Pages 1--28 from Untitled

Enrollment code
EG1 Self Only
EG2 Self and Family

Visit the OPM website at http www opm gov insure
and
this Plan's WEB page at http www mcare org

Authorized for distribution by the
United States Office of
Personnel Management Retirement
and Insurance Service RI 73 445 1
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M CARE HMO 2000
Table of Contents
Introduction .1
Plain language .1
How to use this brochure .2
Section 1 Health Maintenance Organizations .3
Section 2 How we change for 2000 .3
Section 3 How to get benefits .4 6
Section 4 What to do if we deny your claim or request for service .7 8
Section 5 Benefits .9 17
Section 6 General exclusions Things we don't cover .18
Section 7 Limitations Rules that affect your benefits .19 20
Section 8 FEHB FACTS .21 23
Inspector General Advisory Stop Healthcare Fraud .24
Summary of benefits .25
Premiums .26 2
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M CARE HMO 2000
Introduction
M CARE 2301 Commonwealth Blvd
Ann Arbor MI 48105 2945
This brochure describes the benefits you can receive from M CARE HMO under its contract CS 2341 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 the Plan is entitled to the benefits stated in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 3 Premiums are listed at the end of this brochure

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

We refer to M CARE HMO as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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M CARE HMO 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

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

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

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M CARE HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes 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

Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all 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 Plan Your share of the Non Postal premium will increase by 14.4 for Self Only or 14.3 for Self and Family
The copay for prescription drugs increased from 5 to 10 for brand name per prescription unit or refill See Page 15
A maintenance drug benefit is being added See Page 15
The copay for fertility drugs increased from 5 to 50 See Page 15
The copay for sexual dysfunction drugs increased from 5 to 50 See Page 15
Before obtaining Mental Conditions and Substance Abuse services you must contact the contracted Central Diagnostic Referral agency that serves your area See Page 14

The service area expanded See Page 4

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M CARE HMO 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live in our service area This is where our providers practice Our
service area service area is

The entire Michigan counties of Clinton Eaton Genesee Hillsdale Ingham Livingston Macomb Oakland Shiawassee

Washtenaw and Wayne
And portions of the following Michigan counties Barry
Maple Grove Prarieville Barry Johnston and Assyria Townships Calhoun
Bedford Pennfield Convis Lee Clarence Springfield Emmett Marshall Marengo Sheridan LeRoy Newton Fredonia Eckford Albion Athens Tekonsha Clarendon
and Homer Townships Cities of Springfield Battle Creek Marshall and Albion Villages of Athens Tekonsha and Homer
Jackson Jackson City Parma Village Blackman Columbia Grass Lake Henrietta Leoni
Liberty Napoleon Norvell Parma Rivers Sandstone Spring Arbor Springport Summit Tompkins and Waterloo Townships
Kalamazoo Alamo Cooper Richland Ross Oshtemo Kalamazoo Comstock Charleston Texas
Pavillion Climax Prarie Ronde and Schoolcraft Townships Cities of Parchment Kalamazoo Galesburg and Portage Villages of Richland Augusta Climax and
Schoolcraft Lapeer
Almont Arcadia Attica Deerfield Dryden Elba Hadley Imlay Lapeer Marathon Mayfield Metamora Oregon and Rich Townships Lapeer City and Imlay Village
Monroe Ash Berlin Frenchtown London and Milan Townships
St Clair Berlin and Ira Townships
Saginaw Albee Birch Run Blumfield Bridgeport Buena Vista Carrollton Frankenmuth
James Kochville Richland Saginaw Spaulding Swan Creek Taymouth Thomas Tittabawassee and Zilwaukee Townships and the cities of Birch Run Frankenmuth
Saginaw and Zilwaukee
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 or urgent 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 4,000 in copayments or coinsurance for one family member or 8,000 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 and coinsurance since you are responsible for informing us when you reach the limits
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M CARE HMO 2000
Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a
claims 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 This plan is a network model plan which draws together local medical groups and individual
health care practice associations with the University of Michigan Medical Center to provide a full range of medical services to members You choose a primary care doctor from one of this plan's medical

groups or health centers located through our service area The locations and names of this plan's primary care doctors can be found in the M CARE Provider Directory

