2000
A Health Maintenance Organization
For changes
in benefits
see page 5
Serving North Central New York and Utica Rome area Enrollment in this Plan is limited see page 4 for requirements
Enrollment Code
AH1 Self Only
AH2 Self and Family
Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United States Office of
Personnel Management
Table of Contents
Introduction 3
Plain Language 3
How to use this Brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
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 17
Section 7 Limitations Rules that affect your benefits 18
Section 8 FEHB FACTS 19
Inspector General Advisory Stop Health Care Fraud 22
Summary of Benefits for HMOBlue 2000 23
2000 Rate Information 24
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Introduction
BlueCross BlueShield of Utica Watertown Inc d b a HMOBlue Utica Business Park 12 Rhoads Drive Utica NY 13502
6398
This brochure describes the benefits you can receive from HMOBlue under its contract CS2294 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 8 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 HMOBlue 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 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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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 or group of physicians
hospital or other provider will be available and or remain under contract with us Our providers follow generally accepted
medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary
changes 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 HMO Blue's non postal premium will increase by 5 5 for Self Only or 1 2 for Self and Family
We are introducing a Maximum Allowable Cost MAC For those prescription drugs on the
MAC list you now pay the brand name drug copay plus the cost difference between the cost of
the brand name drug listed on the MAC list and the cost of the generic substitute for that drug
Previously only the brand name copay applied to brand name drugs and the price difference was
not charged
The copay for maintenance drugs ordered by mail has been increased to a 10 copay per
prescription unit or refill for generic drugs or a 40 copay per prescription unit or refill for brand
name drugs Previously there was no copay for generic drugs and a 20 copay for brand name
drugs
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Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers
service area practice Our service area is The New York counties of Chenango Clinton Delaware Essex Franklin Fulton Hamilton Herkimer Jefferson Lewis Madison Montgomery Oneida
Oswego Otsego and St Lawrence
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 However you may also contact
HMO USA at 1 800 4 HMOUSA for urgent care and they will set up an appointment with a
doctor in the area where you are visiting or instruct you to go to the emergency room We will
not pay for health care services that are not emergency care or authorized by HMO USA
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 Guest Membership is available in most parts of the
United States from HMO USA Contact HMOBlue for more information regarding Guest
Membership If you or a family member move you do not have to wait until Open Season to
change plans Contact your employing or retirement office
How much do I pay You must share the cost of some services This is called either a copayment a set dollar
for services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for preventive care and hospitalization see benefits
for further description of no cost services you receive from HMOBlue Your out of pocket
expenses for benefits we cover are limited to the copayments stated in this brochure
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 BlueCross BlueShield of Utica Watertown d b a HMO Blue is a division of Excellus Health
health care Care Inc HMO Blue is an individual practice association HMO You and each member of your family must select a primary care doctor to coordinate all medical needs There are over
1200 primary care doctors to choose from representing family practice general practice
internal medicine OB GYN and pediatrics The Plan also contracts with an additional 2500
specialists throughout the service area
Benefits for urgent care outside of this Plan's may be covered This Plan is affiliated with
HMO USA a network of Blue Cross and Blue Shield HMOs that can coordinate your medical
care If you need more information this Plan can tell you more about its reciprocity benefits
What do I do if my Call us We will help you select a new one
primary care
physician leaves the
Plan
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician will
to go into the hospital make the necessary hospital arrangements and supervise your care
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What do I do if I'm in First call our customer service department at 800 722 7884 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 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Your primary care physician will arrange your referral to a specialist
care If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care
physician will use our criteria when creating your treatment plan The physician may have to
get an authorization or approval beforehand
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to
seeing a specialist a specialist ask if you can see your current specialist If your current specialist does not
when I enroll 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 Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the receive services from your current specialist until we can make arrangements for you to see
Plan someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to
serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the contract with the provider unless the termination is for cause If you are in the second or third
Plan or this Plan trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
leaves the Program 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 Your physician must get our approval before sending you to a hospital referring you to a
medical services 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 ZRGTKOGPVCN1KPXGUVKICVKQPCNRTQEGFWTGUCTGFGHKPGFCUCPRTQEGFWTGVTGCVOGPVFTWI
service is experimental DKQNQIKECNRTQFWEVQTFGXKEGJGTGKPCHVGTTGHGTTGFVQCUVGEJPQNQIVJCVKPVJGUQNGFKUETGVKQP
or investigational QHVJG2NCPCTGFGVGTOKPGFVQDGGZRGTKOGPVCNQTKPXGUVKICVKQPCNKPPCVWTG0 ZRGTKOGPVCNQTKPXGUVKICVKQPCNOGCPUVJCVVJGVGEJPQNQIKUFGVGTOKPGFPQVVQ
JCXGHKPCNCRRTQXCNHTQOVJGCRRTQRTKCVGIQXGTPOGPVTGIWNCVQTDQF DGRTQXGPDGPGHKVHQTVJGRCTVKEWNCTFKCIPQUKUQTVTGCVOGPVQHVJGOGODGTUEQPFKVKQP
DGTGEQIPKGFDVJGOGFKECNEQOOWPKVCUTGHNGEVGFKPVJGRWDNKUJGFRGGTTGXKGYGF NKVGTCVWTGCUGHHGEVKXGQTCRRTQRTKCVGHQTVJGRCTVKEWNCTFKCIPQUKUQTVTGCVOGPVQHVJG
OGODGTUEQPFKVKQPQT
DGCUDGPGHKEKCNCUCPGUVCDNKUJGFCNVGTPCVKXG0 Your primary care physician will work with our medical director and medical staff to determine
if a service is experimental or investigational
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Section 4 What to do if we deny your claim or request for service
