MVP
Health Plan
2000 A Health Maintenance Organization
Serving Upstate New York and Vermont
Enrollment in this Plan is limited see page 3 for requirements
changes Eastern Region For
benefits 2 Enrollment code in
see page GA1 Self Only
GA2 Self and Family
Central Region
Enrollment code M91 Self Only
M92 Self and Family
MidHudson Region
Enrollment code MX1 Self Only
MX2 Self and Family
Vermont
Enrollment code VW1 Self Only
VW2 Self and Family
Visit the OPM website at httpwwwopmgovinsure
and
our website at httpwwwmvphealthplancom
Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
MVP Health Plan 2000
Table of Contents
Introduction 1
Plain language 1
How to use this brochure 1
Section 1 Health Maintenance Organizations 2
Section 2 How we change for 2000 2
Section 3 How to get benefits 34
Section 4 What to do if we deny your claim or request for service 56
Section 5 Benefits 714
Section 6 General exclusions Things we dont cover 15
Section 7 Limitations Rules that affect your benefits 1516
Section 8 FEHB FACTS 1619
Inspector General Advisory Stop Healthcare Fraud 19
Summary of benefits 20
Premiums 21
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MVP Health Plan 2000
Introduction
MVP Health Plan Inc 111 Liberty St Schenectady NY 12305
This brochure describes the benefits you can receive from MVP Health Plan under its contract CS2362 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 2 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Governments 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 MVP Health Plan as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plans
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 nonFEHB benefits
6 General exclusions Things we dont 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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MVP Health Plan 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 preventa tive care such as routine office visits physical exams wellbaby 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 plans 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
andor remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treat
ment
Section 2 How we change for 2000
Programwide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care
changes office visits
This year you have a right to more information about this Plan care management our networks facili ties 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 OBGYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB program See Sec tion 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical
records ask your health care provider for them You may ask that a physician amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief
statement to it If they do not provide you your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer
Changes to this Your share of the nonpostal premium for code GA will increase by 216 for Self Only or 368 for
Plan Self and Family
Your share of the nonpostal premium for code M9 will increase by 338 for Self Only or 498 for Self and Family
Your share of the nonpostal premium for code MX will increase by 357 for Self Only or 526 for Self and Family
Your share of nonpostal premium for code VW will increase by 221 for Self Only or 218 for Self
and Family
Contraceptive devices and injectables are now covered See page 12
The copay for advanced infertility services will require you to pay 50 of the charges See page 8
Certain prescriptions may be obtained through this Plans mailorder program See page 12
The copay for therapeutic services such as dialysis chemotherapy radiation therapy and inhalation
therapy will require you to pay a 10 copay See page 7
External prosthetic devices and ostomy supplies will require you to pay 20 of the charges See page 7
Drugs for the treatment of multiple sclerosis will be covered under this Plans prescription drug benefit See page 12
This Plans service area has expanded Our Vermont VW service area now includes Caledonia Essex 2 Orange Orleans Windham and Windsor counties See page 3
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MVP Health Plan 2000
Section 3 How to get benefits
What is this Plans To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is as follows
Eastern Region GA1 Self only GA2 Self and family The New York counties of Albany Fulton Hamilton Montgomery Rensselaer Saratoga Schenectady Schoharie Warren and Washington
Central Region M91 Self only M92 Self and family The New York counties of Broome
Chenango Delaware Herkimer Lewis Madison Oneida Onondaga Otsego and Tioga
MidHudson Region MX1 Self only MX2 Self and family The New York counties of Columbia
Dutchess Greene Orange Putnam and Ulster
Vermont VW1 Self only VW2 Self and family The Vermont counties of Addison Bennington
Caledonia Chittenden Essex Franklin Grand Isle Lamoille Orange Orleans Rutland Washing
ton Windham and Windsor
Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan
If your dependents live out of the area you should consider enrolling in a feeforservice 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 You must share the cost of some services This is called either a copayment a set dollar amount or pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you
receive services
After you make copayments equal to or greater than two times the cost of the total annual plan pre mium 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 or coin
surance for your prescription drugs do not count toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to You normally wont have to submit claims to us unless you receive emergency services from a submit claims provider who doesnt 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 circum stances beyond your control prevented you from filing on time
Who provides As an Individual Practice Association IPA model HMO this Plan offers over 7000 doctors operat my health care ing out of private practices who are available to serve you as a Primary Care Physician PCP or
Specialist Plan PCPs may refer you to any Plan Specialist except in Vermont Vermont PCPs who
are part of the Vermont Managed Care VMC network may only refer you to VMC Specialists Please refer to the Plans Provider Listing which clearly identifies all VMC physicians If you
have any questions regarding the referral process please call the Member Services Department at
8886876277 However a woman may see her gynecologist without having to obtain a referral For hospital care you will be using the general acute hospital facilities located throughout our ser
