents to enroll in the FEHB Program The
demonstration will last for three years beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be
effective January 1 2000 DoD and OPM have set up some special procedures to successfully implement the Demonstration
Project noted below Otherwise the provisions described in this brochure apply

Who is Eligible
DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare You are a dependent of an active or retired uniformed service member and are eligible for Medicare
You are a qualified former spouse of an active or retired uniformed service member and you have not remarried or You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you are not eligible to enroll under
the DoD FEHBP Demonstration Project

Where are the demonstration areas
Dover AFB DE Commonwealth of Puerto Rico
Fort Knox KY Greensboro Winston Salem High Point NC
Dallas TX Humboldt County CA area
Naval Hospital Camp Pendleton CA New Orleans LA

When Can I Join
Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your
coverage will begin January 1 2000 DoD has set up an Information Processing Center IPC in Iowa to provide you with
information about how to enroll IPC staff will verify your eligibility and provide you with FEHB Program information plan
brochures enrollment instructions and forms The toll free phone number for the IPC is 1 877 DOD FEHB 1 877 363 3342

You may select coverage for yourself self only or for you and your family self and family during the 1999 2000 and 2001
Open Seasons Your coverage will begin January 1 of the year following the Open Season that you enrolled

If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact the IPC to find out how to
enroll and when your coverage will begin

DoD has a web site devoted to the Demonstration Project You can view information such as their Marketing Beneficiary
Education Plan Frequently Asked Questions demonstration area locations and zip code lists at www tricare osd mil fehbp You
can also view information about the demonstration project including The 2000 Guide to Federal Employees Health Benefits
Plans Participating in the DoD FEHBP Demonstration Project on the OPM web site at www opm gov

Am I eligible for Temporary Continuation of Coverage TCC
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NYLCare Health Plans of the Southwest Inc 2000
See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the only individual eligible for TCC
is one who ceases to be eligible as a member of family under your self and family enrollment This occurs when a child turns
22 for example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10
United States Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP Demonstration Project
ends TCC enrollment terminates after 36 months or the end of the Demonstration Project whichever occurs first You your
child or another person must notify the IPC when a family member loses eligibility for coverage under the DoD FEHBP
Demonstration Project

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

Do I have the 31 Day Extension and Right To Convert
These provisions do not apply to the DoD FEHBP Demonstration Project

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 800 486 3040 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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NYLCare Health Plans of the Southwest Inc 2000
Summary of benefits for NYLCare Health Plans of the Southwest 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 summarized certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF
EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or
day limit Includes in hospital doctor care room and board general
nursing care private room and private nursing care if medically
necessary diagnostic tests drugs and medical supplies use of operating
room intensive care and complete maternity care You pay a 275
admission copay a 100 copay per outpatient surgical visit 11
Extended care All necessary services for up to 60 days per condition You pay a 25 copay per day 11

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days conditions of inpatient care per year You pay 50 of charges these charges do not
apply to the annual copay maximum 13
Substance abuse All necessary care You pay a 275 per admission copay 13
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including

well baby care periodic check ups and routine immunizations laboratory
tests and X rays complete maternity care You pay a 10 copay for
office visit or for house calls by a doctor 9 Home health care
All necessary visits by nurses and health aides You pay a 10 copay per
visit 9 Mental conditions
Up to 20 outpatient visits per year You pay a 25 copay per visit 13 Substance abuse
All necessary outpatient visits You pay a 10 copay per visit 13

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 75 copay to the hospital for each

emergency room visit and any charges for services that are not covered by
this Plan 11 12

Prescription drugs Drugs prescribed by a Plan doctor and obtained from Home Delivery Pharmacy Service or at a participating pharmacy You pay a 5 copay for

generic drugs or 10 for name brand drugs per prescription unit or refill
of up to a 30 day supply A 5 copay plus the difference in retail price
applies if name brand drugs are requested when generic drugs are legally
substitutable 14

Dental care Accidental injury benefit full dental care you pay copays for most Primary Dentist services 15

Vision care No current benefit
Out of pocket limit Copayments are required for a few benefits however after your out ofpocket expenses reach a maximum of 650 per Self only and 1,500 per

Self and family enrollment per calendar year covered benefits will be
provided at 100 This copay maximum does not include costs of
prescription drugs inpatient care of mental conditions and dental
services 4

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NYLCare Health Plans of the Southwest Inc 2000
2000 Rate Information for
NYLCare Health Plans of the Southwest

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

Dallas Ft Worth East West Texas
Self Only V21 77.59 25.86 168.11 56.03 91.81 11.64 91.81 11.64

Self and Family V22 169.97 56.66 368.27 122.76 201.13 25.50 201.02 25.61

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