If we deny services or 1 Be in writing
won't pay your claim 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
you may ask us to 3 Be made within six months from the date of our initial denial or refusal We may extend
reconsider our this time limit if you show that you were unable to make a timely request due to reasons
decision Your beyond your control
request must
We have 30 days from 1 Maintain our denial in writing
the date we receive 2 Pay the claim
your reconsideration 3 Arrange for a health care provider to give you the service or
request to 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
to review a denial 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 Call us at 800 722 7884 and we will expedite our review
serious or life
threatening condition
and you haven't
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request for inform OPM so that they can give your claim expedited treatment too Alternatively you can
care and my condition call OPM's health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m
is serious or life Eastern Time Serious or life threatening conditions are ones that may cause permanent loss of
threatening bodily functions or death if they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
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
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 Your request must be complete or OPM will return it to you You must send the following
OPM information
1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply
to which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
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
my disputed claim to Programs Contract Division III P O Box 436 Washington D C 20044
OPM
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our
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 I Federal law governs your lawsuit benefits and payment of benefits The Federal court will
file a lawsuit 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
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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Section 5 Benefits
Medical and Surgical Benefits
What is covered Plan doctors and other Plan providers provide a comprehensive range of preventive diagnostic and treatment services This includes all necessary office visits you pay a 10 office visit copay but no
additional copay for laboratory tests and for x rays
Within the service area house calls will be provided if in the judgement of the plan doctor such care is
necessary and appropriate You pay a 10 copay for a doctor's house call or home visits by nurses and
health aides
The following services are included and are subject to the office visit copay unless otherwise stated
Preventive care including well baby care and periodic check ups copay waived for well child care to age 19
Preventive Care includes Routine Gynecological Exams Through a participating HMOBlue Provider female Members shall have direct access to primary and preventive obstetric and
gynecological services including two annual exams You pay nothing
Preventive Care includes Screening Pap Smear Periodic Pap Smears are covered at intervals recommended by your physician You pay nothing
Preventive Care includes Annual Physical Exams A routine physical examination by your PCP is covered for adults without cost to you This exam must be performed by your PCP You pay
nothing Limited to one per calendar year
Hearing Exam With a PCP Referral an annual routine hearing examination is covered when performed by a participating provider You pay a 10 co pay Limited to one per calendar year
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 and above one mammogram every year In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness You
pay nothing
Routine immunizations and boosters Copay waived for member to age 19
Consultations by specialists
Second Surgical Opinion With a PCP referral a second surgical opinion is covered if your PCP and or specialist recommends that surgery be performed
Spinal Manipulation Services are covered for medically necessary correction of structural imbalance distortion or subluxation in the human body
Diagnostic procedures such as laboratory tests and X rays You pay nothing Preauthorization Required for MRI and MRA only
Diagnostic Services including colonscopy and endoscopy procedures Pre authorization is required
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital
up to 48 hours after a regular delivery and 96 hours after a cesarean 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 You pay nothing
Voluntary sterilization and family planning services the copay is waived
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum the copay is waived for allergy treatment and allergy serum
Nutritional Counseling When provided by a registered dietitian and determined by us to be medically necessary You pay nothing Limited to one visit per year Pre authorization is
required
The insertion of internal prosthetic devices such as pacemakers and artificial joints breast prosthesis and surgical bras as well as their replacement
All human organ transplants will be covered that are both not experimental or investigational and determined to be safe and effective
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
Kidney Dialysis You pay nothing
Chemotherapy radiation therapy and inhalation therapy the copay is waived
Surgical treatment of morbid obesity
Orthopedic devices such as braces You pay 20 of charges Foot orthotics excluded
Prosthetic devices such as artificial limbs and eyes and lenses following cataract removal You pay 20 of charges
Standard Durable Medical Equipment such as casts trusses apnea monitor braces and crutches wheelchairs special hospital beds and a home dialysis unit The Plan's Medical
Director will determine medical necessity and whether items should be purchased or rented
The Plan will only pay for DME obtained from vendors or suppliers designated by the
Plan You pay 20 of charges
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
Outpatient surgery the copay is waived
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 11
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Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical
procedures occurring within or adjacent to the oral cavity or sinuses including but not limited
to treatment of fractures and excision of tumors and cysts All other procedures involving the
teeth or intra oral areas surrounding the teeth are not covered including any dental care
involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional
defect or from an injury or surgery that has produced a major effect on the member's appearance
and if the condition can reasonably be expected to be corrected by such surgery
A patient and her attending physician may decide whether to have breast reconstruction surgery
following a mastectomy and whether surgery on the other breast is needed to produce a
symmetrical appearance
Inpatient physical rehabilitation is covered when performed in a Plan approved free standing