vice area dependent upon where your doctors have admitting privileges Any covered medically
necessary service that cannot be provided at the community hospitals will be arranged for at other appropriate facilities
What do I do Call us We will help you select a new one if my primary
care physician leaves the Plan
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MVP Health Plan 2000
Section 3 How to get benefits continued
What do I do if I need Talk to your Plan physician If you need to be hospitalized your primary care physician or special to go into the hospital ist will make the necessary hospital arrangements and supervise your care
What do I do if First call our Member Services Department at 8886876277 If you are new to the FEHB Im in the we will arrange for you to receive care If you are currently in the FEHB Program and are
hospital when I switching to us your former plan will pay for the hospital stay until join this Plan You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist Do not go to a specialist specialty care unless your PCP has issued a referral for you Your PCP will provide or authorize all followup
care for you as well You must return to your PCP after you see a specialist unless your PCP has
authorized additional visits
Women may see any plan gynecologist for routine office visits or care related to pregnancy without
a referral
If you need to see a specialist frequently because of a chronic complex or serious medical condi
tion 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 and must get authorization from the plan Medical Direc
tor Your PCP will submit hisher recommendation to our Medical Director and then the Medical
Director will notify both you and your PCP in writing as to our decision Please contact our Mem ber Services Department at 8886876277 if you have any questions about this process
What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a if I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for you I enroll 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 receive specialist leaves the Plan services from your current specialist until we can make arrangements for you to see someone else
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue a serious illness and seeing your provider for up to 90 days after we notify you that we are terminating our contract with
my provider leaves the provider unless the termination is for cause If you are in the second or third trimester of preg the Plan or this Plan nancy you may continue to see your OBGYN 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 Pro gram If you are in your second or third trimester your new plan will pay for the OBGYN care
you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist medical services or recommending followup care Before giving approval we consider if the service is medically
necessary and if it follows generally accepted medical practice
How do you decide We generally will not cover any treatment procedure drug device or any hospitalization for an if a service is experimental or investigational service This plan will cover experimental and investigational treat
experimental or ment if we feel that investigational The proposed treatment has demonstrated promise in treating your condition through a
nationallyrecognized clinical trial
An expert panel has reviewed the proposed treatment and found it to be appropriate
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MVP Health Plan 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or wont pay your claim you may ask us to reconsider our decision Your request must Be in writing
Refer to specific brochure wording explaining why you believe our decision is wrong and
Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to Maintain our denial in writing
Pay the claim
Arrange for a health care provider to give you the service or Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our decision based on the information we already have
When may I ask OPM 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 Call us at 8886876277 and we will expedite our review or life threatening
condition and you havent responded to
my request for service
What if you have If we expedite our review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPMs
for care and my Health Benefits Contracts Division 3 at 2026060755 between 8 am and 5 pm Serious or life condition is serious threatening conditions are ones that may cause permanent loss of
bodily functions or death if they or life threatening 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 ini time limits tial denial or refusal of service You may also ask OPM to review your claim
if
We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information
A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
Copies of all letters you sent us about the claim Copies of all letters we sent you about the claim and
Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make Those who have a legal right to file a disputed claim with OPM are the request Anyone enrolled in the Plan
The estate of a person once enrolled in the Plan and Medical providers legal counsel and other interested parties who are acting as the enrolled
persons representative They must send a copy of the persons specific written consent with 5
the review request
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MVP Health Plan 2000
Section 4 What to do if we deny your claim or request for service continued
Where should I mail Send your request for review to my disputed claim to Office of Personnel Management Office of Insurance Programs Contracts Division 3 P O
Box 436 Washington DC 20044
What if OPM upholds OPMs decision is final There are no other administrative appeals If OPM agrees with our deci the Plans denial sion 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit 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 de
scribed above
Your records and the Privacy Act
Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to determine if our denial
of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this infor
mation to support the disputed claim decision If you file a lawsuit this information will become part of the court record
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MVP Health Plan 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay
but no additional copay for laboratory tests and Xrays Within the service area house calls will be
provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a
