Pages 1--28 from Rl73-303 2000.pdf

For changes benefits in
see page 5
Serving Central and Northeastern Pennsylvania

Enrollment in this Plan is limited see page 6 for requirements
Enrollment code
N91 Self Only
N92 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
this Plan's website at http www psghs edu

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

RI 73 303 1
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Penn State Geisinger Health Plan 2000
Table of Contents
Page

Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits .6 8
Section 4 What to do if we deny your claim or request for service 8 10
Section 5 Benefits 10 20
Section 6 General exclusions Things we don't cover 20
Section 7 Limitations Rules that affect your benefits 21 22
Section 8 FEHB FACTS 22 24
Inspector General Advisory Stop Healthcare Fraud 25
Summary of benefits Inside back cover
Premiums Back cover

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Penn State Geisinger Health Plan 2000
Introduction
Penn State Geisinger Health Plan
100 North Academy Avenue

Danville PA 17822 3020

This brochure describes the benefits you can receive from Penn State Geisinger Health Plan under its contract CS 2231 with the
Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the
official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this
brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 5 Premiums are listed at the end of this brochure

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

We refer to Penn State Geisinger Health Plan as this Plan throughout this brochure even though in other legal documents you will
see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not re written the Benefits section of this brochure You will find new benefits language next year

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Penn State Geisinger Health Plan 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

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

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

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
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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Penn State Geisinger Health Plan 2000
Section 1 Health Maintenance Organization
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and
injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services or point of service benefits POS see
page 18 for specific POS benefits 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
changes primary care office visits

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

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your
OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information

You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician

amend a record that is not accurate not relevant or incomplete If the physician does not
amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you

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

Changes to this Your share of the non postal premium will decrease by 3.4 for Self Only and by 3.4 for
Plan Self and Family

The Plan now provides coverage for certain serious mental illnesses See page 15
The Plan has added mail order prescription drug coverage available at participating mail order pharmacies for up to a 90 day supply of maintenance medication subject to a 16 copay per

prescription unit or refill See page 17
The Plan now provides coverage for diabetic supplies Previously diabetic supplies except for insulin and disposable needles and syringes were excluded from coverage See page 17

The Plan now provides coverage for diabetes related foot orthotics subject to a member copay of 50 of charges Previously all foot orthotics whether diabetes related or not were
excluded from coverage See page 11
The Plan now provides coverage for diabetic medical equipment subject to no member copay up to a calendar year maximum Plan payment of 2,500 per person See page 12

Women may now select a participating provider to obtain all medically necessary obstetric and gynecological care without prior approval from their primary care physician Previously
women could self refer but only for one routine gynecological visit per year See page 10
This Plan's service area has been expanded in the State of Pennsylvania to include the full counties of Berks Cameron Jefferson and York and portions Zip Codes of Cumberland

Elk and Perry counties see page 6 5 5
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Penn State Geisinger Health Plan 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice Our
Plan's service service area is All of Berks Blair Bradford Cambria Cameron Carbon Centre Clearfield
area Clinton Columbia Dauphin Huntingdon Jefferson Juniata Lackawanna Lancaster Lebanon Luzerne Lycoming Mifflin Monroe Montour Northumberland Pike Schuylkill Snyder

Sullivan Susquehanna Tioga Union Wayne Wyoming and York counties
You may also enroll with us if you live in the following places Portions of Bedford
Cumberland Elk Perry and Potter counties as denoted by the following zip codes

Bedford 15521 15554 16614 16633 16650 16655 16659 16664 16667 16670 16672
16679 16695

Cumberland 17007 17011 17013 17025 17043 17055 17065 17324
Elk 15821 15823 15827 15831 15841 15846 15860 15868
Perry 17020 17024 17031 17037 17040 17045 17053 17062 17068 17074 17090
Potter 17729

Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care or certain point of service benefits
see page 18 for details 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 You must share the cost of some services This is called either a copayment a set dollar amount
I pay for or coinsurance a set percentage of charges Please remember you must pay this amount when
services you receive services except for emergency care

After you pay 741.12 in copayments or coinsurance for one family member or 1,926.90 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 copayment maximum is separate from the out of pocket maximum
for the charges you pay when you use POS benefits as described on page 19 This is called a
catastrophic limit However copayments or coinsurance for your prescription drugs 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
submit claims provider who doesn't contract with us or you use point of service benefits If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims

by December 31 of the year after the year you received the service Either OPM or we can
extend this deadline if you show that circumstances beyond your control prevented you from
filing on time