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

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

What do I do if I'm in First call our customer service department at 800 658 8878 If you are new to the FEHB
the hospital when I Program we will arrange for you to receive care If you are currently in the FEHB Program and
join this Plan 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 92 nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Your primary care physician will arrange your referral to a specialist When you receive a referral
care from your primary care doctor you must return to the primary care doctor after the consultation All follow up care must be provided or arranged by the primary care doctor On referrals the

primary care doctor will give specific instructions to the specialist as to what services are authorized

If additional services or visits are suggested by the specialist you must first check with your primary care doctor Do not go to the specialist unless your primary care doctor has arranged for and
this Plan has issued an authorization for the referral in advance
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 Your primary care doctor will work with
this Plan to get the appropriate authorization for these services
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a
seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate
when I enroll 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 Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see someone else

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M CARE HMO 2000
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue
serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract
provider leaves the with the provider unless the termination is for cause If you are in the second or third trimester
Plan or this Plan of pregnancy you may continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for

or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your post partum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services 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 Normally procedures treatments drugs or devices that are experimental or investigational are
a service is experimental not covered Final determination of whether a service is experimental or investigation is based
or investigational on evaluating

the Member's medical record any medical protocol s under which the service is to be delivered

any informed consent document s which the Member has signed or will be asked to sign in order to receive the service
published medical or scientific literature regarding the service as applied or proposed to be applied to the injury or illness published in this context meaning communication to the
medical or scientific community through an article or report subject to peer review before communication and communication in a publication issued by the Food and Drug
Administration FDA or the Department of Health and Human Services HHS or successor agencies which pertain to the service

Antineoplastic drug therapy shall be provided in accordance with Section 21054b of the Michigan Public Health Code HMO Act

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M CARE HMO 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must

1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond
your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial 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 Call us at 800 658 8878 and we will expedite our review
life threatening condition
and you haven't responded
to my request for services

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will
my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you may
my condition is serious call OPM's health benefit Division III at 202 606 0755 between 8 a m and 5 p m Serious or
or life threatening 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 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

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M CARE HMO 2000
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following 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 went you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make Those who have a legal right to file a disputed claim with OPM are
the request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and 3 Medical providers legal counsel and other interested parties who are acting as the enrolled

person's representative They must send a copy of the person's specific written consent with the review request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim Contract Division III P O Box 436 Washington D C 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our
the Plan's denial 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
I file a lawsuit 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

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M CARE HMO 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 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 judgment of the Plan doctor such care is necessary and appropriate
you pay a 5 copay for a doctor's house call or 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 checkups copay is waived through age 6
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two
years for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms
are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays 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
cesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage under
the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for maternity will be covered under either a Self Only or
Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services Diagnosis and treatment of 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 or double and pancreas 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 Transplants
are covered when approved by the 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 such as braces foot orthotics
Prosthetic devices such as artificial limbs breast prostheses or surgical bras and their replacements and lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9 11
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M CARE HMO 2000
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 introoral

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 will decide whether or not to have breast reconstruction surgery following a
mastectomy including whether or not to have surgery on the other breast in order to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 60 visits 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 self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 10 The following type of artificial insemination is covered intrauterine insemination IUI you pay 10 cost of donor sperm is not
covered Fertility drugs are covered under Prescription Drug Benefit Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for up to 6 weeks you pay nothing
Hearing aids are limited to one device every third calendar year
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Homemaker services Transplants not listed as covered
Long term rehabilitative therapy Chiropractic services

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M CARE HMO 2000
Hospital Extended Care Benefits
What is covered 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 nothing All necessary services are covered

Hospital care 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 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including

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

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

Inpatient dental the hospitalization but not the cost of the professional dental services Conditions for which
procedures 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 14 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 13
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M CARE HMO 2000
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 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 If you are in an emergency situation please call your primary care doctor In extreme emergencies
the service area 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 should 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 be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care 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 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that

time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived

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M CARE HMO 2000
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan

What is not covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area Medical and hospital costs resulting from a normal full term delivery of a baby outside
the service area
Filing claims for 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 7

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M CARE HMO 2000
Mental Conditions Substance Abuse Benefits
All members must contact the contracted Central Diagnostic Referral agency at the toll free number listed on the front of their member identification card before obtaining Mental Health
Substance Abuse services
To contact CDR members from Calhoun Eaton Clinton Ingham Jackson Lenawee Livingston Monroe and Washtenaw counties must call University of Michigan Medical Center Michigan
Center for Diagnosis and Referral at 734 998 7940 Members from Wayne county must contact Eastwood Managed Care at 800 603 0677 All other areas must contact Value Behavioral Health
at 800 688 8586
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 52 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay nothing for each covered visit
Inpatient care Up to 45 days of hospitalization per episode you pay nothing These 45 days of inpatient care can be exchanged on a two for one basis for up to 90 days of partial hospitalization in a day or night
program These 45 days of inpatient care are renewable after 60 days without inpatient treatment
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse 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
What is covered same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment when preauthorized by the Central Diagnostic Referral agency listed
on the front of their member identification card

Outpatient care Up to 20 outpatient visits to Plan providers for treatment you pay nothing for each covered visitall charges thereafter

Inpatient care Up to one admission per calendar year at an approved residential treatment center you pay nothing
What is not covered Treatment that is not authorized by a Plan doctor

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M CARE HMO 2000
Prescription Drug Benefits
Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 34 day supply or one commercially prepared unit i e one inhaler one vial
ophthalmic medication or insulin You pay a 5 copay per prescription unit or refill for generic drugs and 10 for brand name drugs A 10 brand name copay applies when there is a generic
available but the physician prescribes dispense as written or when there is no generic available When generic substitution is permissible i e a generic drug is available and the prescribing
doctor does not require the use of a name brand drug but you request the name brand drug you pay the price difference between the generic and name brand drug as well as the 10 copay per
prescription unit or refill
At no time will the copay exceed 50 of the retail cost for the drug
M CARE uses an open or voluntary prescription drug formulary Medications listed in the therapeutic selection guide provided to physicians are recommended but not required to qualify
for prescription drug coverage Nonformulary drugs will be covered when prescribed by a plan doctor

Covered medications and accessories include
Drugs for which a prescription is required by law Oral and injectable contraceptive drugs contraceptive diaphragms
Implanted time release medications such as Norplant For Norplant you pay a one time copay of 10 per prescription For other internally implanted time release medications you
pay 5 for generic 10 for brand name There is no charge when the device is implanted during a covered hospitalization There will be no refund of any portion of these copays if
the implanted time release medication is removed before the end of its expected life Insulin and disposable needles and syringes for its injection covered at no charge
Diabetic supplies including glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets
Disposable needles and syringes needed to inject covered prescribed medication other than insulin
Smoking cessation drugs and medication including nicotine patches Intravenous fluids and medication for home use provided under home health services at no
charge
Limited Benefits Sexual dysfunction drugs have dispensing limitations you pay 50 copay per prescription unit or refill for generic or name brand drugs Contact the plan for details
Fertility drugs for induction of ovulation subject to a 50 copay per prescription unit or refill
Drugs included on the M CARE Maintenance Drug List may be dispensed in maximum quantities of a 90 day supply or 100 unit doses whichever is greater Generic drugs included on
this list will be subject to a 5 copay and brand name drugs will be subject to a 10 copay
What is not covered Drugs available without a prescription or for which there is a non prescription equivalent available
Vitamins and nutritional substances that can be purchased without a prescription Drugs obtained at a non Plan pharmacy except for out of area emergencies
Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes
Drugs to enhance athletic performance

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 17
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M CARE HMO 2000
Other Benefits
Dental care Restorative services and supplies necessary to promptly repair but not replace sound natural
Accidental Injury benefit teeth The need for these services must result from an accidental injury You pay nothing