10 copay for a doctors house call and 10 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 wellbaby care and periodic checkups for certain wellbaby visits you pay nothing
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
Outpatient surgery at the hospital you pay a 10 copay per surgery
Consultations by specialists Diagnostic procedures such as laboratory tests and Xrays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor Copays are waived for maternity care you pay a 10 copay for the initial visit only The mother at her option may remain in the hospital up to 48 hours after a
regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medi
cally 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 mothers hospital confinement for maternity will be covered un
der either a Self Only or Self and Family enrollment other care of an infant who requires defini tive 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 kidney and liver transplants allogeneic donor bone marrow transplants autolo gous bone marrow transplants autologous stem cell and peripheral stem cell support for the
following conditions acute lymphocytic or nonlymphocytic leukemia advanced Hodgkins
lymphoma advanced nonHodgkins lymphoma advanced neuroblastoma breast cancer mul tiple 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 you pay a 10 copay per visit
Chemotherapy radiation therapy and inhalation therapy you pay a 10 copay per visit
Surgical treatment of morbid obesity Orthopedic devices such as braces you pay 20 of charges
Prosthetic devices such as artificial limbs and lenses following cataract removal and breast
prostheses including the surgical bra for an external prosthesis and their replacement follow ing a mastectomy you pay 20 of charges
Ostomy supplies you pay 20 of charges
Durable medical equipment such as wheelchairs and hospital beds you pay 20 of charges Chiropractic services spinal manipulation only
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 7
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MVP Health Plan 2000
Medical and Surgical Benefits continued
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of
fractures and excision of tumors and cysts All other procedures involving the teeth or intraoral
areas surrounding the teeth are not covered including any dental care involved in the 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 members appearance and if the con
dition can reasonably be expected to be corrected by such surgery A patient and their attending physi
cian will decide whether or not to have breast reconstruction surgery following a mastectomy includ
ing whether or not to have surgery on the other breast in order to produce a symmetrical appearance
Shortterm rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant improvement can
be expected within two months you pay a 10 copay per outpatient session Speech therapy is lim ited to treatment of certain speech impairments of organic origin Occupational therapy is limited to
services that assist the member to achieve and maintain selfcare and improved functioning in other
activities of daily living
Diagnosis and treatment of infertility is covered you pay a 10 copay for Basic services and 50 of charges for Advanced services Basic infertility services are those services provided for the
initial evaluation and testing for infertility You pay a 10 copay for all basic infertility services
except for semen analysis postcoital examinations and hysterosalpingograms for which you pay
50 of charges Advanced infertility services are those services provided in addition to basic infer tility services In order for advanced services to be covered you must obtain a referral to an appro
priate plan specialist from your PCP and both you and your spouse must have already received ba
sic infertility services Covered advanced infertility services include tubal surgery laporoscopy ad ministration of HCG and Progesterone injections up to six 6 cycles of artificial insemination ad
ministration of the injectable agents Menotropins and Urofollitropins Administration of Serophene
Clomid and varicocele surgery
The following types of artificial insemination are covered intravaginal insemination IVI intracer
vical insemination ICI and intrauterine insemination IUI you pay 50 of charges cost of donor sperm is not covered Other assisted reproductive technology ART procedures such as in vitro
fertilization and embryo transfer including GIFT and ZIFT are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for up to 36 visits 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 surgicallyinduced sterility Surgery primarily for cosmetic purposes
Blood and blood derivatives not replaced by the member
Hearing aids Longterm rehabilitative care
Homemaker services
Transplants not listed as covered Corrective eye glasses and frames or contact lenses including the fitting of the lenses
Foot orthotics
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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MVP Health Plan 2000
HospitalExtended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hos pitalized 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 for up to 45 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu of hos
pitalization 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
In certain cases skilled nursing care may be received on an inpatient basis in a hospital even though the appropriate level of care is the level of care provided in a skilled nursing facility for example
when there is no skilled nursing facility near you In these instances the inpatient hospital days
will count toward your 45day skilled nursing facility annual maximum benefit
Hospice care Supportive and palliative care for a terminally ill member is covered for up to 210 days 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 ter
minal stages of illness with a life expectancy of approximately six months or less
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor service
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 the
hospitalization but not the cost of the professional dental services Conditions for which hospital ization 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 appropri ate See page 11 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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MVP Health Plan 2000
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that requires emergency immediate medical or surgical care Some problems are emergencies because if not treated prompt