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Penn State Geisinger Health Plan 2000
Section 3 How to get benefits continued
Who provides This Plan is a Mixed Model Prepayment MMP HMO Penn State Geisinger Health Plan Clinic
my health doctors and selected independent doctors who comprise the Penn State Geisinger Health Plan
care Physician Panel provide care to Plan members and practice at many locations in Central and Northeastern Pennsylvania The network includes 1,257 primary care doctors and 2,991

specialty care doctors Members can also receive care from non Plan providers at additional
costs see POS Benefits on page 18

The first and most important decision each member must make is the selection of a primary care
doctor The decision is important since it is through this source that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care doctor
to obtain any necessary authorizations from the Plan before referring you to a specialist or
making arrangements for hospitalization Services of other providers are covered only when you
have been referred by your primary care doctor or when you use POS benefits with the
following exception women may see their Plan obstetrician gynecologist without a referral for
an annual routine examination as well as medically necessary obstetrical and gynecological
visits

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

What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or
I need to go specialist will make the necessary hospital arrangements and supervise your care If a specialist
into the to whom you have been referred recommends hospitalization be sure to obtain authorization
hospital from your primary care physician

What do I do if First call our Customer Service Team at 800 447 4000 If you are new to the FEHB Program
I'm in the we will arrange for you to receive care If you are currently in the FEHB Program and are
hospital when I switching to us your former plan will pay for the hospital stay until
join this Plan You are discharged not merely moved to an alternative care center or

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

These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will arrange your referral to a specialist
specialty care If you need to see a specialist frequently because of a chronic complex or serious medical

condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician
will use our criteria when creating your treatment plan All follow up care must be provided or
authorized by the primary care doctor Do not go to the specialist for a second visit unless your
primary care doctor has arranged for and the Plan has issued and authorization for the referral

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

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Penn State Geisinger Health Plan 2000
Section 3 How to get benefits continued
What do I do if Call your primary care physician who will arrange for you to see another specialist You may
my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the someone else
Plan

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

or provide your care for up to 90 days after you receive notice that your prior plan is leaving the
FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a
authorize specialist or recommending follow up care Before giving approval we consider if the service is
medical medically necessary and if it follows generally accepted medical practice Services of other
services providers are covered only when you have been referred by your primary care physician or when you use POS benefits with the exception of women self referring to an obstetrician gynecologist

for medically necessary care

How do you The Plan's Medical Technology Assessment Committee which meets quarterly makes decisions
decide if a on whether or not new or presently non covered medical procedures equipment or treatments are
service is considered to be experimental or investigational In some instances the determination of
experimental or experimental or investigational is not only based on the procedures but also on the individual's
investigational diagnosis In arriving at its determination of whether or not a procedure equipment or treatment is experimental or investigational the Medical Technology Assessment Committee looks at

whether a drug service device or procedure is accepted as standard medical treatment of the
condition being treated and whether any such drug service device or procedure requires
Federal and or other governmental agency approval which has been granted at the time the drug
service device or procedure was dispensed or received

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

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Penn State Geisinger Health Plan 2000
Section 4 What to do if we deny your claim or request for service continued
If we ask your medical provider for more information we will send you a copy of our request
We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the
information we already have

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

What if I have Call us at 800 447 4000 and we will expedite our review
a serious or life
threatening
condition and you
haven't responded
to my request for
service

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

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information

What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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

Who can make 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
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Penn State Geisinger Health Plan 2000
Section 4 What to do if we deny your claim or request for service continued
Where should I Send your request for review to Office of Personnel Management Office of Insurance
mail my disputed Programs Contracts Division 3 P O Box 436 Washington D C 20044
claim to OPM

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

What laws apply if If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
I file a lawsuit third year after the year in which you received the disputed services or supplies

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

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

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

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

Section 5 Benefits
Medical and Surgical A comprehensive range of preventive diagnostic and treatment services is provided by this
Benefits Plan's doctors and other Plan providers This includes all necessary office visits you pay a 10 copay for office visits but no additional copay for laboratory tests and X rays Within the service

area house calls will be provided if in the judgement of the Plan doctor such care is necessary
and appropriate you pay a 10 copay for a doctor's house call and nothing for home visits by
nurses and health aides

