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Health Partners of Alabama Inc 2000
Table of Contents
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB facts 21
Section 9 Non FEHB Benefits Available to Plan Members 25
Inspector General Advisory Stop Health care Fraud 27
Summary of Benefits inside back cover
Premiums back cover
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Health Partners of Alabama Inc 2000
Introduction
Health Partners of Alabama Inc
Two Perimeter Park South
Suite 200 West
Birmingham Alabama 35243
This brochure describes the benefits you can receive from Health Partners of Alabama Inc under its contract
CS2156 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits
FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan
is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible
family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and
are shown on page 4 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Government's communication more responsive accessible and
understandable to the public by requiring agencies to use plain language Health plan representatives and Office of
Personnel Management staff have worked cooperatively to make portions of this brochure clearer In it you will find
common everyday words except for necessary technical terms you and other personal pronouns active voice
and short sentences
We refer to Health Partners of Alabama 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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How to use this brochure
This brochure has nine 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
9 Non FEHB Benefits Available to Plan Members Benefits described in this section are neither offered nor
guaranteed under the contract with the FEHB Program but are made available to all members of this Plan
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific
physicians hospitals and other providers that contract with us These providers coordinate your health care services
The care you receive includes preventative care such as routine office visits physical exams well baby care and
immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you
must pay copayments and coinsurance listed in this brochure When you receive emergency services 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
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Health Partners of Alabama Inc 2000
Section 2 How we change for 2000
Program wide
Changes 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 you 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 with your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five
years This screening is for colorectal cancer
Changes to this Plan Your share of the non postal standard option premium will increase by 22.7 for
Self Only or 37.2 for Self and Family
A 100 copay per admission is required for hospital or extended care facility
admissions
A 50 copay is required for all necessary outpatient surgery
Durable medical equipment is limited to standard models only
A 15 copay is required for all physician office visits including chiropractic
treatment vision exams house calls and short term rehabilitative therapy
A 50 copay is required for hospital emergency room or urgent care
center visits
A 20 copay is required for mental health substance abuse outpatient
care
A 5 copay for a generic drug 15 copay for a preferred brand name drug
and 25 copay for a non preferred brand name drug is required for
medications prescribed at participating pharmacies
A 10 30 50 copay is required for a 90 day supply through the mail
order program
Services resulting from accidental injury to sound natural teeth require
a 100 inpatient admission copay or 50 outpatient surgery copay
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Health Partners of Alabama Inc 2000
Section 3 How to get benefits
What is this Plan's
service area To enroll with us you must live or work in our service area This is where our providers practice Our service area is
The Alabama counties of Autauga Baldwin Bibb Blount Bullock Calhoun Cherokee
Chilton Clarke Coosa Cullman Dallas Dekalb Elmore Jefferson Lowndes Macon
Marion Mobile Monroe Montgomery Russell Shelby St Clair Talladega Walker
Washington and Winston
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
for services You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance a set percentage of charges Please remember you must pay this
amount when you receive services
After you pay 1,000 in copayments for one family member or 2 000 for two or more
family members you do not have to make any further payments for certain services for
the rest of the year This is called a catastrophic limit However copayments 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 since you are responsible for
informing us when you reach the limits
Do I have to submit
claims You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't contract with us If you file a claim please send us all of the
documents for your claim as soon as possible You must submit claims by December 31
of the year after the year you received the service Either OPM or we can extend this
deadline if you show that circumstances beyond your control prevented you from filing on
time
Who provides my
health care Health Partners of Alabama is an independent provider association type Health Maintenance Organization known in the FEHB Program as an IPP or Individual Practice
Plan which means the HMO contracts with more than one medical provider You have
approximately 900 primary care doctors to choose from in varied locations and access to
over 1450 specialists who provide care on referral from your primary care doctor A
woman may see her plan obstetrician gynecologist without referral from her primary care
physician
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What do I do if my primary
care physician leaves
the Plan Call us We will help you select a new one
What do I do if I need to go
into the hospital Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will make the necessary hospital arrangements and
supervise your care
What do I do if I'm in the
hospital when I join