ly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially lifethreatening such as heart attacks strokes poison
ings 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 eg the 911 tele
phone system or go to the nearest hospital emergency room Be sure to tell the emergency room per
sonnel that you are a Plan member so they can notify the Plan You or a family member should 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
fol lowing your admission unless it was not reasonably possible to notify the Plan within that time
If you need to be hospitalized in a nonPlan facility 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 nonPlan 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 nonPlan 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 followup care recommended by nonPlan providers must be ap
proved 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 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 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 followup care recommended by nonPlan providers must be ap
proved 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 Nothing per hospital emergency room visit or per urgent care center visit for emergency services that are covered benefits of this Plan
What is covered Emergency care at a doctors 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 fullterm delivery of a baby outside the service area
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MVP Health Plan 2000
Emergency Benefits continued
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care nonPlan 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 provi sions of the contract on which denial was based If you disagree with the Plans decision you may
request reconsideration in accordance with the disputed claims procedure described on page 5
Mental ConditionsSubstance Abuse Benefits
Mental conditions You must contact the Plan at 8886876277 prior to services being rendered
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 outpatient visits to Plan doctors or other psychiatric personnel each calendar year you pay a 10 copay per visit for 1st5th visit and you pay the lesser of 50 of charges or a 30 copay
per visit for the 6th20th visit all charges thereafter
Inpatient care Up to 30 days of hospitalization and 30 inpatient professional visits each calendar year you pay nothing for the first 30 days of hospitalization you pay the lesser of 50 of charges or a 30 copay
per visit for up to 30 visits for inpatient professional services 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 shortterm 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 shortterm psychiatric condition
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medi cal nonpsychiatric 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 diag nosis and treatment
Outpatient care Up to 60 outpatient visits to Plan providers for treatment each calendar year you pay a 10 copay for each covered visit all charges thereafter
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
What is not covered Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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MVP Health Plan 2000
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 30day or 100 unit supply whichever is less or one commercially prepared
unit ie one inhaler one vial ophthalmic medication You pay a 5 copay per retail prescription
unit or refill when the prescription is filled with a generic drug You pay a 10 copay per retail pre scription unit or refill when the prescription is filled with a brand name drug
This Plan offers a mailorder prescription benefit for Planapproved maintenance drugs Drugs ob
tained through our mailorder program will be dispensed for up to a 90day or 300 unit supply whichever is less You pay a 10 copay per mailorder prescription unit or refill when the pre
scription is filled with a generic drug You pay a 20 copay per mailorder prescription unit or
refill when the prescription is filled with a brand name drug If you are unsure about whether or not a particular drug that you are taking is available through our mailorder program please call
our Member Services Department at 8886876277
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary
The Plans drug formulary is administered through the Plans Pharmacy and Therapeutics PT
Committee The Plans PT Committee uses utilization pharmacoeconomic and clinical data to develop the Plans formulary Not every Plan member may be able to tolerate formulary drugs due
to clinical ineffectiveness or adverseallergic reactions This Plan will cover nonformulary drugs
when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral contraceptive drugs contraceptive diaphragms Insulin covered under Medical and Surgical benefits you pay the lesser of a 10 copay or
20 of total cost per each 31day supply
Disposable needles and syringes needed to inject covered prescribed medication and other medical supplies such as dressings and antiseptics covered under Medical and Surgical ben
efits you pay 20 of cost
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedicts solution or equivalent glucose monitors and acetone test tablets covered under
Medical and Surgical benefits you pay the lesser of a 10 copay or 20 of cost per each 31
day supply Enteral formulas when medically necessary please contact Plan for details
Drugs for the treatment of multiple sclerosis
Intravenous fluids and medication for home use implantable drugs such as Norplant and some injectable drugs such as Depo Provera are covered under Medical and Surgical Ben
efits
Limited benefits Drugs to treat sexual dysfunction are limited Contact Plan for dose limits you pay 10 per prescription
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a nonPlan pharmacy except for outofarea emergencies
Vitamins and nutritional substances that can be purchased without a prescription Drugs for cosmetic purposes
Drugs to enhance athletic performance
Refills due to a lost or misused prescription drug supply Drugs used in connection with the provision of a noncovered service or benefit
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MVP Health Plan 2000
Other Benefits
Dental care
What is covered The following preventive and diagnostic services are covered for Plan members under age 19 you pay a 10 copay per visit
One initial oral exam followed by periodic exams once every six months
Bite wing xrays once every six months Full mouth xrays and panoramic xrays once every 36 months
Routine cleaning scaling and polishing of teeth once every six months