What is covered The following services are included and are subject to the office visit copay unless stated
otherwise

Preventive care including well baby care periodic check ups and women may self refer to their Plan obstetrician gynecologist for an annual routine examination as well as medically

necessary obstetrical and gynecological visits
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 and up one mammogram every year In addition

to routine screening mammograms are covered when prescribed by the doctor as medically
necessary to diagnose and treat your illness

Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The 10 copay is waived after the first visit for maternity

care The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically
necessary

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Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
If enrollment in this Plan is terminated during pregnancy benefits will be provided after coverage
under this Plan has ended Ordinary nursery care of the newborn child during the covered
portion of the mother's hospital confinement for maternity will be covered under either a Self
Only or Self and Family enrollment other care of an infant who requires definitive treatment will
be covered only if the infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver lung single and double and pancreas kidney
transplants allogeneic donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following conditions acute
lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced nonHodgkin's
lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial
ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors
Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be limited to
clinical trials based on recommendations by the National Cancer Institute as determined by
the Plan's Medical Director Transplants are covered when approved by the Plan's Medical
Director 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 rigid appliances or apparatus used to support align or correct bone and
muscle deformities such as braces and diabetes related foot orthotics you pay 50 of
charges No coverage is provided for disposable supplies or dental appliances of any sort

Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need

All necessary medical and surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers

Surgical placement of devices for the purpose of drug delivery and or contraception i e
Norplant IUDs You pay 50 of charges for the device The office visit copay is waived
There is no coverage for removal within one year except when medically necessary i e side
affects adverse events

Cardiac rehabilitation
Nutritional supplements formulas for the treatment of aminoacidopathies such as
phenylketonuria PKU branched chain ketonuria galectosemia and homocystinuria

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Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical
procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to
extraction of partially or totally bony impacted wisdom teeth treatment of fractures excision of
tumors and cysts of the jaw bone and nondental treatment required due to accidental or traumatic
injury All other procedures involving the teeth or intra oral areas surrounding the teeth are not
covered including any dental coverage involved in the treatment of temporomandibular joint
TMJ pain dysfunction syndrome Surgery for correction of temporomandibular joint TMJ
dysfunction is covered upon radiologic determination of pathology

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 Coverage is provided for breast prostheses and surgical bras as well as their
replacements

Short term rehabilitative therapy physical speech and occupational is provided on an
inpatient or outpatient basis for up to 45 dates of service but no less than two consecutive
months per condition if significant improvement can be expected within two months you pay
nothing Speech therapy is limited to treatment of certain speech impairments of organic origin
Occupational therapy is limited to services that assist the member to achieve and maintain selfcare
and improved functioning in other activities of daily living

Durable medical equipment such as standard wheelchairs and hospital beds are covered at 100
of the cost of rental or purchase up to a calendar year maximum Plan payment of 2,500 per
member

Diabetic medical equipment such as blood glucose monitors insulin infusion devices and
pumps injection aids such as needle free injection devices bent needle set for insulin pump
infusion and non needle cannula for insulin infusion are covered at 100 up to a calendar year
maximum Plan payment of 2,500 per member

Prosthetic devices such as artificial limbs are covered subject to a maximum Plan payment of
5,000 per member per calendar year Members age 19 and older are limited to the initial
prosthesis and replacement of an existing prosthetic every five 5 years For members through
18 years this benefit includes the replacement or modification of devices required due to the
member's growth in addition to the initial device You pay nothing

Diagnosis and treatment of infertility is covered you pay a 10 office visit copay The following
types of artificial insemination are covered intracervical insemination ICI and intrauterine
insemination IUI You pay a 10 office visit copay 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

What is not covered Physician examinations that are not necessary for medical reasons such as those required for obtaining a continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induces sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Transplants not listed as covered
Long term rehabilitative therapy
Foot orthotics except for diabetes related foot orthotics
Chiropractic services
Blood and blood derivatives not replaced by the member
12 Eye refractions and eyeglasses and external lenses following cataract removal 12
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Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Hospital Extended The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
Care Benefits hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including

Hospital care 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 short term stays of up to 60 days per episode 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
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility up to a lifetime maximum of 10,000 per member 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 Life Lion is included