this Plan First call our customer service department at statewide except Mobile 205 9681400 locally or toll free at 1 800 947 5093 Mobile service area call locally 334470
8503 or toll free at 1 800 735 2439 If you are new to the FEHB Program
we will arrange for you to receive care If you are currently in the FEHB
Program and are switching to us your former plan will pay for the hospital stay
until
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 care Your primary care physician will arrange your referral to a specialist except in a medical emergency or when a primary care physician has designated another
doctor to see their patients
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 treatment plan will permit you to visit your
specialist without the need to obtain further referrals
What do I do if I am seeing
a specialist when I enroll Your primary care physician will decide what treatment you need If they decide to refer you to a specialist ask if you can see your current specialist If your
current specialist does not participate with us you must receive treatment from a
specialist who does Generally we will not pay for you to see a specialist who
does not participate with our Plan
What do I do if my specialist
leaves the Plan Call your primary care physician who will arrange for you to see another specialist You may receive services from your current specialist until we can
make arrangements for you to see someone else
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But what if I have a serious
illness and my provider
leaves the Plan or this Plan
leaves the Program Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your provider for up to 90 days after we notify you
that we are terminating our contract with the provider unless the termination is
for cause If you are in the second or third trimester of pregnancy you may
continue to see your OB GYN until the end of your postpartum care
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
medical services Your physician must get our approval before sending you to a hospital referring you to a specialist or 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 a
service is experimental or
investigational Health Partners of Alabama employs a proactive strategy for determining new and emerging technology The strategy includes an ongoing review of new drugs
devices and treatments which are supported by evidence based criteria The
criteria is compiled from computerized literature searches clinical trials review
professional associations association standards regulatory agency
endorsements and research based vendors
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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
Be in writing
Refer to specific brochure wording explaining why you believe our decision is
wrong and
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
Maintain our denial in writing
Pay the claim
Arrange for a health care provider to give you the service or
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 to
review a denial You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will determine if we correctly applied the terms of our
contract when we denied your claim or request for service
What if I have a serious or
life threatening condition
and you haven't responded
to my request for service Call us at 205 968 1400 or 1 800 947 5093 and we will expedite your review
What if you have denied my
request for care and my
condition is serious or life
threatening If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so they can give your claim expedited treatment as
well Alternatively you can call OPM's health benefits Contact Division IV at
202 606 0737 between 8 a m and 5 p m Serious or life threatening conditions
are ones that may cause permanent loss of bodily functions or death if they are
not treated as soon as possible
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we
uphold our initial denial or refusal of service You may also ask OPM to review your
claim if
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
You provided us with additional information we asked for and we did not answer
within 30 days In this case OPM must receive your request within 120 days of the
date we asked you for additional information
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What do I send to
OPM Your request must be complete or OPM will return it to you You must send the following information
A statement about why you believe our decision is wrong based on specific
benefit provisions in this brochure
Copies of documents that support your claim such as physicians letters
operative reports bills medical records and explanation of benefits EOB
forms
Copies of all letters you sent us about the claim
Copies of all letters we sent you about the claim and
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
request Those who have a legal right to file a disputed claim with OPM are
Anyone enrolled in the Plan
The estate of a person once enrolled in the Plan and
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
What if OPM
upholds
the Plan's denial OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your 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 file a lawsuit 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
the Privacy Act Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you 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
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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
15 office visit copay but no additional copay for laboratory tests and X rays Within the
service area house calls will be provided if in the judgment of the Plan doctor such care
is necessary and appropriate you pay a 15 copay for a doctor's house call nothing for
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
annually 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 including laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal
delivery and postnatal care by a Plan doctor Copays are waived for maternity care
The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if
medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary
nursery care of the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self and
Family enrollment other care of an infant who requires definitive treatment will be
covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services tubal ligations you pay a 250
copay vasectomies you pay a 100 copay Norplant is covered you pay the office
visit copay nothing for the cost of the drug
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy
serum
Routine annual eye examinations for diabetics
The insertion of internal prosthetic devices such as pacemakers and artificial joints
you pay 20 of charges for the cost of the device
Cornea heart heart lung kidney lung single double and liver transplants
allogeneic donor bone marrow transplants autologous bone marrow transplants
autologous stem cell and peripheral stem cell support for the following conditions
acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal
retroperitoneal and ovarian germ cell tumors 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
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Surgical treatment of morbid obesity
Home health services of nurses and health aides including the administration of
intravenous fluids and medications when prescribed by your Plan doctor who will
periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from
Plan doctors and other Plan providers you pay a 100 copay per admission
Routine foot care for diabetics and members with peripheral vascular disease
Routine hearing screening covered annually no age limit Referral required if not
performed by the primary care physician
All necessary outpatient surgery from Plan doctors and other Plan providers you pay
a 50 copay
Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including
but not limited to treatment of fractures and excision of tumors and cysts All other
procedures involving the teeth or intra oral areas surrounding the teeth are not covered
including any dental care involved in treatment of temporomandibular joint TMJ pain
dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional
defect or from an injury or surgery that has produced a major effect on the member's
appearance and if the condition can reasonably be expected to be corrected by such
surgery A patient and her attending physician may decide whether to have breast
reconstructive surgery following a mastectomy and whether surgery on the other breast is
needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an
inpatient or outpatient basis for up to two months per condition if significant improvement
can be expected within two months you pay 15 per outpatient session Speech therapy is
limited to treatment of certain speech impairments of organic origin Occupational
therapy is limited to services that assist the member to achieve and maintain self care and
improved functioning in other activities of daily living
Durable medical equipment such as wheelchairs and hospital beds orthopedic devices
such as braces and prosthetic devices such as artificial limbs initial device only lenses
following cataract removal breast prosthesis and surgical bras are covered you pay 20
of charges Ostomy supplies are covered when purchased at participating DME providers
The maximum Plan payment is 5,000 per member per year Durable medical equipment
standard models will be rented or purchased at the Plan's option wheelchairs that are
used on a permanent basis are limited to one per lifetime except when replacement is due
to normal growth and development The maintenance and repair of durable medical
equipment orthopedic devices and prosthetic devices are not covered
Diagnosis and treatment of infertility is covered you pay 20 The following types of
Artificial insemination are covered intravaginal insemination IVI intracervical
insemination ICI and intrauterine insemination IUI you pay 50 cost of donor sperm
is not covered Other assisted reproductive technology ART procedures that enable a
woman with otherwise untreatable infertility to become pregnant through other artificial
conception procedures such as in vitro fertilization and embryo transfer are not covered
Additionally oral and injectable medications are not covered
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Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial
infarction is provided at a Plan facility for up to 36 visits or 6 months you pay nothing
Chiropractic treatments are covered for up to 12 visits per member per year you pay a
15 copay per visit Referral by primary care physician is required
What is not covered Physical examinations that are not necessary for medical reasons such as those
required for obtaining or continuing employment or insurance attending school or
camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Homemaker services
Blood and blood derivatives
Long term rehabilitative therapy
Foot orthotics
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 100 copay for admission All
necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically
necessary the doctor may prescribe private accommodations or private duty nursing
care
Specialized care units such as intensive care or cardiac care units
Extended Care The Plan provides a comprehensive range of benefits for up to 90 days per calendar year when full timed 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 100 copay per admission All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility Services include inpatient and outpatient care and family counseling
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
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Limited Benefits
Inpatient dental
procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need 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
detoxification Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis 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 15 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Blood and blood derivatives
Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical
emergency A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe 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
Emergencies within
the Service Area If you are in an emergency situation please call your primary care doctor In extreme emergencies if you 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 a Plan doctor
believes care can he better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full