or Hospital based physical rehabilitation treatment center Treatment includes physical speech
and occupational therapy You pay nothing Limited to 60 days per calendar year Preauthorization
is required
Short term outpatient therapy is covered including physical therapy occupational therapy
pulmonary therapy and speech therapy which in the judgment of The Plan's Medical Director
can be expected to result in significant improvement through short term therapy You pay a 10
copay Limited to two consecutive months of short term therapy per acute condition Preauthorization
is required
Diagnosis and treatment of infertility is covered you pay nothing The following types of
artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay 50 of charges cost of donor sperm is not
covered Fertility drugs are covered under the 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 for up to 60 visits per calendar year you pay a 10 copay per visit
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
Hearing Aids
Long term rehabilitative therapy
Homemaker services
Any fees imposed by a Provider for a missed appointment or any fees for completion of forms or copies of Non Plan records
Human Organ and Bone Marrow Transplants that are determined to be an Experimental Investigational Procedure or are not safe and effective
Foot orthotics and corrective shoes
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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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 nothing 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 with no dollar limit for 45 days per member per calendar year when full time skilled nursing care is necessary and confinement in a
skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by
the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice
facility for up to 210 days 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 stage of illness
Ambulance service Benefits are provided for both ground and air ambulance transportation ordered or authorized by
a Plan doctor Preauthorization is required for air ambulance You pay nothing
Limited benefits
Inpatient Dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
Procedures need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
hospitalization but not the cost of the professional dental services Conditions for which
hospitalization would be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition except for children to age 7
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification 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 Limit of 7 days per confinement 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 13
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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
the service area 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 It is your responsibility to ensure that the
Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within
that time If you are hospitalized in non Plan facilities and Plan doctors believe care can be
better provided in a Plan hospital you will be transferred when medically feasible with any
ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your
condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 35 per hospital emergency room visit or 10 per 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 the Benefits are available for any medically necessary health service that is immediately required
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 35 per hospital emergency room visit or 10 per 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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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
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency care
providers 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 6
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or
disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 visits to Plan doctors consultants or other psychiatric personnel each calendar year
you pay a 10 copay per visit for visits 1 4 and 25 per visit for visits 5 20 all charges
thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days and all
charges thereafter
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the
medical non psychiatric aspects of substance abuse including alcoholism and drug addiction
the same as for any other illness or condition and to the extent shown below the services
necessary for diagnoses and treatment
Outpatient care Up to 60 outpatient visits per calendar year for the treatment of alcoholism and drug addiction
you pay a 10 copay per visit
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program
in an alcohol or drug rehabilitation center approved by the Plan you pay nothing during the
benefit period all charges thereafter The 30 days per calendar year limitation is an aggregate
that includes any days of inpatient hospitalization for detoxification
What is not covered Treatment that is not authorized by a Plan doctor
Any services related to a methadone maintenance program
Care provided in a non therapeutic residential facility
Benefits for days of care that consist primarily of participation in programs of a social recreational or companionship nature
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 30 day supply
You pay a 5 copay per prescription unit or refill for generic
drugs or a 20 copay per prescription unit or refill for name brand drugs Some brand name drugs are
listed on the Plan's Maximum Allowable Cost MAC list For drugs on this list you pay the brand
name copay plus the difference in cost between the brand name drug on the MAC list and its generic
equivalent
GENERIC DRUGS Generic substitution will be made when permissible for certain brand name
drugs Contact the Plan for a listing of which drugs are subject to the generic substitution policy If
for reasons of medical necessity a member requires the brand name or non preferred medication
prior authorization may be requested through Diversified Pharmaceutical Services Inc DPS who
will notify the physician of their decision within 24 to 48 hours
MAINTENANCE DRUGS Maintenance drugs may be ordered by mail and will be dispensed for up
to a 90 day supply You pay 10 for generic drugs or a 40 copay per prescription unit or refill for
brand name drugs
DRUG FORMULARY Drugs are prescribed by Plan doctors and dispensed in accordance with the
Plan's drug formulary Nonformulary drugs will be covered when prescribed by a Plan doctor The
complete BlueCross BlueShield of Utica Watertown Drug formulary is available upon request from
the Plan
Covered medications and accessories include
Drugs for which a prescription is required by law
Insulin with a copay charge applied to each vial
Disposable needles and syringes needed to inject covered prescribed medication
All FDA approved contraceptive drugs and devices
Drugs obtained at a non Plan pharmacy the Plan will pay 50 of the Usual Customary and Reasonable UCR charge as determined by the Plan
Fertility drugs