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover 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 16 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
emergency believe endangers your life or could result in a serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated

promptly they might become 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

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Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Emergencies within When an emergency happens provided that it will not place you at an increased risk of injury
the service area you should make a reasonable effort to contact your primary care physician or our Tel A Nurse staff for medical direction If you are unable to contact your primary care physician or the TelA

Nurse staff you should make a reasonable effort to safely proceed to the nearest participating
provider emergency room If you are not able to contact your primary care physician Tel ANurse
staff or are unable to safely proceed to a participating provider emergency room you
should proceed to the nearest emergency room

If you need to be hospitalized in a non Plan facility the Plan must be notified within 24 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 a Plan doctor believes
care can be better provided in a Plan hospital you will be transferred when medically feasible
with any ambulance charges covered in full

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

To be covered by this Plan any follow up care recommended by non Plan providers must be
authorized in advance by a member's primary care doctor or the Medical Director except as
covered under POS benefits

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

You pay 25 per hospital emergency room visit or 10 per urgent care center visit or doctor's office visit for emergency services that are covered benefits of this Plan If the emergency results in
admission to a hospital the copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the service area because of injury or unforeseen illness If you need to be hospitalized the Plan must be notified within 24 hours or on the first 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
authorized in advance by a member's primary care doctor or the Medical Director except as
covered under POS benefits

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

You pay 25 per hospital emergency room visit or 10 per urgent care center visit or doctor's office visit for emergency services that are covered benefits of this Plan If the emergency results in
admission to a hospital the copay is waived

What is covered Emergency care at a doctor's office or urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan

What is not Elective care or non emergency care including follow up care that can be provided within the
covered Penn State Geisinger Health Plan system

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 14 14
14 Page 15 16
Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
non Plan providers care upon 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 8

Mental
Conditions 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

Outpatient care Up to 30 outpatient visits 55 minutes in length to a Plan psychiatrist or psychologist each calendar year you pay a 25 copay for each covered individual therapy visit and a 10 copay for
each covered group therapy visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for hospital care a 25 copay for each day of psychiatric care while hospitalized for the first 30 days all charges
thereafter
Partial hospitalization is provided for up to 60 days each calendar year Two days of partial
hospitalization count as one day toward the 30 day inpatient limit

Serious mental illness Serious mental illness includes
What is covered 1 Schizophrenia 2 Bipolar Disorder

3 Obsessive Compulsive Disorder
4 Major Depressive Disorder
5 Panic Disorder
6 Anorexia Nervosa
7 Bulimia Nervosa
8 Schizo Affective Disorder and
9 Delusional Disorder

To the extent shown below the Plan provides the following services necessary for the diagnosis
and treatment of serious mental illness

15 15
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Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Outpatient care Up to a maximum of 60 outpatient visits individual and group therapy combined up to 55 minutes each visit to a Plan psychiatrist or psychologist each calendar year you pay a 25
copay for each covered individual therapy visit and a 10 copay for each covered group therapy
visit

Inpatient care Up to a maximum of 30 days of hospitalization each calendar year you pay nothing for hospital care a 25 copay for each 55 minute visit by a Plan psychiatrist or psychologist while
hospitalized for the first 30 days all charges thereafter
One 1 inpatient day may be converted to two 2 outpatient visits for up to an additional 60
outpatient visits per calendar year

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not
covered 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 This plan provides medical and hospital services such as acute detoxification services for the
What is covered 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 Up to 30 outpatient visits to Plan providers for treatment each calendar year you pay nothing for the first 30 visits 50 of charges for all subsequent courses of treatment

Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate unit program
in an alcohol or drug detoxification or rehabilitation center approved by the Plan you pay
nothing during the benefit period 50 of charges for all subsequent courses of treatment

Swing days Up to 30 outpatient visits per calendar year may be exchanged on a two for one basis for up to 15 additional inpatient days of rehabilitation with certification by a Plan doctor

What is not Treatment not authorized by a Plan doctor
covered

Prescription Drug Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will
Benefits be dispensed for up to a 34 day supply You pay an 8 copay per prescription unit or refill for up to a 34 day supply

What is covered In lieu of name brand drugs generic drugs will be dispensed when an approved generic is available If a name brand drug is dispensed when a generic is available you pay the difference
in cost between the generic and the name brand drug in addition to the 8 copayment When
there is a documented therapeutic failure using a generic drug Penn State Geisinger Health Plan
will authorize the member to obtain a name brand product for the 8 copayment In such cases
the doctor is required to provide evidence from the patient's chart for review by Penn State
Geisinger Health Plan or a representative