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Benefits within
the Service Area Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy
to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must
be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would
have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 50 per urgent care center visit for
emergency services that are covered benefits of this Plan
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 50 per hospital emergency room visit or 50 per urgent care center visit for
emergency services that are covered benefits of this Plan
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service determined by the Plan to be medically necessary
What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have
been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby
outside the service area
Filing claims for
non Plan providers With your authorization the Plan will pay benefits directly to the providers of your emergency 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
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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 All necessary outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay a 20 copay for each covered visit
Inpatient care All necessary hospitalization each calendar year you pay a 100 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 Inpatient services for the
psychiatric aspects are provided in conjunction with the mental conditions benefit shown
above The mental conditions benefit limitations apply to any covered inpatient substance
abuse care Outpatient services are covered as shown below
Outpatient care Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay a 20 copay for each covered visit
The substance abuse benefits may be combined with the outpatient mental conditions
benefit shown above provided such treatment is necessary as a mental conditions benefit
and is approved by the Plan to permit an additional 20 outpatient visits per calendar year
with the applicable mental conditions benefit copayment
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 31 day supply or 100 unit supply whichever is
less 240 milliliters of liquid 8 oz 60 grams of ointment creams or topical preparation
or one commercially prepared unit i e one inhaler one vial ophthalmic medication or
insulin In lieu of name brand drugs generic drugs will be dispensed when substitution is
permissible The Health Partners of Alabama prescription drug benefits for the FEHB are
not restricted or limited by the Plan's drug formulary You pay a 5 copay for a generic
drug 15 copay for a preferred brand name drug and 25 copay for a non preferred brand
name drug You pay the generic copay plus the difference in cost between the brand name
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and generic for any prescription filled for a brand name drug that has a generic
equivalent Prior authorization is required on all compounded prescriptions
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs and diaphragms
Insulin
Diabetic supplies limited to insulin syringes needles and blood glucose strips
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medications for home use are provided under home health
services at no cost see page 11
Prenatal vitamins and oral infant vitamin drops by prescription only
Zyban and over the counter Nicotrol may be purchased at your name brand copay in
conjunction with a participating smoking cessation program Pre authorization is
required
Limited benefits Smoking cessation drugs and medication in conjunction with a participating smoking
cessation program Nicotrol is limited to six 6 weeks and a 15 copay per seven 7
day supply Zyban is limited to twelve 12 weeks
Toradol therapy limited to 28 tablets per month
Diflucan 150mg limited to 1 tablet per copay
Sedative hypnotics limited to 15 tablets or capsules per copay
Zoloft limited to 100mg strength scored tablet
Migraine therapy is limited to a quantity of dosage units as indicated per product
package labeling for treatment of one episode of care per copay
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
Fertility drugs
Nicorette
Implanted time release medications except Norplant
Injectable contraceptive drugs except Depo Provera
Contraceptive jellies ointments or foams
Injectable drugs excluding insulin and Imitrex
Anorexiants and other drugs FDA approved or utilized for weight loss
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Other Benefits
Dental Care
Accidental injury
benefit Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result from an accidental injury You pay
the applicable 100 inpatient admission copay or 50 outpatient surgery copay
What is not covered Other dental services not shown as covered
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions which include the written lens prescription may be
obtained from Plan providers once every 24 months You pay a 15 copay per visit A
routine eye exam may be obtained once every 12 months for diabetics
What is not covered Eye exercises
Corrective eyeglasses and frames or contact lenses
including the fitting of the lenses
Smoking Cessation
What is covered Health Partners offers A Healthy Habit Smoking Cessation Program to help members address both the behavioral and chemical addiction to nicotine Members are eligible for
this six month program once per lifetime You pay a 20 copay For more information or
to enroll in A Healthy Habit please call 1 888 467 3426
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Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not
cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or
condition
We do not cover the following Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or
psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see
Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of
the mother would be endangered if the fetus were carried to term
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB
Program and
Expenses you incurred while you were not enrolled in this Plan
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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
25 Non FEHB benefits available to Plan members regarding Seniors First