Fluoride treatments once every six months to age 16 Pulp vitality testing and diagnostic casts as needed
Space maintainers and recementation thereof as needed
Intraoral and periepical xrays as needed Sealants once per tooth per child to age 16
You may see the dental provider of your choice to receive benefits Your provider may require you to pay for the services at the time they are rendered in which case you should submit a claim to us
for full reimbursement less your 10 copay You may obtain a claim form by calling the Plan at
8886876277 Claim forms should be mailed to Dental Benefit Providers 7200 Wisconsin Ave Suite 800 Bethesda Maryland 20814 You must file claims promptly If you do not file your
claims promptly we will still accept them if they are filed as soon as reasonably possible How
ever the Plan will neither accept nor provide coverage for claims that are submitted later than one year after a service is performed
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth benefit are covered The need for these services must result from an accidental injury You pay nothing
Treatment must be performed within 12 months of the accident
What is not covered Other dental services not shown as covered Services which are not approved by the Council of Dental Therapeutics of the American Dental
Association ADA
Services rendered by a medical department clinic or similar facility of the childs employer labor union mutual benefit association or other similar group
Charges for dental appointments that are not kept
Hospitalization for any dental procedures except as noted under Inpatient dental procedures on page 9
Dental implants
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye eye refractions to provide a written lens prescription for eyeglasses are covered once
every 24 months and must be obtained from Plan providers You pay a 10 copay per visit
What is not covered Corrective lenses or frames Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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MVP Health Plan 2000
NonFEHB 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 outof
pocket maximum copay charges These benefits are not subject to the FEHB disputed claims procedure
Outofarea student MVP Health Plan will offer extended outofarea coverage for any of your dependent dependent coverage children up to age 22 provided that the child is a fulltime
student at an accredited college or university A fulltime student is enrolled in at least twelve 12 credit hours per
semester This extended benefit covers your child outside of MVPs service area for care and services that he or she would normally obtain within MVPs service area
with the exception of preventive care including wellchild care physical exams immuniza
tions and elective inpatient hospital services which is not covered Preventive care must be arranged by the students primary care physician PCP and should take place within
MVPs service area
For elective outpatient surgery and specialty care the student is not required to access care through his or her PCP If you wish to obtain these services without PCP involvement
then you must contact MVP at 8886876277 to obtain authorization for these services
If your child obtains services outside MVPs service area or within MVPs service area
but not arranged by his or her PCP your child is responsible for the entire cost of services
including the applicable copay Coverage for these types of services is limited to 2500 per year MVP will reimburse you for the usual and customary cost of these services mi
nus the applicable copay after you submit properly completed claim forms You will not
be reimbursed for claims filed later than one year after the date of service You must sub mit claims to us at the following address MVP Health Plan Inc PO Box 2207
Schenectady NY 12301
For questions on claims submission or this outofarea benefit please call the MVP Mem
ber Services Department at 8886876277
Expanded vision MVP Health Plan has made arrangements with local optical shops which entitle you to care various discounts on designated eyewear purchases Please see the MVP Health Plan
Something Extra brochure for listings of participating optical shops
Fitness programs MVP Health Plan has made arrangements with local Health and Fitness Clubs and Weight Control Centers which entitle you to discounts on designated enrollment membership or
registration fees Please see the MVP Health Plan Something Extra brochure for a listing
of participating Health and Fitness Clubs and Weight Control Centers
Safety equipment MVP Health Plan offers you discounts on safety equipment for the home and car and for personal use when purchased through our Something Extra program
If you have any questions about any of these benefits please contact the MVP Member Services Department at 8886876277
Benefits on this page are not part of the FEHB contract
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MVP Health Plan 2000
Section 6 General exclusions Things we dont 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 nonPlan providers except for authorized referrals or emergencies see Emergency Benefits or eligible selfre ferred services
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occa
sion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a MedicareChoice plan and also remain en
rolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
MedicareChoice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a MedicareChoice plan contact your retirement office If you later want to reenroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the MedicareChoice 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 MedicareChoice plans contact your local Social Security Administration
SSA office or request it from SSA at 8006386833
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance 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 which
ever 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
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MVP Health Plan 2000
Section 7 Limitations Rules that affect your benefits continued
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek dama ges 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 workplacerelated 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 pro
ceeding 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 pro
vide 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 or Agencies indirectly pays for
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 OPMs website httpwwwopmgov lists the specific types of information that we must make available to you