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

16 16
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Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Mail order Only outpatient maintenance prescription drugs prescribed by a Plan or referral doctor may be
pharmacy obtained at a participating mail order pharmacy The drugs will be dispensed for up to a
benefits minimum and not less than a 90 day supply you pay a 16 copay 2 times the regular prescription drug copay of 8 per prescription unit or refill Some drugs are not available

through the mail order program and must be obtained as described above
Covered medications and accessories include
Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs contraceptive diaphragms
Implanted devices for the purpose of drug delivery and or contraception i e Norplant
Intrauterine Devices you pay 50 of the cost of the implanted contraceptive device and
nothing for the implantation The office copay is waived There is no coverage for removal
within one year except when medically necessary i e side effects adverse events Norplant
and IUDs are covered under Medical and Surgical Benefits

Insulin
Diabetic supplies including oral pharmacological agents for controlling blood sugar insulin
syringes and needles and blood glucose monitor supplies such as lancets and glucose test
strips

Disposable needles and syringes needed to inject covered prescribed medication

Intravenous fluids and medication for home use implantable drugs such as Norplant and some
injectable drugs are covered under Medical and Surgical Benefits

Limited benefits Human growth hormones you pay 20 of charges per prescription unit or refill
Sexual dysfunction drugs are subject to dosage limits set by the Plan Contact the Plan for
details

Tobacco Cessation
Reimbursement for Tobacco Cessation pharmaco therapies are limited to prescription items only
in the following circumstances

Members must use a Plan certified counselor or tobacco cessation program and attend at least
4 of 6 sessions

You pay 22 per program session No office visit copay for tobacco cessation counseling
sessions

Lifetime limit of 3 programs with an interim of 6 months between programs
Initially each member must pay full cost of each session as well as the cost of any prescription
item associated with the program Reimbursement is made when the course is completed You
are responsible for the 8 copay for each prescription item Send receipts for prescription
drugs and sessions to Penn State Geisinger Health Plan Pharmacy Department 100 North
Academy Avenue Danville PA 17822 3045

What is not Drugs available without a prescription or for which there is a non prescription equivalent
covered available
Drugs obtained at a non Plan pharmacy except for out of area emergencies The Plan now
has national availability of Pharmacies through the Perx Select network of Express Scripts
Inc

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
Fertility drugs
17 17
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Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Other benefits
Dental care
What is covered
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth The need for these services must result from an accidental injury not chewing or biting You pay nothing

What is not Other dental services not shown as covered
covered

Medicare Choice Penn State Geisinger Health Plan Gold is a comprehensive benefits package especially for Medicare beneficiaries Under the Gold plan coverage is provided for routine office visits
physical exams immunizations diagnostic testing and X rays as well as hospitalization
To be a member of the Gold plan you must maintain your Medicare Part A and Part B
insurance and care must be provided by your Primary Care Physician including arrangements
for specialty care As an enrollee in both the Penn State Geisinger Health Plan under the Federal
Employees Health Benefits FEHB Program and Penn State Geisinger Health Plan Gold any
applicable coinsurances or deductibles are waived for services covered by the health plans
For more information on Penn State Geisinger Health Plan Gold when you are also enrolled in
the Penn State Geisinger Health Plan under the FEHB Program contact our Customer Service
Team at 1 800 631 1656

Point of Service POS
Benefits

Facts about this Plan's At your option you may choose to obtain benefits covered by this Plan from non Plan doctors
POS option and hospitals whenever you need care except for the benefits listed below or under What is not covered Benefits not covered under Point of Service Benefits must either be received from or

arranged by Plan doctors to be covered When you obtain covered non emergency medical
treatment from a non Plan doctor without a referral from a Plan doctor you are subject to the
deductibles coinsurance and maximum benefit stated below

What is covered All out of network services except those excluded below are covered Out of network services means those services received from a participating or non participating provider without a
referral All such services will be subject to applicable deductibles coinsurance and the lifetime
maximum benefit as listed below All non emergency out of network inpatient admissions and
designated outpatient procedures require pre certification