Other group insurance coverage When anyone has coverage with us and with another group health plan it is called double coverage You must tell us
if you or a family member has double coverage You must also send us documents about other insurance if we ask
for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it
pays benefits next We decide which insurance is primary according to the National Association of Insurance
Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays
we will pay either what is left of the reasonable charge or our regular benefit whichever is less We will not pay
more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your
primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim
with your other plan you must still tell us that you have double coverage
Circumstances beyond our control Under certain extraordinary circumstances we may have to delay your services or be unable to provide them In that
case we will make all reasonable efforts to provide you with necessary care
When others are responsible for injuries When you receive money to compensate you for medical or hospital care for injuries or illness that another person
caused you must reimburse us for whatever services we paid for We will 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
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Health Partners of Alabama Inc 2000
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 compensation
We do not cover
services that You need because of a workplace related disease or injury that the Office of
Workers Compensation Programs OWCP or a similar Federal or State agency
determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we
will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government
Agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
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Health Partners of Alabama Inc 2000
Section 8 FEHB Facts
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information
about your health plan its networks providers and facilities You can also find out about care management which
includes medical practice guidelines disease management programs and how we determine if procedures are
experimental or investigational OPM's website www opm gov lists the specific types of information that we must
make available to you
If you want specific information about us call statewide except Mobile 205 968 1400 locally or toll free at 1 800947
5093 Mobile service area call locally 334 470 8503 or toll free at 1 800 735 2439 or write to Health Partners
of Alabama Inc Two Perimeter Park South Suite 200 West Birmingham Alabama 35243 You may also contact
us by fax at 205 968 1668 or visit our website at http www hlthpart com
Where do I get information about enrolling in the FEHB Program
Your employing or retirement office can answer your questions and give you a Guide to Federal Employees Health
Benefits Plans brochures for other plans and other materials you need to make an informed decision about
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
and premiums
effective The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums begin on the first day of your first pay period that starts on or
after January 1 Annuitants premiums begin January 1
What happens
when I retire When you retire you can usually stay in the FEHB Program Generally you must have been 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 coverage
are available for my
family and me Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried dependent children under age 22 including any foster or step
children your employing 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
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Health Partners of Alabama Inc 2000
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
claims records
confidential We will keep your medical and claims information confidential Only the following will have access to it
This plan and appropriate third parties such as other insurance plans and the Office
of Workers Compensation Programs OWCD when coordinating benefit payments
and subrogating claims
OPM this Plan and subcontractors when they administer this contract
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 cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your
ID card You can also use an Employee Express confirmation letter
What if I paid a
deductible under
my old plan Your old plan's deductible continues until our coverage begins
Pre existing
Conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my
enrollment in this
Plan ends You will receive an additional 31 days of coverage for no additional premium when
Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
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Health Partners of Alabama Inc 2000
YOU MAY BE ELIGIBLE FOR FORMER SPOUSE COVERAGE OR TEMPORARY
CONTINUATION OF COVERAGE
What is former
spouse coverage If you are divorced from a Federal employee or annuitant you may not continue to get benefits 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
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you
separate
If you no longer qualify as a family member you can receive TCC for up to 36
months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay
premiums from the 32 nd day after your regular coverage ends even if several months
have passed
You pay the total premium and generally a 2 percent administrative charge The
government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends
unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC
If you leave Federal service your employing office will notify you of your right to
enroll under 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
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Health Partners of Alabama Inc 2000
Your employing or retirement office will then send your former spouse information
about enrolling in TCC Your former spouse must enroll within 60 days after the
event which qualifies them for coverage or receiving the information whichever is
later
Note Your child or former spouse loses TCC eligibility unless you or your former
spouse notify your employing or retirement office within the 60 day deadline