Vision care In addition to the medical and surgical benefits provided for the diagnosis and treatment of
What is covered diseases of the eye annual eye refractions to provide a written lens prescription may be obtained from Plan providers You pay nothing

What is not covered Corrective lenses or frames Eye exercises

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
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M CARE HMO 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members of this Plan The cost
of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure
Medicare prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare 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 join this Medicare prepaid plan but will probably have to pay for hospital coverage in addition to
the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid plan Contact us at 800 810 1699 for information on the Medicare prepaid plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan call 800 810 1699 for information
on the benefits available under the Medicare HMO
M CARE LifeLong Program As part of M CARE's LifeLong Health Management Program M CARE offers Health Education
Health Classes classes to all of its members M CARE pays 100 percent of the fee for approved classes in the following categories Childbirth Preparation Safety CPR First Aid and Smoking Cessation

classes If you would like more information on these classes or would like a class listing please contact M CARE's LifeLong Health Management Program at 888 448 3865

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 17 19
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M CARE HMO 2000
Section 6 General Exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to
prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan doctors or hospitals except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices Procedures services drugs and supplies related to abortions except when the life of the
mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program
and Expenses you incurred while you were not enrolled in this Plan

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M CARE HMO 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 17
Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage
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 Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible for injuries 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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M CARE HMO 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 We do not cover services and supplies that a local State or Federal Government agency directly
Agencies or indirectly pays for

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M CARE HMO 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 insure lists the specific types of information that we must make available to you
If you want specific information about us call 800 658 8878 TDD 800 649 3777 or write to 2301 Commonwealth Blvd Ann Arbor Michigan 48105 2945 You may also contact us by fax
at 734 747 7152 by e mail at custserv mcare org or visit our website at www mcare org
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 benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums effective 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 When you retire you can usually stay in the FEHB Program Generally you must have been
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 coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for my unmarried dependent children under age 22 including any foster or step children your employing
family and me 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

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove
family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

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M CARE HMO 2000
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

subrogation 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 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 Your old plan's deductible continues until our coverage begins
under my old plan

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 You will receive an additional 31 days of coverage for no additional premium when
enrollment in this
Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
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

Temporary If you leave Federal service or if you lose coverage because you no longer qualify as a family
Continuation member you may be eligible for TCC For example you can receive TCC if you are not able to
of Coverage TCC 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 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

22 You are not eligible for TCC if you can receive regular FEHB Program benefits 24
24 Page 25 26
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
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

How can I convert You may convert to an individual policy if
to individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or

did not pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or

You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan Coverage 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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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 800 658 8878 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 N W Room 6400 Washington DC 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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Summary of Benefits for M CARE 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day care 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 11
Extended All necessary services up to 100 days per calendar year You pay nothing 11 care

Mental Diagnosis and treatment of acute psychiatric conditions for up to 45 days of conditions inpatient care renewable after 60 days You pay nothing 14
Substance Up to one approved program per calendar year for residential treatment You pay abuse nothing 14
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or care 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 and 5 per house call
by a doctor copays are waived for maternity care and well baby care through age six 9
Home health All necessary visits by nurses and health aides You pay a 5 copay care per visit 9

Mental conditions Up to 52 outpatient visits per year You pay nothing 14
Substance abuse Up to 20 outpatient visits per year You pay nothing 14
Emergency Reasonable charges for services and supplies required because of a medical care 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 12
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 drugs copay generic 10 brand name per prescription unit or refill Drugs for treatment

of infertility or sexual dysfunction are subject to a 50 copay per unit or refill 15
Dental care Accidental injury benefit You pay nothing 16
Vision care One refraction annually You pay nothing 16
Out of Pocket Copayments are required for a few benefits however after your out of pocket maximum expenses reach a maximum of 4,000 per Self Only or 8,000 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 4

RATE INFORMATION ON BACK COVER

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2000 Rate Information for
M CARE 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 EG1 65.53 21.84 141.98 47.32 77.54 9.83 77.54 9.83
Self and Family EG2 173.70 57.90 376.35 125.45 205.55 26.05 201.02 30.58

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