Precertification Precertification is the process whereby all non emergency out of network inpatient admissions and designated outpatient procedures are reviewed and approved by the Plan prior to the
provision of services The purpose of precertification review is to determine medical necessity
and appropriate length of stay Non emergency out of network inpatient admissions and
designated outpatient procedures normally covered under the point of service provision that have
not been precertified will be covered but you will be subject to a maximum penalty of 500

You must call 1 800 447 4000 to obtain an authorized number and authorization form in order to
receive coverage from non emergency out of network inpatient admission and designated
outpatient procedures

18 18
18 Page 19 20
Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
Deductible Deductible means a specified dollar amount for out of network services that must be incurred and paid by you before the Plan will assume any liability for all or part of the remaining covered
services The deductible must be met every calendar year For Self Only the amount is 250 for
Self and Family the amount is 750

Coinsurance Coinsurance means the specified portion of the usual customary and reasonable UCR allowance that you are required to pay After the deductible is met the Plan will pay 80 of the
UCR allowance and you pay 20 of the UCR allowance until you reach the annual out of pocket
amount exclusive of deductible and amounts in excess of the UCR allowance The UCR
allowance means the allowance for covered services determined from time to time by the Plan
to be reasonable considering the degree of professional and technical involvement necessary to
perform the service This UCR allowance shall not exceed the amount customarily charged by
providers in the same geographical location where the procedure is performed The UCR
allowance will be determined on the basis of when care is provided not when payment is made
The UCR allowance is set at the 90th percentile of Medicode UCR allowances

Maximum benefit There will be an out of pocket maximum of 2,500 per Self Only and 7,500 per Self and Family enrollment This will be the maximum dollar amount excluding deductible and amounts
in excess of the UCR allowance that you are required to pay toward out of network services in a
given calendar year Any amounts paid by you in excess of the UCR allowance will not be
counted toward satisfying the maximum out of pocket amounts This maximum out of pocket
amount is in addition to the in network annual maximum copayment amount out of pocket

The lifetime maximum benefit is the maximum amount of benefits this Plan will cover under this
point of service provision Once you reach the maximum out of pocket amount the Plan will
pay 100 of the UCR allowance until the lifetime maximum of 1,000,000 is reached There is
no in network lifetime maximum

Hospital extended Non emergency out of network inpatient hospital admissions require precertification as described
care benefits above They will be covered subject to deductible coinsurance and maximum benefit limits also listed above The hospital charge sometimes called a facility charge does not cover any charges

for doctors services

Emergency benefits Are not covered under this benefit as all emergency care is covered as in network services
What is not 500 penalty for failure to precertify non emergency out of network inpatient admissions and
covered designated procedures
Durable medical equipment
Prosthetics
Orthotics
Inpatient mental health care
Outpatient prescription drugs
Substance abuse outpatient mental health care and emergency care will be covered only as
defined under in network benefits

Any service for which a claim has not been properly submitted
Any service that exceeds lifetime maximum benefit

19 19
19 Page 20 21
Penn State Geisinger Health Plan 2000
Section 5 Benefits continued
How to obtain To receive coverage you will be required to file a claim for all out of network services To
benefits receive a claim form you should call the Plan at 1 800 447 4000 You should keep a record of out of network services incurred by yourself and each family dependent If during a calendar

year charges for out of network services exceed the deductible you must complete a claim form
and submit it together with itemized bills to the following address

Penn State Geisinger Health Plan
100 North Academy Avenue
Danville PA 17822 3026
Attention Claims Department

You must sign Section A of the claim form before the Plan will issue payment to a provider or
reimburse you for out of network services under this provision If the claim qualifies as a
covered expense you or the provider will receive reimbursement from the Plan Claims for
services must be submitted to the Plan no later than twelve months after the end of the calendar
year in which covered services are provided If you are not satisfied with the Plan's adjudication
of a claim you may utilize the Plan's established grievance procedure

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

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric
practice

Care by non Plan providers except for authorized referrals or emergencies see Emergency
Benefits or eligible self referred services see Point of Service benefits

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

20 20
20 Page 21 22
Penn State Geisinger Health Plan 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to 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 For information on the
Medicare Choice plan offered by this Plan see page 18

Other group When anyone has coverage with us and with another group health plan it is called double
insurance coverage You must tell us if you or a family member has double coverage You must also send
coverage us documents about other insurance if we ask for them When you have double coverage one plan is the primary payer it pays benefits first The other

plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if
you do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our provide them In that case we will make all reasonable efforts to provide you with necessary
control care