How can I convert to
individual coverage You may convert to an individual policy if
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
Certificate of Group
Health Plan
Coverage If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled with us You can use this
certificate when getting health insurance or other health care coverage You must arrange
for the other coverage within 63 days of leaving 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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Health Partners of Alabama Inc 2000
Section 9 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 who are members of this Plan The cost of the benefits
described on this page is not included in the FEHB premium any charges for these services do not count toward any
FEHB deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed
claims procedure
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in a Medicare
plan Seniors First As indicated on page 19 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 this john 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 Seniors First at 1 800 888 7647 for information on Seniors First
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 1 800 888 7647 for information on the benefits
available under the Medicare HMO
Eyewear 25 discount at Participating Providers
Discount dental
services Oral Exam and Cleaning 15 copay per child
15 copay per adult
Other Dental Services
20 discount
Services are provided by participating dentists at a discount to Health Partners members and therefore cannot be
used in coordinating benefits with any other dental plan For a list of participating providers contact the United
Concordia Customer Service Department at 1 800 UCC DENT or 1 800 822 3368 Please identify yourself as a
Health Partners of Alabama FEHB member
Mail Order
Drug Option The Mail Order Drug Option now available to members of Health Partners is in addition to your current Health Partners prescription drug benefit program It is ideal for those
who take prescription medication on an ongoing basis because you can now enjoy several
important advantages
Convenience of home delivery postage paid
Security of receiving larger quantities of medication at one time and
Toll free customer service number
The mail order program permits dispensing of a 90 day supply of maintenance drugs Your copayment for a 90 day
supply is 10 generic 30 preferred brand name 50 non preferred brand name
Please refer to the enclosed brochure for additional information and details
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Health Partners of Alabama Inc 2000
SportsFirst 70 Discount on Enrollment Fee
Health Partners of Alabama Inc arranges for these services through local practitioners
but does not credential these practitioners nor make any warranties regarding the quality
of their services
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Health Partners of Alabama Inc 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has
charged you for services you did not receive billed you twice for the same service or misrepresented any
information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at statewide except Mobile 205 968 1400 locally or toll free
at 1 800 947 5093 Mobile service area call locally 334 470 8503 or toll free at 1 800 735 2439 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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Health Partners of Alabama Inc 2000
Summary of Benefits for Health Partners of Alabama 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations
and exclusions set forth in this brochure This chart merely summarizes certain important expenses covered by the
Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on
your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS
PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED
OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Care
Hospital Comprehensive range of medical and surgical services without dollar or
day limit Includes in hospital doctor care room and board general nursing care
private room and private nursing care if medically necessary diagnostic tests
drugs and medical supplies use of operating room intensive care and complete
maternity care You pay a 100 copay per admission 12
Extended Care All necessary services for up to 90 days per year You pay a 100 copay per
admission 12
Mental Conditions All necessary inpatient care You pay a 100 copay per admission 15
Substance Abuse Covered under mental conditions benefit 15
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 15 copay per office visit copays are waived
for maternity care 15 per house call by a doctor
Home Health Care All necessary visits by nurses and home health aides You pay nothing 11
Mental Conditions All necessary outpatient visits per year You pay a 20 copay per visit 15
Substance Abuse Up to 20 outpatient visits per year You pay a 20 copay per visit 15
Emergency Care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay per visit to the hospital for each emergency room
visit and any charges for services which are not covered benefits of this Plan 13
Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 generic 15 preferred brand name 25 non preferred brand name copay per
prescription unit or refill 15
Dental Care Accidental injury benefit you pay applicable copay 17
Vision Care One refraction every 24 months You pay a 15 copay per visit 17
Out of Pocket Limit Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per Self Only enrollment or 2,000 per Self
and Family enrollment per calendar year covered benefits will be provided at
100 This copayment maximum does not include prescription drugs 5
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2000 Rate Information for Health Partners of Alabama
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 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
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
Non Postal Postal A Postal B
Premium Premium Premium
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 DF1 78.83 27.67 170.80 59.95 93.06 13.44 93.26 13.24
Self and Family DF2 175.97 96.67 381.27 209.45 207.74 64.90 201.02 71.62
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