If you want specific information about us call 8886876277 or write to us at MVP Health Plan 111 Liberty St Schenectady NY 12305 You may also contact us by fax at 5183567460 or visit our website at httpwwwmvphealthplancom
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 dont determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums effective Annuitants premiums begin January 1
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MVP Health Plan 2000
Section 8 FEHB FACTS continued
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation
of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for retirement office authorizes coverage for Under certain circumstances you may also get coverage my family and me for a disabled child 22 years of age or older who is incapable of selfsupport
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 en
rolled 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 andor prosecuting alleged civil or criminal ac
tions
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 SF2809 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 plans deductible continues until our coverage begins deductible under my
old plan
Preexisting 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
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MVP Health Plan 2000
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 Your enrollment ends unless you cancel your enrollment or
Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouses 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 spouses 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 7927 which describes TCC and the RI 705 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 2percent administrative charge The government
does not share your costs
You receive another 31day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC in 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 no tice 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 60day deadline
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MVP Health Plan 2000
When you lose benefits continued
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
How can I get a If you leave Federal service your employing office will notify you if individual coverage is avail Certificate of Group able You must apply in writing to us within 31 days after you receive this notice However if you
Health Plan Coverage 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 cover age due to preexisting conditions
If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
indicates how long you have been enrolled with us You can use this certificate when getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of
leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclu
sions 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 8886876277 and explain the situation If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE 2024183300
US Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street NW 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
MVP Health Plan 2000
Summary of Benefits for MVP Health Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan paysprovides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital doctor care room and board general nursing
care private room and private nursing care if medically necessary
diagnos tic tests drugs and medical supplies use of operating room intensive care
and complete maternity care You pay nothing 9
Extended care All necessary services for up to 45 days per year You pay nothing 9
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing for hospitalization a 30 copay or
50 of charges whichever is less for up to 30 visits for professional services
11
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay
nothing
11
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness
or injury including specialists care preventive care including wellbaby
care periodic checkups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay per office visit 10
copay per house call by a doctor a 10 copay per outpatient surgery at the
hospital a 10 copay per visit for shortterm rehabilitative therapy
Home health care All necessary visits by nurses and health aides You pay a 10 copay per 7
visit
Mental conditions Up to 20 outpatient visits per year You pay a 10 copay per visit for 1st 5th visits a 30 copay or 50 of charges whichever is less for 6th 20th
7
visits
Substance abuse Up to 60 outpatient visits per year You pay a 10 copay per visit
Emergency care Reasonable charges for services and supplies required because of a medical 11
emergency You pay a 35 copay to the hospital for each emergency room 11
visit within the service area and any charges for services that are not cov ered by this Plan
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 10 copay brand name or 5 copay generic per Retail prescription 10
unit or refill and a 20 copay brand name or 10 copay generic per mail order prescription unit or refill
Dental care Accidental injury benefit you pay nothing Preventive dental care for chil dren under 19 You pay a 10 copay per visit 12
Vision care One refraction every twentyfour 24 months You pay 10 per visit
13
Out of pocket maximum Your outofpocket expenses for benefits covered under this Plan are lim
ited to the stated copayments which are required for a few benefits
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2000 Rate Information for MVP Health Plan
NonPostal rates apply to most nonPostal 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 US 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 702 to determine which rate applies to you
Postal rates do not apply to noncareer 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 Plan
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Gov't Your Gov't Your USPS Your USPS Your Enrollment Code Share Share Share Share Share Share Share Share
Eastern Region
Self Only GA1 73.41 24.47 159.05 53.02 86.87 11.01 86.87 11.01
Self and Family GA2 175.97 70.13 381.27 151.95 207.74 38.36 201.02 45.08
Central Region
Self Only M91 73.17 24.39 158.54 52.84 86.58 10.98 86.58 10.98
Self and Family M92 175.97 69.54 381.27 150.67 207.74 37.77 201.02 44.49
MidHudson Region
Self Only MX1 78.83 29.70 170.80 64.35 93.06 15.47 93.26 15.27
Self and Family MX2 175.97 95.35 381.27 206.59 207.74 63.58 201.02 70.30
Vermont Region
Self Only VW1 78.83 29.26 170.80 63.40 93.06 15.03 93.26 14.83
Self and Family VW2 175.97 96.56 381.27 209.21 207.74 64.79 201.02 71.51
21 23