Intravenous fluids and medication for home use and some injectable drugs are covered under Medical and Surgical Benefits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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Limited benefits Drugs for the treatment of sexual dysfunction have dosage limitations Contact the plan for the dosage limitations
Covered smoking cessation drugs are limited as to which are covered and are limited to one course of treatment per lifetime Contact the plan for which drugs are covered
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent
available
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
Implanted time release medications other than Norplant
Drugs for weight loss
Other Benefits
Dental Care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth are covered The need for these services must result from an accidental injury you pay nothing Accidental dental injuries caused by chewing are not 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 once per calendar year which include the written lens prescription for
eyeglasses may be obtained from Plan providers You pay a 10 copay
What is not covered Corrective lenses or frames
Eye exercises
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it
unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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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
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 beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
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 that another person caused you must reimburse us for whatever services we paid for We will
injuries cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
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
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website www opm gov lists
the specific types of information that we must make
available to you
If you want specific information about us call 800 722 7884 or write to12 Rhoads Dr Utica
NY 13502 You may also contact us by fax at 315 733 2830
Where do I get Your employing or retirement office can answer your questions and give you a Guide to
information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the FEHB need to make an informed decision about
Program When you may change your enrollment
How you can cover your family members What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your
enrollment status without information from your employing or retirement office
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
effective January 1 Annuitants premiums begin January 1
What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been
retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
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What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are available unmarried dependent children under age 22 including any foster or step children your
for my family and employing or retirement office authorizes coverage for Under certain circumstances you may
me also get coverage for a disabled child 22 years of age or older who is incapable of self support which is also authorized by your employing or retirement office
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 No new
enrollment form is necessary
If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification 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 Your old plan's deductible continues until our coverage begins
deductible 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
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What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about your coverage
choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office
Key points about You can pick a new plan
TCC If you leave Federal service you can receive TCC for up to 18 months after you separate If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends If you or your employing office delay processing your request you still have to pay
premiums from the 32 nd day after your regular coverage ends even if several months have
passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under
TCC 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
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How can I convert to You may convert to an individual policy if
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
Health Plan Coverage 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
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 800 722 7884 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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Summary of Benefits for HMOBlue 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 Care Hospital Comprehensive range of medical and surgical services without
dollar or day limit Includes in hospital doctor care room and
board general nursing care private room and private nursing
care if medically necessary diagnostic tests drugs and
medical supplies use of operating room intensive care and
complete maternity care You pay nothing 11
Extended Care All necessary services up to 45 days per year You pay 11
nothing
Mental Diagnosis and treatment of acute psychiatric conditions for up
Conditions to 30 days of inpatient care per year You pay nothing 13
Substance Abuse Covered under mental conditions 14
Outpatient Care Comprehensive range of services such as diagnosis and
treatment of illness or injury including specialist's care
preventive care including well baby care periodic check ups
and routine immunizations laboratory tests and X rays
complete maternity care You pay a 10 copay per office
visit copays are waived for maternity care copy is waived for
annual exams gynecological exams screening pap smeers
mammography 10 per house call by a doctor 8
Home Health All necessary visits by nurses and health aides You pay a
Care 10 copay per visit 9
Mental Up to 20 visits per year You pay a 10 copay per visits 1 4
Conditions and a 25 copay per visit for visits 13
Substance Abuse Up to 60 outpatient visits per year You pay a 10 copay per
visit 14
Emergency Care Reasonable charges for services and supplies required because
of a medical emergency You pay a 35 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
Drugs pharmacy You pay a 5 copay per prescription unit or refill
for generic or a 20 copay for name brands Mail order
maintenance drugs You pay 10 for generic drugs or a 40
copay per prescription unit or refill for brand name drugs 14
Dental Care Accidental injury benefit You pay nothing 15
Vision Care One refraction annually You pay a 10 copay per visit 15
Out of Pocket Your out of pocket expenses for benefits covered under this
Maximum Plan are limited to the stated copayments which are required
for some of the benefits 6
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2000 Rate Information for
HMOBlue
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
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Self Only AH1 67.45 22.48 146.14 48.71 79.81 10.12 79.81 10.12
Self and AH2 171.63 57.21 371.87 123.95 203.10 25.74 201.02 27.82
Family
24 24