When others When you receive money to compensate you for medical or hospital care for injuries or illness
are responsible that another person caused you must reimburse us for whatever services we paid for We will
for injuries cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more

information contact us for our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage

Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency 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 21 21
21 Page 22 23
Penn State Geisinger Health Plan 2000
Section 7 Limitations Rules that affect your benefits continued
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
Government or indirectly pays for
Agencies

Section 8 FEBH 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
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational

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

If you want specific information about us call 800 447 4000 or write to Penn State Geisinger
Health Plan 100 North Academy Avenue Danville PA 17822 3020 You may also contact us
by fax at 570 271 5871 or visit our website at www psghs edu

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 an informed decision about
FEHB Program When you may change your enrollment How you can cover your family members

What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire

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

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I 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

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
available for my or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
family and me If you have a Self Only enrollment you may change to a Self and Family enrollment if you

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

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

If you or one of your family members is enrolled in one FEHB plan that person may not be
22 enrolled in another FEHB plan 22
22 Page 23 24
Penn State Geisinger Health Plan 2000
Section 8 FEBH FACTS continued
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access 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 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
cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before
conditions you enrolled 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 Your enrollment ends unless you cancel your enrollment or
this Plan ends You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

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

your ex spouse's employing or retirement office to get more information about your coverage
choices

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

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

23 23
23 Page 24 25
Penn State Geisinger Health Plan 2000
When you lose benefits continued
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 32nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you
cancel your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under
in 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 You may convert to an individual policy if
convert to Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
individual not pay your premium you cannot convert
coverage You decided not to receive coverage under TCC or the spouse equity law or

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

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

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

If you have been enrolled with us for less than 12 months but were previously enrolled in other
24 FEHB plans you may request a certificate from them as well 24
24 Page 25 26
Penn State Geisinger Health Plan 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 800 447 4000 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

25 25
25 Page 26 27
Penn State Geisinger Health Plan 2000
Summary of Benefits for Penn State Geisinger Health Plan 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 AND SERVICES AVAILABLE AS POS BENEFITS ARE COVERED ONLY WHEN PROVIDED OR ARRANGED
BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general

nursing care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 13

Extended care All necessary services with no dollar limit for short term stays of up to
60 days You pay nothing 13

Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days
of inpatient care per year You pay nothing for hospital care a 25 copay
per day for inpatient psychiatric care There is also coverage for Serious
Mental Illness 15

Substance abuse Up to 30 days per year in a substance abuse treatment program
You pay nothing for the first 30 days and 50 of charges for all
subsequent courses of treatment 16

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 per office visit the 10 copay is waived after the first visit for
maternity care 10 per house call by a doctor 10 11

Home health care All necessary visits by nurses and health aides You pay nothing 11
Mental conditions Up to 30 outpatient visits per year You pay a 25 copay per individual
therapy visit 10 copay per group therapy visit There is also coverage
for Serious Mental Illness 15

Substance abuse Up to 30 outpatient visits per year You pay nothing for the first 30 visits
and 50 of charges for all subsequent courses of treatment 16

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each
emergency room visit and any charges for services that are not covered
by this Plan 13 14

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay an 8 copay per prescription unit or refill 16 17

Dental care Accidental injury benefit you pay nothing 18

26 26
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Penn State Geisinger Health Plan 2000
Vision care No current benefit
Point of Service Services of non Plan doctors and hospitals Not all benefits are
Benefits covered You pay deductibles and coinsurance and a maximum benefit applies 18 20

Out of pocket Copayments are required for a few benefits however after your
maximum out of pocket expenses reach a maximum of 741.12 per Self Only or 1,926.90 per Self and Family enrollment per calendar

year covered benefits will be provided at 100 This copay
maximum does not include charges for prescription drugs This
out of pocket maximum does not apply to the charges you pay when
you use POS benefits rather a separate out of pocket maximum
applies to the charges you pay when you use POS benefits 6

27 27
27 Page 28
2000 Rate Information for
Penn State Geisinger 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 N91 49.01 16.33 106.18 35.39 57.99 7.35 57.99 7.35
Self and Family N92 149.48 49.83 323.88 107.96 176.89 22.42 176.89 22.42

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